Pediatric resident and faculty knowledge of the Denver II.

OBJECTIVE: To assess knowledge of the Denver II, the revised developmental screening tool recommended by the American Academy of Pediatrics, in residents and faculty, and to evaluate a teaching intervention for incoming postgraduate year 1 (PGY-1) trainees. DESIGN: A cross-sectional test of knowledge for all subjects and pretesting and posttesting of the incoming PGY- 1 trainees. SETTING: University of Texas-Houston Medical School Department of Pediatrics. PARTICIPANTS: Faculty (n = 9) and residents (n = 78), including an intervention group (n = 45), of incoming PGY-1 trainees over 2 years. INTERVENTIONS: Postgraduate year 1 trainees in both 1994 through 1995 and 1995 through 1996 viewed the Denver II training videotape on entry into a continuity clinic. Trainees were encouraged to perform Denver II evaluations on at least 1 appropriate patient at each pediatric clinic session and had access to Denver II support materials. MAIN OUTCOME MEASURES: Scores on the Denver II Proficiency Written Test, self-reported measures of comfort, and number of Denver II evaluations performed. RESULTS: The mean (SD) test scores for incoming, preintervention PGY-1 trainees (n = 45) (41.3 [9.6]) did not differ from scores for outgoing PGY-1 trainees (n = 13) (38.5 [10.4]) who had not received the intervention. Postintervention PGY-1 test results were significantly improved (59.4 [10.6]) (P<.001). Test scores for upper-level residents who had participated in the developmental pediatrics rotation (n = 14) were better (55.3 [9.31), but all scored below passing. Residents who had not yet participated in the developmental pediatrics rotation (n = 19) and members of the general pediatric faculty (n = 9) had scores similar to those of PGY-1 trainees (40.9 [13.4] and 39.0 [15.1], respectively). CONCLUSIONS: Residents had a greater knowledge of the Denver II after completing a developmental pediatrics rotation. Our intervention produced significant improvement in PGY-1 trainees' knowledge, raising it to levels similar to those of upper-level residents exposed to developmental pediatrics. Faculty were not expert in using the Denver II.

Accuracy of clinical judgment in neonatal jaundice.

CONTEXT: Recommendations for management of jaundice in newborns presume thatjaundice is a reliable clinical finding and that the pattern and intensity of jaundice reflects the degree of elevation of the serum bilirubin level. OBJECTIVES: To determine whether experienced observers agree in describing the extent of jaundice and to evaluate the reliability of visual assessment as an indication for the measurement of serum bilirubin levels. DESIGN: Comparison of independent judgments of the extent of jaundice between examiners and with actual serum bilirubin measurements. SETTING: Well-newborn nursery in an urban public hospital. PARTICIPANTS: A convenience sample of 122 healthy term newborns whose bilirubin concentration was measured in the course of standard newborn care. Observers were experienced pediatric nurse practitioners, pediatric house staff, and pediatric attending physicians. RESULTS: Agreement was moderately good for whether an infant's skin was darkly pigmented (K = 0.56). However, agreement between observers regarding the presence of jaundice at each specific body site was poor (0%-23% agreement beyond chance); correlation between estimated bilirubin concentrations was similarly poor (Pearson correlation coefficient, 0.37). Correlation between estimated and actual bilirubin values was slightly better (Pearson correlation coefficient, 0.43-0.54). CONCLUSIONS: Clinical examination with visual assessment for jaundice in newborns is neither reliable nor accurate. The decision to perform serum bilirubin testing should be based on additional factors.

Contribution of long-bone radiographs to the management of congenital syphilis in the newborn infant.

OBJECTIVE: To determine the contribution of long-bone radiographs to the diagnosis and management of newborn infants at risk for congenital syphilis. DESIGN: Historical cohort. SETTING: Three large hospitals in Houston, Tex. PATIENTS: Eight hundred fifty-three live born infants who were evaluated for the presence of congenital syphilis. INTERVENTION: Long-bone radiographs done as part of the diagnostic evaluation for the presence of congenital syphilis. MAIN OUTCOME MEASURE: Changes in diagnostic classification or management decisions that were based on radiographic findings in the long bones. RESULTS: For 450 infants, radiographic results did not affect management because clinical or historical factors were present that dictated treatment: 26 infants had clinical symptoms of congenital syphilis (65% [17] had abnormalities on radiographs); and 424 infants were born to mothers who were untreated or reinfected (5.9% [25] had abnormalities on radiographs). All of these infants required a full course of therapy regardless of radiologic findings. Born to mothers with possibly inadequate therapy (according to 1993 Centers for Disease Control and Prevention guidelines), 237 asymptomatic newborn infants were candidates for a single injection of penicillin G benzathine if the results of their evaluations were normal; of these, 2 (0.8%) had abnormal radiographic findings. Of the 166 infants born to adequately treated mothers with appropriately falling serologic titer levels, 1 (0.6%) had abnormal radiographic findings (P=.99 between groups). The results of the long-bone radiographs did not alter management for any of the 853 infants who were evaluated for congenital syphilis. CONCLUSIONS: Long-bone radiographic findings, often abnormal in symptomatic infants, do not differentiate between active infection and past infection. The use of long-bone radiographs should be reconsidered in the routine evaluation of infants for congenital syphilis.

Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children.

BACKGROUND: The optimal duration of oral antibiotic therapy for urinary tract infection (UTI) in children has not been determined. A number of studies have compared single dose therapy to standard therapy for UTI, with mixed results. A course of antibiotics longer than a single dose but shorter than the usual 7-10 days might decrease the relapse rate and still provide some of the benefits of a shortened course of antibiotics. OBJECTIVES: The objective of this review was to assess the benefits and harms of short-course (2-4 days) compared to standard duration (7-14 days) oral antibiotic treatment for acute UTI in children. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Cochrane Library Issue 3, 2002) MEDLINE (1966 - September 2002) and EMBASE (1988 -September 2002) without language restriction. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing short-term (2-4 days) with standard (7-14 days) oral antibiotic therapy were selected if they studied children aged three months to 18 years with culture proven UTI. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (95% CI). MAIN RESULTS: Ten trials were identified in which 652 children with lower tract UTI were evaluated. There was no significant difference in the frequency of positive urine cultures between the short (2-4 days) and standard duration oral antibiotic therapy (7-14 days) for UTI in children at 0-10 days after treatment (eight studies: RR 1.06; 95% CI 0.64 to 1.76) and at one to 15 months after treatment (10 studies: RR 0.95; 95% CI 0.70 to 1.29). There was no significant difference between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment (one study: RR 0.57, 95% CI 0.32 to 1.01) or in recurrent UTI (three studies: RR 0.39, 95% CI 0.12 to 1.29). REVIEWER'S CONCLUSIONS: A 2-4 day course of oral antibiotics appears to be as effective as 7-14 days in eradicating lower tract UTI in children.

Evidence syntheses in child health.

Evidence syntheses, also known as systematic reviews, differ from traditional reviews in that they are scientific evaluations of existing studies. Systematic reviews have explicit and reproducible methods and, as with any other scientific endeavor, the result of an evidence synthesis or systematic review can be critically appraised. Many sources for high-quality evidence syntheses now exist, with considerable support from government agencies to develop both the methods and the products of such reviews. Evidence syntheses can increase the efficiency and effectiveness of medical practice but face many hurdles, particularly in child health. These center around 4 areas: lack of high-quality primary studies, the difficulty of finding studies that do exist, the variability and usefulness of the outcome measures in child health, and problems with production and dissemination. Increasing attention to the need for high-quality child health research will help to ameliorate some of these issues, whereas solutions to others are under development or remain elusive.

Hepatitis B screening in pregnancy: practical aspects.

Hepatitis B may be acquired at birth from a mother who is a chronic carrier and may result in debilitating liver disease later in life. Screening of pregnant women and preventive measures have been shown to be clinically effective and at least marginally cost-effective. The Centers for Disease Control recommends universal screening of pregnant women. Cost-effectiveness has been evaluated using estimated costs and assuming patient compliance. The practical aspects of screening a high-risk population are described in the context of a single program, with discussion of excess costs and problems with implementation.

Evaluation of a lead screening program in Houston, Tex.

Universal screening for childhood lead poisoning is widely debated. Our purpose was to compare screening results at three pediatric clinics within Houston and to evaluate the effectiveness of screening according to published criteria. The clinics were chosen for their geographic and socioeconomic diversity. Children between 6 months and 6 years of age were tested, and the results were classified according to current guidelines. We screened 864 children. Results between sites were significantly different, P = 0.002. No children with blood lead levels greater than 0.45 mumol/L (9 micrograms/dL) were identified at Clinic C compared to 76 (8.8%) from Clinics A and B, but no site had children with levels greater than or equal to 2.20 mumol/L (45 micrograms/dL). The prevalence of childhood lead poisoning can vary even within the city. If regional screening is to replace universal screening, statewide as well as citywide data are needed to identify high-risk areas. This could be done by clinic site, zip code, or census track data with a minimum of 3000 children.

Evidence-based paediatrics.

Evidence-based medicine is practised widely in some specialties and is now part of many undergraduate and graduate medical curricula. However, the extent to which it is used in clinical paediatric practice is not known and its expansion remains a major challenge. Access to technology which facilitates literature searching, and development of journals addressing specific paediatric problems, will encourage the use of evidence-based medicine by the busy paediatrician. Informed practice of evidence-based medicine will ensure that clinical expertise is complemented by a thorough search, evaluation and judicious application of relevant information from the medical literature.

Total and differential leukocyte counts in clinically well children. Information or misinformation?

To determine whether the total and differential leukocyte count is of value as a case-finding test, we applied the evaluation criteria developed by the US Preventive Services Task Force. The criteria comprise review of the current burden of suffering of the disease to be prevented, the attributes of the intervention to be used, and the quality of the evidence available. A literature search revealed no evidence in the form of data from patients, so a chart review of all complete blood cell counts ordered during a 1-year period by one group of pediatricians was undertaken. At least one value outside of published normal ranges was found on 74.7% of the tests performed on clinically well children. No unsuspected illness was discovered as a result of an abnormal total and differential leukocyte count.

Is the practice of paediatric inpatient medicine evidence-based?

OBJECTIVE: To determine whether management provided to paediatric inpatients in general units was supported by high-level evidence. METHODS: A retrospective review was carried out of all patients (n = 142) admitted during one calendar month to two general paediatric units in the USA and Australia. For each patient, the primary diagnosis and primary treatment were determined. A literature review was performed to determine whether the therapy used was evidence-based. The main outcome measure was the level of evidence supporting the primary intervention for the primary diagnosis of each patient. RESULTS: Level I evidence (at least one randomized trial) supported the primary intervention used in 31% of paediatric admissions and level II evidence (convincing non-experimental evidence) supported the primary intervention in 44% of admissions. Primary interventions were not supported by evidence (level III) in only two patients. The remaining 24% of patients were admitted for observation or evaluation only, and received no primary medical or surgical intervention. Most patients whose interventions were supported by randomized trials were admitted with either asthma or appendicitis. CONCLUSIONS: Most primary interventions (75%) in paediatric inpatients were supported by high-level published evidence (level I or II). A large number of patients were admitted for evaluation or observation only, and received no therapeutic intervention. Evidence to support this action is not available.

Short compared with standard duration of antibiotic treatment for urinary tract infection: a systematic review of randomised controlled trials.

AIMS: To compare the effectiveness of short course (2-4 days) with standard duration oral antibiotic treatment (7-14 days) for urinary tract infection (UTI). METHODS: Meta-analysis of randomised controlled trials using a random effects model. Ten trials were eligible, involving 652 children with lower tract UTI recruited from outpatient or emergency departments. Main outcome measures were UTI at the end of treatment, UTI during follow up (recurrent UTI), and urinary pathogens resistant to the treating antibiotic. RESULTS: There was no significant difference in the frequency of positive urine cultures between the short (2-4 days) and standard duration therapy (7-14 days) for UTI in children at 0-7 days after treatment (eight studies: RR 1.06; 95% CI 0.64 to 1.76) and at 10 days to 15 months after treatment (10 studies: RR 1.01; 95% CI 0.77 to 1.33). There was no significant difference between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment (one study: RR 0.57, 95% CI 0.32 to 1.01) or in recurrent UTI (three studies: RR 0.39, 95% CI 0.12 to 1.29). CONCLUSION: A 2-4 day course of oral antibiotics is as effective as 7-14 days in eradicating lower tract UTI in children.

Users' guides to the medical literature: XXIV. How to use an article on the clinical manifestations of disease. Evidence-Based Medicine Working Group.

Clinicians rely on knowledge about the clinical manifestations of disease to make clinical diagnoses. Before using research on the frequency of clinical features found in patients with a disease, clinicians should appraise the evidence for its validity, results, and applicability. For validity, 4 issues are important-how the diagnoses were verified, how the study sample relates to all patients with the disease, how the clinical findings were sought, and how the clinical findings were characterized. Ideally, investigators will verify the presence of disease in study patients using credible criteria that are independent of the clinical manifestations under study. Also, ideally the study patients will represent the full spectrum of the disease, undergo a thorough and consistent search for clinical findings, and these findings will be well characterized in nature and timing. The main results of these studies are expressed as the number and percentages of patients with each manifestation. Confidence intervals can describe the precision of these frequencies. Most clinical findings occur with only intermediate frequency, and since these frequencies are equivalent to diagnostic sensitivities, this means that the absence of a single finding is rarely powerful enough to exclude the disease. Before acting on the evidence, clinicians should consider whether it applies to their own patients and whether it has been superseded by new developments. Detailed knowledge of the clinical manifestations of disease should increase clinicians' ability to raise diagnostic hypotheses, select differential diagnoses, and verify final diagnoses. JAMA. 2000;284:869-875