Top Papers of the Month

3 Top Papers You May Have Missed in March 2022

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. 3 top papers you may have missed in March 2022. Consultant360. Published online April 14, 2022.

As we enjoy a lull in the incidence of COVID-19 infections, here are some articles to help you hone your practice of preventative pediatrics. This month, I highlight articles that discuss screening adolescents for eating disorders, guidelines for placement of tympanostomy tubes, and considerations for expanding newborn metabolic screening. I hope you find these articles relevant and interesting.

Please feel free to share with your colleagues, discuss in your offices, and write to editor@consultant360.com with your thoughts and opinions.

Screening for Eating Disorders1-4

This systematic review and recommendation from the United States Preventive Services Taskforce (USPSTF) is the first that I have read evaluating screening healthy adolescents and adults for eating disorders. The prevalence of eating disorders in the United States is as high as 2% of adolescent females and 1% of adolescent males. As the medical and psychosocial complications of eating disorders can be substantial, screening for eating disorders in healthy adolescents might be an opportunity to identify and intervene early in a potentially serious disease.

The systematic review identifies 1 screening instrument, the SCOFF questionnaire, with adequate sensitivity and specificity in adult females but no sufficiently validated screens for adolescents or for adult males. There is inadequate evidence of the benefits of early detection of eating disorders or of interventions that improve outcomes in any of these populations. The USPSTF concludes that evidence is, at present, inadequate to make a recommendation on screening for eating disorders in otherwise healthy patients and that more research in these areas is needed.

In its 2021 policy statement on Identification and Management of Eating Disorders in Children and Adolescents (cited in 3 Top Papers You Missed in January 2021) the American Academy of Pediatrics (AAP) recommends asking all adolescents questions regarding eating patterns and body image as part of an annual well examination. The AAP further recommends paying close attention to growth and weight parameters and pursuing more extensive questioning when vital signs, weight, or physical examination abnormalities are detected. I have personally identified several adolescents with significant eating disorders by noting an unexpectedly low resting heart rate, even at sick visits, and asking further probing questions. In the absence of sufficient evidence, I will continue to pay careful attention to growth curves, heart rate, and body image questions and await the opportunity for a well-validated screening instrument that might be used during well examinations.

Tympanostomy Tubes in Children5

This guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides an update to its previous statement from 2013 on evidence-based recommendations for placement and management of tympanostomy tubes in children. The following are indications for the placement of tubes:

  1. Bilateral otitis media with effusion (OME) of at least 3 months' duration with documented hearing loss
  2. Bilateral OME of at least 3 months' duration with symptoms attributed to fluid in the middle ear space
  3. Recurrent acute otitis media (AOM) with the presence of OME at time of ear, nose, and throat (ENT) assessment
  4. Recurrent AOM or OME of any duration in a patient at risk for speech or learning difficulties
  5. Unilateral or bilateral OME of at least 3 months' duration that is likely to persist in an at-risk patient

The following are not indications for placement of tubes:

  1.  OME of less than 3 months duration
  2.  Acute or recurrent AOM without OME at the time of evaluation

In addition, the guideline recommends topical antibiotics for the treatment of tympanostomy tube otorrhea, periodic ENT follow-up for children with OME or tube placement, and not using water precautions in children with tubes.

In my experience, placement of pressure equalizer (PE) tubes has usually reduced the frequency of symptomatic ear infections and improved hearing and speech development in children with persistent middle ear effusion. The risk of anesthesia and of acute complications is not high. However, many of my patients with tubes have experienced chronic scarring, some have had chronic non-healing perforations, and a few have developed permanent hearing loss from complications of cholesteatomas. It is the risk of these long-term complications that tempers my enthusiasm for tube placement and makes me follow the recommendations as written above in the otolaryngology guidelines.

Krabbe Disease Newborn Screening6

And finally, a shameless plug: this month, my wife, who is a geneticist and pediatrician, had her first paper that was accepted for publication in Pediatrics.

In teaching medical students and residents, I frequently emphasize the concept, "just because you can order a test does not mean that you should." My wife is a member of the Virginia Newborn Screening Advisory Committee that voted, despite political and family pressure, not to add Krabbe disease (KD) to the diseases screened for on the Virginia Newborn Screening Program (NBS). In this article, she details the scientific and practical considerations that led to the recommendation against screening. She discusses the experience in New York, which has the most data on Krabbe screening, documents family responses in appealing to the Virginia legislature to pass a law mandating screening, and reveals the ultimate resolution of the issue.

She writes, "In Virginia, among the various equity and ethical challenges identified, the most significant would be if a family were to receive a heartbreaking positive KD NBS result, only to learn that because of insurance or other logistical barriers, treatment is unavailable or too late. At present, Virginia is unable to meet the rapid turnaround time and lacks the capacity to use psychosine levels (PSY) to identify an infant with early-infantile Krabbe disease (EIKD) and have diagnostic confirmation to receive stem-cell transplantation within the recommended 30 days of life."

What happened? Did the committee or the legislature prevail? You might just need to read to find out.

Hope you have a great month!

Scott

References:

  1. Davidson KW, Barry MJ, Mangione CM, et al; US Preventive Services Task Force. Screening for eating disorders in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2022;327(11):1061-1067. doi:10.1001/jama.2022.1806
  2. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999; 319:1467. doi:10.1136/bmj.319.7223.1467
  3. Vergano ST. 3 top papers you missed in January 2021. Consultant360. Published online: February 3, 2021.
  4. Hornberger LL, Lane MA, the Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279. doi:10.1542/peds.2020-040279
  5. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Executive summary of clinical practice guideline on tympanostomy tubes in children (update). Otolaryngol Head Neck Surg. 2022;166(2):189-206. doi:10.1177/01945998211065661
  6. Schrier Vergano SA, Kanungo S, Arnold G. Making decisions about Krabbe disease newborn screening. Pediatrics. 2022;149(4):e2021053175. doi:10.1542/peds.2021-053175