- Email: [email protected]
Rapid diagnosis of PICU delirium
Current Best Evidence: Translating Best Evidence into Best Care EDITOR’S NOTE: Studies for this issue were identified using alerts from Archives of Disease in ChildhoodEducation and Practice, Archives of Disease in Childhood-Fetal and Neonatal, Archives of Disease in Childhood, British Medical Journal, Journal of the American Medical Association, New England Journal of Medicine, Pediatric Infectious Disease Journal, Pediatrics, The Journal of Pediatrics, and The Lancet. Search terms were “paediatrics” [All Fields] OR “pediatrics” [All Fields] OR “pediatrics” [MeSH Terms]. In addition, studies were identified using the Clinical Queries feature of PubMed. Cleo Pappas, MLIS, retired, Library of the Health Sciences, University of Illinois at Chicago, contributed to the review and selection of this month’s abstracts. —Jordan Hupert, MD EBM PEARL: RECURSIVE PARTITIONING (RP): RP is a statistically rigorous approach to algorithm development. In its simplest application, at each level of the RP algorithm, a larger group of poorly differentiated patients (with and without the target disease) are statistically partitioned into two groups of mostly affected and mostly unaffected patients. The statistical partition is based on a clinical question (eg, “Does the patient appear clinically well?”). This process is repeated at each subsequent level with other clinical questions. The RP program chooses, from a list of relevant clinical questions, those questions with the highest “purity” (ie, those with the greatest ability to partition patients into affected and unaffected groups). The RP algorithm created with one set of patients (derivation model) is then tested with another set of patients (validation model). Escobar et al (see piece by Young on page 640 regarding article Escobar et al, Pediatrics 2014;133:30-6) employed RP to partition newborns into three sepsisprobability groups (each with a unique, recommended management) based on maternal factors and neonatal clinical presentation. —Jordan Hupert, MD LITERATURE SEARCH PEARL: GOOGLE SCHOLAR (GS): GS is a freely available searching platform designed to retrieve scholarly literature (published and unpublished articles, theses, books, abstracts, and legal documents) among all fields of endeavor, including biomedical research. One may search GS using standard Boolean search terms (AND, OR, NOT), though few filters are permitted other than date of publication (in contrast to PubMed). The GS search algorithm retrieves articles based largely on citation counts. Typically, GS retrieves more articles and more free full-length articles compared with PubMed—though retrieval relevance (to the search topic) is variable (J Med Internet Res 2013;15:e164). On the other hand, compared with GS, the Clinical Queries feature of PubMed retrieved a higher percentage of methodologically high-quality articles (Respir Care 2010;55:578-83). GS may be a nice option for a quick, initial answer to a clinical question. —Jordan Hupert, MD
A data-based approach to evaluation and empiric treatment of newborn sepsis Escobar GJ, Puopolo KM, Wi S, Turk BJ, Kuzniewicz MW, Walsh EM, et al. Stratification of risk of early-onset sepsis in newborns $ 34 weeks’ gestation. Pediatrics. 2014;133:30-6. Question Among newborns with maternal and neonatalspecific risk factors for sepsis, what is the diagnostic accuracy of risk-factor stratification, compared with blood culture, in detecting sepsis? Design Derivation and validation retrospective datasets from randomly selected controls and all blood-culture-positive newborns 1993-2007. Patient-group stratification was based on recursive partitioning. Setting Kaiser Permanente Northern California hospitals and Boston’s Brigham and Women’s Hospital and Beth Israel-Deaconess Medical Center. Participants Newborns $34 weeks’ gestation. 640
Outcomes Stratified sepsis-risk probabilities (posttest) based on maternal (pretest) and newborn clinical (test) risk factors. Main Results Using maternal and neonatal data, a risk stratification scheme divided the neonatal population into three groups: treat empirically (4.1% of all live births, 60.8% of all cases of early-onset sepsis, sepsis incidence of 8.4/1000 live births), observe and evaluate (11.1% of births, 23.4% of cases, sepsis incidence 1.2/1000), and continued observation (84.8% of births, 15.7% of cases, sepsis incidence 0.11/1000). Conclusions Judicious application of this stratified scheme could result in decreased antibiotic treatment in 80 000 to 240 000 US newborns each year. Commentary When labor is complicated by maternal factors such as chorioamnionitis or inadequate intrapartum antibiotic prophylaxis, even well-appearing newborns typically undergo laboratory tests and receive antibiotics based on recommendations of the Centers for Disease Control and Prevention and
Vol. 165, No. 3 September 2014 the American Academy of Pediatrics. Escobar et al propose a stratification scheme dividing newborns into those who should be treated empirically, those who should be observed and evaluated, and those who need only be observed. The scheme is based on a combination of the authors’ previously published early-onset-sepsis risk assessment tool1 and a “Classification of Clinical Signs” described in the current publication. The authors used recursive partitioning of 5 maternal and 3 newborn factors from a case control study that compared 350 newborns with culture positive sepsis (cases) with 1063 controls from a population of 608,014 live births to generate a stratification model that is appealing because it is both intuitive and simple to understand. Its use could substantially reduce the number of newborns tested and treated. Paul C. Young, MD University of Utah Salt Lake City, Utah
Reference 1. Puopolo KM, Draper D, Wi S, Newman TB, Zupancic J, Lieberman E, et al. Estimating the probability of neonatal early onset infection on the basis of maternal risk factors. Pediatrics 2011;128:e1155-63.
supine, discontinuing swaddling as soon as an infant’s earliest attempts to roll are observed, and removing soft bedding and bumper pads from the sleep environment. Commentary Parents often complain that their babies do not sleep well when placed on their backs as recommended. This has led to an exponential increase in products such as infant sleeping bags or wearable blankets, numerous swaddle wraps and swaddling blankets. These are designed to restrict spontaneous limb movements with the aim of preventing infants from waking themselves, thus increasing sleep time.1 The study by McDonnell and Moon highlights that these products are not always safe. Eighty-six percent of the 22 deaths were attributed to asphyxia with 68% of these infants found prone, either rolling to or being placed in this position. As these products and swaddling restrict limb movements, they severely reduce the infant’s ability to roll from back to front or to turn away from suffocating bedding. In 12 cases, swaddle wraps had come loose and covered the infants’ faces. These devices need to be used with caution. Advice to parents needs to be very clear. Infants should be put to sleep supine on a firm surface with no soft or loose bedding. Swaddling should be used only in infants under 3 months of age who cannot yet roll. Rosemary S.C. Horne, PhD Monash University Melbourne, Australia
Swaddling may cause death and injury McDonnell E, Moon RY. Infant Deaths and Injuries Associated with Wearable Blankets, Swaddle Wraps, and Swaddling. J Pediatr. 2014;164:1152-6. Question Among young infants, what are the details of swaddling leading to death and injury? Design Retrospective review of incidents reported to the Consumer Product Safety Commission. Setting United States, 2004-2012. Participants Swaddled infants. Outcomes Death and injury incidents. Main Results There was a total of 36 incidents involving wearable blankets and swaddle wraps, including 22 deaths, 2 injuries, and 12 incidents without injury. The median age at death was 3.5 months; 80% of the deaths were attributed to positional asphyxia related to prone sleeping, and 70% involved additional risk factors, usually soft bedding. Two injuries involved tooth extraction from the zipper. The 12 incidents without injury reported concern for strangulation/ suffocation when the swaddle wrap became wrapped around the face and neck, and a potential choking hazard when the zipper detached. All 12 incidents involving swaddling in ordinary blankets resulted in death. The median age at death was 2 months. Fifty-eight percent of deaths were attributed to positional asphyxia related to prone sleeping, and 92% involved additional risk factors, most commonly soft bedding. Conclusions Reports of sudden unexpected death in swaddled infants are rare. Risks can be reduced by placing infants
Reference 1. van Sleuwen BE, Engelberts AC, Boere-Boonekamp MM, Kuis W, Schulpen TW, L’Hoir MP. Swaddling: a systematic review. Pediatrics 2007;120:e1097-106.
Antibiotic treatment in otitis media reduces middle ear effusion duration Tapiainen T, Kujala T, Renko M, Koivunen P, Kontiokari T, Kristo A, et al. Effect of Antimicrobial Treatment of Acute Otitis Media on the Daily Disappearance of Middle Ear Effusion: A Placebo-Controlled Trial. JAMA Pediatr. 2014;165: 635-41. Question Among children with otitis media (OM), what is the therapeutic efficacy of antibiotics, compared with placebo, in resolution of middle ear effusion (MEE)? Design Randomized controlled trial. Setting Outpatient clinics, Oulu, Finland. Participants Children, 6 months to 15 years old. Outcomes Time to disappearance of MEE. Main Results On day 14, 69% of children in the antimicrobial group and 38% in the placebo group had normal tympanometry findings (number needed to treat [NNT] 4; 95% CI, 2-11). On day 60, 2 children (5%) in the antimicrobial group and 10 children (24%) in the placebo group had persistent MEE (NNT 6; 95% CI, 3-22). 641
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 165, No. 3
Conclusions Antimicrobial treatment effectively reduced the duration of MEE in children with AOM, and the risk for persistent MEE.
Conclusions Caucasian race, residence in rural areas, children aged 5-13 years, and children with less severe disease are at increased risk to receive the non-preferred LTRAM.
Commentary Current guidance on antibiotic treatment of acute otitis media in children is based on a large body of high-level evidence.1 The question is whether further trials can shed a new light on this. Any additional evidence should focus on outcomes that are most relevant to children and their parents. Although this RCT is of high quality, the question is whether its main outcomes - time to disappearance of middle ear effusion and time to normal otoscopy - qualify as such, and whether use of antibiotics is justified. In most children, MEE resolves spontaneously with time, even after 2 months. Any surgical management should be guided by hearing loss and developmental impact. We strongly recommend designing any further studies in this field in close collaboration with parents to ensure patient-centered outcomes.
Commentary National Asthma Education and Prevention Program 2007 guidelines recommend ICS to be the first line therapy for management of pediatric patients with persistent asthma and a leukotriene receptor antagonist (LTRA) as an alternative medication. LTRA is typically used as an add-on medication to ICS when asthma treatment is stepped up. Wu et al demonstrate that among patients receiving Medicaid in South Carolina with persistent asthma, select cohorts are more likely to receive LTRAM. African Americans experience more asthmarelated urgent care visits, higher rates of hospitalizations, and higher death rates1 when compared with Caucasians. Rural patients have less severe asthma compared with urban patients and this may be contributing to their receipt of LTRAM. Lower use of albuterol, oral steroids and outpatient visits in patients receiving LTRAM could be from less severe asthma or from better adherence with LTRAM compared with ICS. LTRAM may be equally effective in a real world situation as it is more acceptable to take a pill than to use an inhaler.2 Evidence suggests that ICS is more effective than LRTAM in maintaining asthma control in older children with persistent asthma, but in preschool children data are conflicting.3 Studies comparing ICS versus LTRAM are needed in preschool children as LTRAM may have a role in younger children with mild persistent asthma. Pending further studies, LRTAM may be considered for children with mild persistent asthma only if they are having difficulty using inhalers or adhering to the twice-daily dosing regimen.
Roderick P. Venekamp, MD University Medical Center Utrecht Utrecht, The Netherlands
Reference 1. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99.
Characteristics associated with leukotriene monotherapy in persistent asthma Wu CL, Andrews AL, Teufel RJ, Basco WT. Demographic Predictors of Leukotriene Antagonist Monotherapy Among Children with Persistent Asthma. J Pediatr. 2014;164:827-31. Question Among children with persistent asthma, what is the association of leukotriene receptor antagonist monotherapy (LTRAM) compared with inhaled corticosteroid therapy (ICS) in baseline demographic and asthma control-related characteristics? Design Cross-sectional secondary analysis of a Medicaid database. Setting South Carolina, 2007-2009. Participants Children with persistent asthma. Outcomes Demographic and asthma-related characteristics. Main Results Compared with children treated with ICS, school-aged children (5- to 13-year-olds relative to children <5 years old [OR 1.46, 95% CI, 1.30-1.64]), Caucasians relative to African Americans (OR 1.40, 95% CI, 1.27-1.53), and rural children relative to urban children (OR 1.18, 95% CI, 1.08-1.3) were all more likely to receive LTRAM. Patients with asthma classified as severe were 51.7% less likely to receive LTRAM (P < .01). 642
Harsha Kumar, MD University of Illinois at Chicago Chicago, Illinois
References 1. Akinbami L. Centers for Disease Control Prevention National Center for Health: The state of childhood asthma. United States, 1980-2005. Advance Data 2006;1-24. 2. Price DL, Musgrave SD, Shepstone L, Hillyer EV, Sims EJ, Gilbert RF, et al. Leukotriene antagonists as first-line or add-on asthma-controller therapy. N Engl J Med 2011;364:1695-707. 3. Castro-Rodriguez JA, Rodrigo GJ. The role of inhaled corticosteroids and montelukast in children with mild-moderate asthma: results of a systematic review with meta-analysis. Arch Dis Child 2010;95:365-70.
Rapid diagnosis of PICU delirium Traube C, Silver G, Kearney J, Patel A, Atkinson TM, Yoon MJ, et al. Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU. Crit Care Med. 2014;42:656-63. Question Among pediatric intensive care unit (PICU) patients, what is the efficacy of a rapid screening tool, compared
CURRENT BEST EVIDENCE
September 2014 with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, in diagnosing pediatric delirium (PD)? Design Independent, blinded assessment of the Cornell Assessment of Pediatric Delirium (CAPD) compared with a psychiatric assessment using the DSM-IV. Setting PICU, Cornell Medical College. Participants Patients in the PICU. Outcomes Test characteristics of the CAPD. Main Results The CAPD had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.584.9%), positive likelihood ratio (+LR) 4.52 (95% CI, 2.97, 6.89), -LR 0.07 (95% CI, 0.01, 0.38). In developmentally delayed children, the CAPD showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%), +LR 1.97 (95% CI, 1.12, 3.46), -LR 0.07 (95% CI, 0.00, 2.26). The CAPD takes less than 2 minutes to complete. Conclusions The CAPD is a valid, rapid, observational screen for the detection of delirium in PICU settings. Commentary There is a growing awareness regarding the importance of PD.1 Today there exist two tools: a neuropsychological scale for children $ 5 years of age: the Pediatric
Confusion Assessment Method for the ICU (pCAM-ICU)2 and the behavioral scale validated by Traube et al, the CAPD. The CAPD’s strengths are: 3 new items to detect also hypoactive PD, developmental anchor points to detect baseline behavioral changes, and methodologic soundness. There are some concerns: the inclusion of 3 new items did not affect the diagnostic cutoff, the pediatric delirium age distribution appears to be PICU dependent, and there is no differential diagnostic algorithm. But given the CAPD’s simplicity and cleverness, this report is a clinically significant step in the exploration of the pediatric delirium field. Jan N.M. Schieveld, MD, PhD Maastricht University Medical Centre Maastricht, The Netherlands
References 1. Schieveld J, Janssen N. Delirium in the Pediatric Patient. JAMA Pediatrics 2014; http://dx.doi.org/10.1001/jamapediatrics.2014.125. 2. Smith H, Boyd J, Fuchs D, Melvin K, Berry P, Shintani A, et al. Diagnosing delirium in critically ill children: validity and reliability of the Pediatric Confusion Assessment Method for the intensive care unit. Crit Care Med 2011;39:150-7.
643
A data-based approach to evaluation and empiric treatment of newborn sepsis Escobar GJ, Puopolo KM, Wi S, Turk BJ, Kuzniewicz MW, Walsh EM, et al. Stratification of risk of early-onset sepsis in newborns $ 34 weeks’ gestation. Pediatrics. 2014;133:30-6. Question Among newborns with maternal and neonatalspecific risk factors for sepsis, what is the diagnostic accuracy of risk-factor stratification, compared with blood culture, in detecting sepsis? Design Derivation and validation retrospective datasets from randomly selected controls and all blood-culture-positive newborns 1993-2007. Patient-group stratification was based on recursive partitioning. Setting Kaiser Permanente Northern California hospitals and Boston’s Brigham and Women’s Hospital and Beth Israel-Deaconess Medical Center. Participants Newborns $34 weeks’ gestation. 640
Outcomes Stratified sepsis-risk probabilities (posttest) based on maternal (pretest) and newborn clinical (test) risk factors. Main Results Using maternal and neonatal data, a risk stratification scheme divided the neonatal population into three groups: treat empirically (4.1% of all live births, 60.8% of all cases of early-onset sepsis, sepsis incidence of 8.4/1000 live births), observe and evaluate (11.1% of births, 23.4% of cases, sepsis incidence 1.2/1000), and continued observation (84.8% of births, 15.7% of cases, sepsis incidence 0.11/1000). Conclusions Judicious application of this stratified scheme could result in decreased antibiotic treatment in 80 000 to 240 000 US newborns each year. Commentary When labor is complicated by maternal factors such as chorioamnionitis or inadequate intrapartum antibiotic prophylaxis, even well-appearing newborns typically undergo laboratory tests and receive antibiotics based on recommendations of the Centers for Disease Control and Prevention and
Vol. 165, No. 3 September 2014 the American Academy of Pediatrics. Escobar et al propose a stratification scheme dividing newborns into those who should be treated empirically, those who should be observed and evaluated, and those who need only be observed. The scheme is based on a combination of the authors’ previously published early-onset-sepsis risk assessment tool1 and a “Classification of Clinical Signs” described in the current publication. The authors used recursive partitioning of 5 maternal and 3 newborn factors from a case control study that compared 350 newborns with culture positive sepsis (cases) with 1063 controls from a population of 608,014 live births to generate a stratification model that is appealing because it is both intuitive and simple to understand. Its use could substantially reduce the number of newborns tested and treated. Paul C. Young, MD University of Utah Salt Lake City, Utah
Reference 1. Puopolo KM, Draper D, Wi S, Newman TB, Zupancic J, Lieberman E, et al. Estimating the probability of neonatal early onset infection on the basis of maternal risk factors. Pediatrics 2011;128:e1155-63.
supine, discontinuing swaddling as soon as an infant’s earliest attempts to roll are observed, and removing soft bedding and bumper pads from the sleep environment. Commentary Parents often complain that their babies do not sleep well when placed on their backs as recommended. This has led to an exponential increase in products such as infant sleeping bags or wearable blankets, numerous swaddle wraps and swaddling blankets. These are designed to restrict spontaneous limb movements with the aim of preventing infants from waking themselves, thus increasing sleep time.1 The study by McDonnell and Moon highlights that these products are not always safe. Eighty-six percent of the 22 deaths were attributed to asphyxia with 68% of these infants found prone, either rolling to or being placed in this position. As these products and swaddling restrict limb movements, they severely reduce the infant’s ability to roll from back to front or to turn away from suffocating bedding. In 12 cases, swaddle wraps had come loose and covered the infants’ faces. These devices need to be used with caution. Advice to parents needs to be very clear. Infants should be put to sleep supine on a firm surface with no soft or loose bedding. Swaddling should be used only in infants under 3 months of age who cannot yet roll. Rosemary S.C. Horne, PhD Monash University Melbourne, Australia
Swaddling may cause death and injury McDonnell E, Moon RY. Infant Deaths and Injuries Associated with Wearable Blankets, Swaddle Wraps, and Swaddling. J Pediatr. 2014;164:1152-6. Question Among young infants, what are the details of swaddling leading to death and injury? Design Retrospective review of incidents reported to the Consumer Product Safety Commission. Setting United States, 2004-2012. Participants Swaddled infants. Outcomes Death and injury incidents. Main Results There was a total of 36 incidents involving wearable blankets and swaddle wraps, including 22 deaths, 2 injuries, and 12 incidents without injury. The median age at death was 3.5 months; 80% of the deaths were attributed to positional asphyxia related to prone sleeping, and 70% involved additional risk factors, usually soft bedding. Two injuries involved tooth extraction from the zipper. The 12 incidents without injury reported concern for strangulation/ suffocation when the swaddle wrap became wrapped around the face and neck, and a potential choking hazard when the zipper detached. All 12 incidents involving swaddling in ordinary blankets resulted in death. The median age at death was 2 months. Fifty-eight percent of deaths were attributed to positional asphyxia related to prone sleeping, and 92% involved additional risk factors, most commonly soft bedding. Conclusions Reports of sudden unexpected death in swaddled infants are rare. Risks can be reduced by placing infants
Reference 1. van Sleuwen BE, Engelberts AC, Boere-Boonekamp MM, Kuis W, Schulpen TW, L’Hoir MP. Swaddling: a systematic review. Pediatrics 2007;120:e1097-106.
Antibiotic treatment in otitis media reduces middle ear effusion duration Tapiainen T, Kujala T, Renko M, Koivunen P, Kontiokari T, Kristo A, et al. Effect of Antimicrobial Treatment of Acute Otitis Media on the Daily Disappearance of Middle Ear Effusion: A Placebo-Controlled Trial. JAMA Pediatr. 2014;165: 635-41. Question Among children with otitis media (OM), what is the therapeutic efficacy of antibiotics, compared with placebo, in resolution of middle ear effusion (MEE)? Design Randomized controlled trial. Setting Outpatient clinics, Oulu, Finland. Participants Children, 6 months to 15 years old. Outcomes Time to disappearance of MEE. Main Results On day 14, 69% of children in the antimicrobial group and 38% in the placebo group had normal tympanometry findings (number needed to treat [NNT] 4; 95% CI, 2-11). On day 60, 2 children (5%) in the antimicrobial group and 10 children (24%) in the placebo group had persistent MEE (NNT 6; 95% CI, 3-22). 641
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 165, No. 3
Conclusions Antimicrobial treatment effectively reduced the duration of MEE in children with AOM, and the risk for persistent MEE.
Conclusions Caucasian race, residence in rural areas, children aged 5-13 years, and children with less severe disease are at increased risk to receive the non-preferred LTRAM.
Commentary Current guidance on antibiotic treatment of acute otitis media in children is based on a large body of high-level evidence.1 The question is whether further trials can shed a new light on this. Any additional evidence should focus on outcomes that are most relevant to children and their parents. Although this RCT is of high quality, the question is whether its main outcomes - time to disappearance of middle ear effusion and time to normal otoscopy - qualify as such, and whether use of antibiotics is justified. In most children, MEE resolves spontaneously with time, even after 2 months. Any surgical management should be guided by hearing loss and developmental impact. We strongly recommend designing any further studies in this field in close collaboration with parents to ensure patient-centered outcomes.
Commentary National Asthma Education and Prevention Program 2007 guidelines recommend ICS to be the first line therapy for management of pediatric patients with persistent asthma and a leukotriene receptor antagonist (LTRA) as an alternative medication. LTRA is typically used as an add-on medication to ICS when asthma treatment is stepped up. Wu et al demonstrate that among patients receiving Medicaid in South Carolina with persistent asthma, select cohorts are more likely to receive LTRAM. African Americans experience more asthmarelated urgent care visits, higher rates of hospitalizations, and higher death rates1 when compared with Caucasians. Rural patients have less severe asthma compared with urban patients and this may be contributing to their receipt of LTRAM. Lower use of albuterol, oral steroids and outpatient visits in patients receiving LTRAM could be from less severe asthma or from better adherence with LTRAM compared with ICS. LTRAM may be equally effective in a real world situation as it is more acceptable to take a pill than to use an inhaler.2 Evidence suggests that ICS is more effective than LRTAM in maintaining asthma control in older children with persistent asthma, but in preschool children data are conflicting.3 Studies comparing ICS versus LTRAM are needed in preschool children as LTRAM may have a role in younger children with mild persistent asthma. Pending further studies, LRTAM may be considered for children with mild persistent asthma only if they are having difficulty using inhalers or adhering to the twice-daily dosing regimen.
Roderick P. Venekamp, MD University Medical Center Utrecht Utrecht, The Netherlands
Reference 1. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99.
Characteristics associated with leukotriene monotherapy in persistent asthma Wu CL, Andrews AL, Teufel RJ, Basco WT. Demographic Predictors of Leukotriene Antagonist Monotherapy Among Children with Persistent Asthma. J Pediatr. 2014;164:827-31. Question Among children with persistent asthma, what is the association of leukotriene receptor antagonist monotherapy (LTRAM) compared with inhaled corticosteroid therapy (ICS) in baseline demographic and asthma control-related characteristics? Design Cross-sectional secondary analysis of a Medicaid database. Setting South Carolina, 2007-2009. Participants Children with persistent asthma. Outcomes Demographic and asthma-related characteristics. Main Results Compared with children treated with ICS, school-aged children (5- to 13-year-olds relative to children <5 years old [OR 1.46, 95% CI, 1.30-1.64]), Caucasians relative to African Americans (OR 1.40, 95% CI, 1.27-1.53), and rural children relative to urban children (OR 1.18, 95% CI, 1.08-1.3) were all more likely to receive LTRAM. Patients with asthma classified as severe were 51.7% less likely to receive LTRAM (P < .01). 642
Harsha Kumar, MD University of Illinois at Chicago Chicago, Illinois
References 1. Akinbami L. Centers for Disease Control Prevention National Center for Health: The state of childhood asthma. United States, 1980-2005. Advance Data 2006;1-24. 2. Price DL, Musgrave SD, Shepstone L, Hillyer EV, Sims EJ, Gilbert RF, et al. Leukotriene antagonists as first-line or add-on asthma-controller therapy. N Engl J Med 2011;364:1695-707. 3. Castro-Rodriguez JA, Rodrigo GJ. The role of inhaled corticosteroids and montelukast in children with mild-moderate asthma: results of a systematic review with meta-analysis. Arch Dis Child 2010;95:365-70.
Rapid diagnosis of PICU delirium Traube C, Silver G, Kearney J, Patel A, Atkinson TM, Yoon MJ, et al. Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU. Crit Care Med. 2014;42:656-63. Question Among pediatric intensive care unit (PICU) patients, what is the efficacy of a rapid screening tool, compared
CURRENT BEST EVIDENCE
September 2014 with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, in diagnosing pediatric delirium (PD)? Design Independent, blinded assessment of the Cornell Assessment of Pediatric Delirium (CAPD) compared with a psychiatric assessment using the DSM-IV. Setting PICU, Cornell Medical College. Participants Patients in the PICU. Outcomes Test characteristics of the CAPD. Main Results The CAPD had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.584.9%), positive likelihood ratio (+LR) 4.52 (95% CI, 2.97, 6.89), -LR 0.07 (95% CI, 0.01, 0.38). In developmentally delayed children, the CAPD showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%), +LR 1.97 (95% CI, 1.12, 3.46), -LR 0.07 (95% CI, 0.00, 2.26). The CAPD takes less than 2 minutes to complete. Conclusions The CAPD is a valid, rapid, observational screen for the detection of delirium in PICU settings. Commentary There is a growing awareness regarding the importance of PD.1 Today there exist two tools: a neuropsychological scale for children $ 5 years of age: the Pediatric
Confusion Assessment Method for the ICU (pCAM-ICU)2 and the behavioral scale validated by Traube et al, the CAPD. The CAPD’s strengths are: 3 new items to detect also hypoactive PD, developmental anchor points to detect baseline behavioral changes, and methodologic soundness. There are some concerns: the inclusion of 3 new items did not affect the diagnostic cutoff, the pediatric delirium age distribution appears to be PICU dependent, and there is no differential diagnostic algorithm. But given the CAPD’s simplicity and cleverness, this report is a clinically significant step in the exploration of the pediatric delirium field. Jan N.M. Schieveld, MD, PhD Maastricht University Medical Centre Maastricht, The Netherlands
References 1. Schieveld J, Janssen N. Delirium in the Pediatric Patient. JAMA Pediatrics 2014; http://dx.doi.org/10.1001/jamapediatrics.2014.125. 2. Smith H, Boyd J, Fuchs D, Melvin K, Berry P, Shintani A, et al. Diagnosing delirium in critically ill children: validity and reliability of the Pediatric Confusion Assessment Method for the intensive care unit. Crit Care Med 2011;39:150-7.
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