- Email: [email protected]
Independent predictors identified for developmental dysplasia of the hip
Translating Best Evidence into Best Care EDITOR’S NOTE: Studies for this issue were identified using the Clinical Queries feature of PubMed, “hand” searching JAMA Pediatrics and The Journal of Pediatrics, and from customized EvidenceUpdates alerts. EVIDENCE-BASED MEDICINE PEARL: INTENTION TO TREAT (ITT): ITT is an important methodological validity issue of a clinical therapeutic study. ITT can be summarized as “analyze what you randomize” —even if patients do not take their assigned therapy or drop out of the study. The purpose of ITT methodology is to mirror typical, real-life clinical conditions. For example, consider a two-group, parallel-design, randomized controlled trial comparing amoxicillin and placebo for the treatment of otitis media. A number of the patients randomized to the amoxicillin group never take the amoxicillin. Simple logic may suggest that either those patients should be removed from analysis or switched to the placebo group. ITT requires these patients to be analyzed in the amoxicillin group because patients do not always take their medicine, and they do not always follow-up. Outcome measures (eg, number needed to treat) are derived from these real-life groups, and are therefore reflective of what is likely to occur in the real-life clinical venue. SEARCHING PEARL: ADVANCED USE OF PUBMED—ANNE O’TATE: PubMed is a free, US-governmentsupported search and retrieval system of the MEDLINE biomedical database. Since PubMed’s debut, a number of programs have been developed to organize PubMed results in a user-friendly manner. Anne O’Tate is one of those programs, designed to identify and summarize key features of the most relevant articles. Anne O’Tate (http://arrowsmith.psych.uic.edu/cgi-bin/arrowsmith_uic/AnneOTate.cgi) is a free service that offers a number of ways to organize one’s PubMed search to facilitate specific topic retrieval or specific field browsing. Examples include: (1) “important words”—organizes the retrieved articles by words that occur more frequently in the literature retrieved, than in PubMed generally, thus identifying a lexicon specific to the literature retrieved; (2) “topics” organizes by medical subject headings (MeSH terms); and (3) “cluster by function”—organizes by larger topics (from the MeSH terms), generating themes and allowing the user to gain a quick overview of the retrieved literature. —Jordan Hupert, MD
Urokinase and VATS are equally effective for septated empyema Marhuenda C, Barcelo C, Fuentes I, Guilln G, Cano I, Lopez M, et al. Urokinase Versus VATS for Treatment of Empyema: A Randomized Multicenter Clinical Trial. Pediatrics. 2014;134:e1301-7. Question Among children with septated empyema, what is the therapeutic efficacy of drainage and urokinase compared with video-assisted thoracoscopic surgery (VATS), as measured by post-treatment length of hospital stay (LOS)? Design Randomized, controlled, multicenter study. Setting 6 university hospitals in Spain. Participants Previously healthy children <15 years old with septated empyema. Intervention Drainage and urokinase vs VATS. Primary Outcome Post treatment LOS. Main Results No statistically significant differences were found between drainage and urokinase and VATS in the median postoperative stay (10 vs 9 days). Conclusions Drainage plus urokinase instillation is as effective as VATS for first-line treatment of septated empyema. Commentary All currently available treatment options for childhood empyema are effective and safe, and most children make a complete recovery irrespective of the intervention 1320
received. This has led to inherent center or physician bias in the primary treatment of choice. Marhuenda et al, report that intrapleural urokinase and VATS were equally efficacious as primary treatment options for septated empyema in children. Similarly, previous prospective studies also state clinical equipoise between intrapleural fibrinolytics and VATS.1-3 However, this study did not measure important outcomes such as the amount of pain associated with the intervention, long-term pulmonary function, and exercise tolerance. Nevertheless, being a multicenter trial, perhaps the results from this trial are more extrapolatable—particularly as only patients with effusions in ultrasonographic stages 2 and 3 were included. Although this study further strengthens evidence in favor of intrapleural urokinase as the primary treatment for childhood empyema, a multicenter equivalence study comparing the two interventions, inclusive of outcomes other than hospital stay, will lay the case to rest. Samatha Sonnappa, MD, DCH, PhD UCL Institute of Child Health London, United Kingdom
References 1. Sonnappa S, Cohen G, Owens CM, van Doorn C, Cairns J, Stanojevic S, et al. Comparison of Urokinase and Video-assisted Thoracoscopic
Vol. 166, No. 5 May 2015
Surgery for Treatment of Childhood Empyema. Am J Respir Crit Care Med 2006;174:221-7. 2. St Peter SD, Tsao K, Spilde TL, Keckler SJ, Harrison C, Jackson MA, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009;44:106-11. 3. Cobanoglu U, Sayir F, Bilici S, Melek M. Comparison of the methods of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III empyema: a prospective randomized study. Pediatr Rep 2011;3:e29.
patients.2 In clinical trials where a “no treatment” group is included, it is possible to control for any nonspecific effects of treatment by subtracting changes in the no treatment group from the changes observed in the placebo and treatment groups. Parents and physicians want symptomatic relief of cough associated with upper respiratory tract infections. If a placebo is low cost, has no or minimal adverse effects, and it can reduce unnecessary antibiotic treatment, it appears to be a preferable treatment option.3 Herman A. Cohen, MD Tel Aviv University Tel Aviv, Israel
Demonstration of placebo effect for nonspecific cough medicine Paul IM, Beiler JS, Vallati JR, Duda LM, King TS. Placebo effect in the treatment of acute cough in infants and toddlers: a randomized clinical trial. JAMA Pediatr. 2014;168:1107-13. Question Among children with nonspecific cough, what is the therapeutic efficacy of placebo, compared with no treatment, in reducing cough frequency? Design Randomized, controlled trial. Setting Two university affiliated outpatient clinics in Pennsylvania, US. Participants Infants 2-47 months of age with nonspecific acute cough duration of 7 days or less. Interventions (1) Pasteurized agave nectar; (2) natural grape-flavored water with caramel color (placebo); and (3) no treatment. Primary Efficacy Measure Change in cough frequency between the first night and the end of the second night. Main Results Significant differences in symptom improvement were detected between the study groups, with agave nectar and placebo proving to be superior to no treatment, but no significant differences for any outcome were found when comparing agave nectar against placebo. Conclusions In a comparison of agave nectar, placebo, and no treatment, a placebo effect was demonstrated, with no additional benefit offered by agave nectar. Commentary This high-quality randomized-controlled trial demonstrates that agave nectar and placebo were superior to no treatment in relieving nonspecific cough in children aged 2 to 47 months. However, no significant differences were detected between the agave nectar and placebo groups. Eccles suggests four different effects to antitussive medicine: pharmacological, physiological, true placebo, and nonspecific effects.1 The pharmacological effect is related to the active ingredient of the medicine. The physiological effects can be attributed to physical properties of the medicine such as taste, smell, viscosity, acidity, texture, and temperature. A true placebo effect refers to the psychological therapeutic effect of the treatment, and it depends on the belief in the effectiveness of the treatment and the attitude of the patient towards the therapist. Nonspecific effects included the natural (spontaneous) recovery from the illness. Lee et al also demonstrate that placebo treatment has significant antitussive activity in adult
References 1. Eccles R. Mechanism of the placebo effect of sweet cough syrups. Respir Physiol Neurobiol 2006;152:340-8. 2. Lee P, Jawad M, Hull D, West W, Shaw K, Eccles R. The antitussive effect of placebo treatment on cough associated with acute upper respiratory infection. Psychosom Med 2005;67:314-7. 3. Tylor JA, Opel DJ. Using the placebo effect to treat cold symptoms in children. JAMA Pediatr 2014;168:1091-2.
Limited efficacy of antigastroesophageal reflux medications in children Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Pharmacological treatment of children with gastro-oesophageal reflux. Cochrane Database Syst Rev. 2014;11:CD008550. Question Among children with gastroesophageal reflux (GER), what is the therapeutic efficacy of acid suppressant medications, compared with placebo, in resolving signs and symptoms of acid reflux? Design Systematic review. Setting Various inpatient and outpatient settings. Participants Children from birth to 16 years of age with signs and/or symptoms of GER. Intervention Various antireflux medications. Outcomes Improvement in clinical GER signs and/or symptoms. Main Results Based on moderate-level evidence, proton pump inhibitors (PPIs) reduce GER symptoms in children with confirmed erosive esophagitis. Some evidence suggests H2 blockers adequately treat GER symptoms. For both classes of drugs, the effects are only in older children. In infants, moderate evidence indicates that Gaviscon Infant (sodium alginate, magnesium alginate, mannitol; Reckitt-Benckiser Healthcare, Slough, England) improves symptoms. Conclusions In pediatric patients with GER, there is mild to moderate evidence supporting the use of PPIs and H2 antagonists in older children, and Gaviscon Infant in infants. Commentary GER is common among infants and children, with prevalence as high as 30%-67%.1,2 At this frequency of 1321
THE JOURNAL OF PEDIATRICS
www.jpeds.com
disease, it is challenging to establish a causal relationship between symptoms and disease, and as Tighe et al illustrate, it is difficult to demonstrate the efficacy of pharmacologic therapy. In addition, GER has a wide range of symptoms and morbidities. For older children and adolescents with symptoms compatible with GER, especially those with abnormal endoscopies, the evidence establishing the effectiveness of a variety of antacid therapies was modest, limited mostly by methodological concerns. Their smaller numbers and more variable inclusion criteria inherently limit clinical trials in pediatrics. Children with developmental disabilities are at high risk for GER and esophagitis, but this population could not be assessed in this analysis. The crying infant who spits up is an almost daily challenge in pediatric practice. Unfortunately, the evidence that pharmacologic therapy is effective in this age group is weak. The safety profile of many of the commonly used medications, including PPIs, reflects few adverse effects, leading to a “why not just try it” attitude among clinicians. The number of prescriptions written for PPIs in infants has increased significantly.3 This comprehensive analysis of the published literature provides an opportunity to rethink that wisdom. James Berman, MD University of Illinois at Chicago Chicago, Illinois
References 1. Gunasekaran TS, Dahlberg M. Prevalence of gastroesophageal reflux symptoms in adolescents: is there a difference in different racial and ethnic groups? Dis Esophagus 2011;24:18-24. 2. Nelson S, Chen E, Syniar G, Christoffel K. Prevalence of Symptoms of Gastroesophageal Reflux During Infancy: A Pediatric Practice-Based Survey. Arch Pediatr Adolesc Med 1997;151:569-72. 3. Barron JJ, Tan H, Spalding J, Bakst AW, Singer J. Proton pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol Nutr 2007;45:421-7.
Vol. 166, No. 5 meta-analysis was not performed. Most trials found improvement in breastfeeding, though many studies had methodological flaws. Conclusions Frenotomy may improve breastfeeding in infants with tongue-tie. Commentary Ankyloglossia, or tongue-tie, a congenital condition characterized by a short, thickened, or abnormally tight lingual frenulum, affects between 1.7 % and 4.7% of all infants. Feeding difficulties (both breast and bottle) have been reported in up to 44% of infants with tongue-tie due to a variety of reasons including poor latch, nipple trauma, and inability to feed continuously. However, there is still controversy over the effectiveness of frenotomy (releasing the tongue-tie) on improving breastfeeding.1 The review attempts to promote a balanced approach to the problem of tongue-tie and breastfeeding, summarizing what is known from research evidence and making good practice recommendations based on clinical opinion. In a baby with tongue-tie experiencing breastfeeding difficulties, a two-week wait is recommended to see if the feeding problems resolve before frenotomy is performed. The authors suggest that the complications of frenotomy should be minimized by use of a check list, which is a mixture of opinion and recommendations based on evidence. The review is a helpful summary of current evidence, but the underlying problem is that ankyloglossia is a spectrum condition. Clinical effects depend on the insertion of the frenulum and the functional impact of the lingual tethering on the baby’s ability to suck effectively. As the correlation between the appearance of the tongue and the effect on breastfeeding is not strong, a professional experienced in breastfeeding needs to perform a functional assessment of feeding. However, the existing breastfeeding assessment tools each have their own limitations. Further trial evidence is still needed to clarify the best management of the milder cases of tongue-tie.2 Alan Emond, MD, MB BChir(Cantab) University of Bristol Bristol, United Kingdom
Frenotomy may help resolve breastfeeding problems due to tongue-tie Power RF, Murphy JF. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Arch Dis Child. 2014:306211. Question Among babies with clinically significant ankyloglossia (tongue-tie), what is the therapeutic efficacy of frenotomy, compared with no frenotomy, in improving infant feeding? Design Systematic review.
References 1. Messner AH, Lalakea ML, Aby J, Macmahon J, Bari E. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryng Head and Neck Surg 2000;126:36-9. 2. Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed 2014;99:F189-95.
Setting Mostly outpatient clinics. Participants Breastfeeding infants with tongue-tie. Intervention Frenotomy or none/sham. Outcomes Feeding improvement. Main Results A total of 316 infants were enrolled in 5 frenotomy randomized trials. As methodology varied significantly, 1322
Independent predictors identified for developmental dysplasia of the hip Roposch A, Protopapa E, Cortina-Borja M. Weighted Diagnostic Criteria for Developmental Dysplasia of the Hip. J Pediatr. 2014;165:1236-40.
CURRENT BEST EVIDENCE
May 2015 Question Among newborns, what are the independent history and physical exam predictors of developmental dysplasia of the hip (DDH), modeled from simulated scenarios? Design Delphi technique of 26 experts rated the likelihood of DDH among 52 vignettes, employing, in various combinations, the seven most important (by international consensus) history and physical exam DDH diagnostic criteria. Setting Simulated clinical scenarios. Participants 26 board-certified pediatric orthopedic surgeons. Intervention Simulated clinical scenarios. Outcomes Independent predictors of DDH. Main Results Our model identified 4 of 7 criteria as predictive of DDH (P < .001): Ortolani/Barlow test, limited abduction, leg length discrepancy, and first-degree family history of DDH. There was substantial correlation between the probability of DDH predicted by the model and that derived from an independent expert panel (r = 0.73; P < .001). Conclusions Weighted clinical criteria for inferring the likelihood of DDH produced consistent results in the judgment of two separate groups of experts. Commentary DDH with subluxation or dislocation leads to osteoarthritis of the hip. However, the long-term outcome of persisting mild dysplasia is unclear. Risk factor, screening, and intervention studies variably report hips that are dysplastic, subluxated, dislocatable, or dislocated, confusing interpretation. Roposch et al, employing the Delphi technique representing expert opinion, partially agrees with meta-analyses of observational studies reporting risk factors for DDH.1,2 Ortiz-Neira et al (31 studies) reported significant
risk factors included breech presentation, female sex, left hip side, first born, and family history.3 Mode of delivery was nonsignificant. De Hundt (30 studies, 1 494 387 infants) reported risk was increased by breech delivery, female sex, family history of DDH, and abnormal hips at clinical examination.1 Systematic review of universal or targeted ultrasound-screening trials has found no significant reduction in late diagnosed DDH, surgery, or avascular necrosis of the femoral head. Due to the low incidence of late DDH, the analysis was underpowered.3 Universal, but not targeted, ultrasound screening was associated with a significant increase in treatment. Targeted ultrasound may result in similar medical costs overall. Although low-level evidence currently guides screening for DDH, there is now widespread implementation of clinical examination combined with risk-factor-targeted ultrasound screening. David A. Osborn, PhD University of Sydney Sydney, Australia
References 1. de Hundt M, Vlemmix F, Bais JM, Hutton EK, de Groot CJ, Mol BW, et al. Risk factors for developmental dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2012;165:8-17. 2. Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns. Eur J Radiol 2012;81:e344-51. 3. Shorter D, Hong T, Osborn DA. Screening programmes for developmental dysplasia of the hip in newborn infants. Cochrane Database Syst Rev 2011;CD004595.
1323
Urokinase and VATS are equally effective for septated empyema Marhuenda C, Barcelo C, Fuentes I, Guilln G, Cano I, Lopez M, et al. Urokinase Versus VATS for Treatment of Empyema: A Randomized Multicenter Clinical Trial. Pediatrics. 2014;134:e1301-7. Question Among children with septated empyema, what is the therapeutic efficacy of drainage and urokinase compared with video-assisted thoracoscopic surgery (VATS), as measured by post-treatment length of hospital stay (LOS)? Design Randomized, controlled, multicenter study. Setting 6 university hospitals in Spain. Participants Previously healthy children <15 years old with septated empyema. Intervention Drainage and urokinase vs VATS. Primary Outcome Post treatment LOS. Main Results No statistically significant differences were found between drainage and urokinase and VATS in the median postoperative stay (10 vs 9 days). Conclusions Drainage plus urokinase instillation is as effective as VATS for first-line treatment of septated empyema. Commentary All currently available treatment options for childhood empyema are effective and safe, and most children make a complete recovery irrespective of the intervention 1320
received. This has led to inherent center or physician bias in the primary treatment of choice. Marhuenda et al, report that intrapleural urokinase and VATS were equally efficacious as primary treatment options for septated empyema in children. Similarly, previous prospective studies also state clinical equipoise between intrapleural fibrinolytics and VATS.1-3 However, this study did not measure important outcomes such as the amount of pain associated with the intervention, long-term pulmonary function, and exercise tolerance. Nevertheless, being a multicenter trial, perhaps the results from this trial are more extrapolatable—particularly as only patients with effusions in ultrasonographic stages 2 and 3 were included. Although this study further strengthens evidence in favor of intrapleural urokinase as the primary treatment for childhood empyema, a multicenter equivalence study comparing the two interventions, inclusive of outcomes other than hospital stay, will lay the case to rest. Samatha Sonnappa, MD, DCH, PhD UCL Institute of Child Health London, United Kingdom
References 1. Sonnappa S, Cohen G, Owens CM, van Doorn C, Cairns J, Stanojevic S, et al. Comparison of Urokinase and Video-assisted Thoracoscopic
Vol. 166, No. 5 May 2015
Surgery for Treatment of Childhood Empyema. Am J Respir Crit Care Med 2006;174:221-7. 2. St Peter SD, Tsao K, Spilde TL, Keckler SJ, Harrison C, Jackson MA, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009;44:106-11. 3. Cobanoglu U, Sayir F, Bilici S, Melek M. Comparison of the methods of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III empyema: a prospective randomized study. Pediatr Rep 2011;3:e29.
patients.2 In clinical trials where a “no treatment” group is included, it is possible to control for any nonspecific effects of treatment by subtracting changes in the no treatment group from the changes observed in the placebo and treatment groups. Parents and physicians want symptomatic relief of cough associated with upper respiratory tract infections. If a placebo is low cost, has no or minimal adverse effects, and it can reduce unnecessary antibiotic treatment, it appears to be a preferable treatment option.3 Herman A. Cohen, MD Tel Aviv University Tel Aviv, Israel
Demonstration of placebo effect for nonspecific cough medicine Paul IM, Beiler JS, Vallati JR, Duda LM, King TS. Placebo effect in the treatment of acute cough in infants and toddlers: a randomized clinical trial. JAMA Pediatr. 2014;168:1107-13. Question Among children with nonspecific cough, what is the therapeutic efficacy of placebo, compared with no treatment, in reducing cough frequency? Design Randomized, controlled trial. Setting Two university affiliated outpatient clinics in Pennsylvania, US. Participants Infants 2-47 months of age with nonspecific acute cough duration of 7 days or less. Interventions (1) Pasteurized agave nectar; (2) natural grape-flavored water with caramel color (placebo); and (3) no treatment. Primary Efficacy Measure Change in cough frequency between the first night and the end of the second night. Main Results Significant differences in symptom improvement were detected between the study groups, with agave nectar and placebo proving to be superior to no treatment, but no significant differences for any outcome were found when comparing agave nectar against placebo. Conclusions In a comparison of agave nectar, placebo, and no treatment, a placebo effect was demonstrated, with no additional benefit offered by agave nectar. Commentary This high-quality randomized-controlled trial demonstrates that agave nectar and placebo were superior to no treatment in relieving nonspecific cough in children aged 2 to 47 months. However, no significant differences were detected between the agave nectar and placebo groups. Eccles suggests four different effects to antitussive medicine: pharmacological, physiological, true placebo, and nonspecific effects.1 The pharmacological effect is related to the active ingredient of the medicine. The physiological effects can be attributed to physical properties of the medicine such as taste, smell, viscosity, acidity, texture, and temperature. A true placebo effect refers to the psychological therapeutic effect of the treatment, and it depends on the belief in the effectiveness of the treatment and the attitude of the patient towards the therapist. Nonspecific effects included the natural (spontaneous) recovery from the illness. Lee et al also demonstrate that placebo treatment has significant antitussive activity in adult
References 1. Eccles R. Mechanism of the placebo effect of sweet cough syrups. Respir Physiol Neurobiol 2006;152:340-8. 2. Lee P, Jawad M, Hull D, West W, Shaw K, Eccles R. The antitussive effect of placebo treatment on cough associated with acute upper respiratory infection. Psychosom Med 2005;67:314-7. 3. Tylor JA, Opel DJ. Using the placebo effect to treat cold symptoms in children. JAMA Pediatr 2014;168:1091-2.
Limited efficacy of antigastroesophageal reflux medications in children Tighe M, Afzal NA, Bevan A, Hayen A, Munro A, Beattie RM. Pharmacological treatment of children with gastro-oesophageal reflux. Cochrane Database Syst Rev. 2014;11:CD008550. Question Among children with gastroesophageal reflux (GER), what is the therapeutic efficacy of acid suppressant medications, compared with placebo, in resolving signs and symptoms of acid reflux? Design Systematic review. Setting Various inpatient and outpatient settings. Participants Children from birth to 16 years of age with signs and/or symptoms of GER. Intervention Various antireflux medications. Outcomes Improvement in clinical GER signs and/or symptoms. Main Results Based on moderate-level evidence, proton pump inhibitors (PPIs) reduce GER symptoms in children with confirmed erosive esophagitis. Some evidence suggests H2 blockers adequately treat GER symptoms. For both classes of drugs, the effects are only in older children. In infants, moderate evidence indicates that Gaviscon Infant (sodium alginate, magnesium alginate, mannitol; Reckitt-Benckiser Healthcare, Slough, England) improves symptoms. Conclusions In pediatric patients with GER, there is mild to moderate evidence supporting the use of PPIs and H2 antagonists in older children, and Gaviscon Infant in infants. Commentary GER is common among infants and children, with prevalence as high as 30%-67%.1,2 At this frequency of 1321
THE JOURNAL OF PEDIATRICS
www.jpeds.com
disease, it is challenging to establish a causal relationship between symptoms and disease, and as Tighe et al illustrate, it is difficult to demonstrate the efficacy of pharmacologic therapy. In addition, GER has a wide range of symptoms and morbidities. For older children and adolescents with symptoms compatible with GER, especially those with abnormal endoscopies, the evidence establishing the effectiveness of a variety of antacid therapies was modest, limited mostly by methodological concerns. Their smaller numbers and more variable inclusion criteria inherently limit clinical trials in pediatrics. Children with developmental disabilities are at high risk for GER and esophagitis, but this population could not be assessed in this analysis. The crying infant who spits up is an almost daily challenge in pediatric practice. Unfortunately, the evidence that pharmacologic therapy is effective in this age group is weak. The safety profile of many of the commonly used medications, including PPIs, reflects few adverse effects, leading to a “why not just try it” attitude among clinicians. The number of prescriptions written for PPIs in infants has increased significantly.3 This comprehensive analysis of the published literature provides an opportunity to rethink that wisdom. James Berman, MD University of Illinois at Chicago Chicago, Illinois
References 1. Gunasekaran TS, Dahlberg M. Prevalence of gastroesophageal reflux symptoms in adolescents: is there a difference in different racial and ethnic groups? Dis Esophagus 2011;24:18-24. 2. Nelson S, Chen E, Syniar G, Christoffel K. Prevalence of Symptoms of Gastroesophageal Reflux During Infancy: A Pediatric Practice-Based Survey. Arch Pediatr Adolesc Med 1997;151:569-72. 3. Barron JJ, Tan H, Spalding J, Bakst AW, Singer J. Proton pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol Nutr 2007;45:421-7.
Vol. 166, No. 5 meta-analysis was not performed. Most trials found improvement in breastfeeding, though many studies had methodological flaws. Conclusions Frenotomy may improve breastfeeding in infants with tongue-tie. Commentary Ankyloglossia, or tongue-tie, a congenital condition characterized by a short, thickened, or abnormally tight lingual frenulum, affects between 1.7 % and 4.7% of all infants. Feeding difficulties (both breast and bottle) have been reported in up to 44% of infants with tongue-tie due to a variety of reasons including poor latch, nipple trauma, and inability to feed continuously. However, there is still controversy over the effectiveness of frenotomy (releasing the tongue-tie) on improving breastfeeding.1 The review attempts to promote a balanced approach to the problem of tongue-tie and breastfeeding, summarizing what is known from research evidence and making good practice recommendations based on clinical opinion. In a baby with tongue-tie experiencing breastfeeding difficulties, a two-week wait is recommended to see if the feeding problems resolve before frenotomy is performed. The authors suggest that the complications of frenotomy should be minimized by use of a check list, which is a mixture of opinion and recommendations based on evidence. The review is a helpful summary of current evidence, but the underlying problem is that ankyloglossia is a spectrum condition. Clinical effects depend on the insertion of the frenulum and the functional impact of the lingual tethering on the baby’s ability to suck effectively. As the correlation between the appearance of the tongue and the effect on breastfeeding is not strong, a professional experienced in breastfeeding needs to perform a functional assessment of feeding. However, the existing breastfeeding assessment tools each have their own limitations. Further trial evidence is still needed to clarify the best management of the milder cases of tongue-tie.2 Alan Emond, MD, MB BChir(Cantab) University of Bristol Bristol, United Kingdom
Frenotomy may help resolve breastfeeding problems due to tongue-tie Power RF, Murphy JF. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Arch Dis Child. 2014:306211. Question Among babies with clinically significant ankyloglossia (tongue-tie), what is the therapeutic efficacy of frenotomy, compared with no frenotomy, in improving infant feeding? Design Systematic review.
References 1. Messner AH, Lalakea ML, Aby J, Macmahon J, Bari E. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryng Head and Neck Surg 2000;126:36-9. 2. Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed 2014;99:F189-95.
Setting Mostly outpatient clinics. Participants Breastfeeding infants with tongue-tie. Intervention Frenotomy or none/sham. Outcomes Feeding improvement. Main Results A total of 316 infants were enrolled in 5 frenotomy randomized trials. As methodology varied significantly, 1322
Independent predictors identified for developmental dysplasia of the hip Roposch A, Protopapa E, Cortina-Borja M. Weighted Diagnostic Criteria for Developmental Dysplasia of the Hip. J Pediatr. 2014;165:1236-40.
CURRENT BEST EVIDENCE
May 2015 Question Among newborns, what are the independent history and physical exam predictors of developmental dysplasia of the hip (DDH), modeled from simulated scenarios? Design Delphi technique of 26 experts rated the likelihood of DDH among 52 vignettes, employing, in various combinations, the seven most important (by international consensus) history and physical exam DDH diagnostic criteria. Setting Simulated clinical scenarios. Participants 26 board-certified pediatric orthopedic surgeons. Intervention Simulated clinical scenarios. Outcomes Independent predictors of DDH. Main Results Our model identified 4 of 7 criteria as predictive of DDH (P < .001): Ortolani/Barlow test, limited abduction, leg length discrepancy, and first-degree family history of DDH. There was substantial correlation between the probability of DDH predicted by the model and that derived from an independent expert panel (r = 0.73; P < .001). Conclusions Weighted clinical criteria for inferring the likelihood of DDH produced consistent results in the judgment of two separate groups of experts. Commentary DDH with subluxation or dislocation leads to osteoarthritis of the hip. However, the long-term outcome of persisting mild dysplasia is unclear. Risk factor, screening, and intervention studies variably report hips that are dysplastic, subluxated, dislocatable, or dislocated, confusing interpretation. Roposch et al, employing the Delphi technique representing expert opinion, partially agrees with meta-analyses of observational studies reporting risk factors for DDH.1,2 Ortiz-Neira et al (31 studies) reported significant
risk factors included breech presentation, female sex, left hip side, first born, and family history.3 Mode of delivery was nonsignificant. De Hundt (30 studies, 1 494 387 infants) reported risk was increased by breech delivery, female sex, family history of DDH, and abnormal hips at clinical examination.1 Systematic review of universal or targeted ultrasound-screening trials has found no significant reduction in late diagnosed DDH, surgery, or avascular necrosis of the femoral head. Due to the low incidence of late DDH, the analysis was underpowered.3 Universal, but not targeted, ultrasound screening was associated with a significant increase in treatment. Targeted ultrasound may result in similar medical costs overall. Although low-level evidence currently guides screening for DDH, there is now widespread implementation of clinical examination combined with risk-factor-targeted ultrasound screening. David A. Osborn, PhD University of Sydney Sydney, Australia
References 1. de Hundt M, Vlemmix F, Bais JM, Hutton EK, de Groot CJ, Mol BW, et al. Risk factors for developmental dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2012;165:8-17. 2. Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns. Eur J Radiol 2012;81:e344-51. 3. Shorter D, Hong T, Osborn DA. Screening programmes for developmental dysplasia of the hip in newborn infants. Cochrane Database Syst Rev 2011;CD004595.
1323