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Top Papers of the Month

Top Papers You May Have Missed in October 2022

11/30/2022

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

CITATION:
Vergano ST. Top papers you may have missed in October 2022. Consultant360. Published online November 7, 2022.

As of this writing (early November 2022), pediatricians around the United States are treating an outbreak of pediatric respiratory viral illnesses. I appreciate pediatricians taking the time during this outbreak to read about intriguing publications from the past month. In addition to new recommendations on screening for anxiety and firearm safety, I have included an article relevant to the current surge of bronchiolitis admissions. As always, please feel free to send your impressions and thoughts to us at editors@consultant360.com. Thank you for all you do in caring for our sick children!

Screening for Anxiety in Children and Adolescents1

This new recommendation from the United States Preventive Services Task Force (USPSTF) addresses screening children and adolescents for anxiety disorders, a topic not previously evaluated by the group. The targeted population is healthy pediatric patients without symptoms of anxiety or previously diagnosed anxiety disorders. After systematically examining the availability and accuracy of screening tests and the potential benefits and harms of early detection and treatment, the task force concluded that screening for anxiety disorders is recommended for healthy children and adolescents between 8 and 18 years of age.

Anxiety disorders are prevalent within the pediatric population, with one recent study finding that 7.8% of US children have current anxiety disorders.2. Although few medications are FDA approved to treat anxiety in this age group, both research studies and my own personal experience support the efficacy of cognitive-behavioral therapy and selective serotonin reuptake inhibitors in the treatment of anxiety disorders in these patients. The review also finds efficacy for a combination of both psychotherapy and medications, as well as for collaborative care, a team-based approach between the primary care clinician and the mental health team. Given the potential benefits to early detection and intervention, the USPSTF concludes that there is a moderate net benefit to screening children between 8 and 18 years of age, although the frequency of screening is not specified.

I am not certain that I will be implementing the recommendation for anxiety screening in my patients. The technical report accompanying the statement provides details about the literature on screening instruments.3 It offers support for two commonly used questionnaires, the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the Social Phobia Inventory (SPIN). It seems to me that both have limitations. Although the SCARED has proven useful to me in the diagnosis and follow-up of my patients with anxiety disorders, I participated in a trial testing its use as a screener. My experience was that it was cumbersome as a screening instrument, difficult for families, and consistently disliked by the nurses in the office who needed to input its results (we had access to electronic scoring but only paper versions of the questionnaires). The SPIN seems a reasonable screen for social phobia but not for anxiety disorders more broadly. Finally, the technical statement reports that public comment advocated for other screeners (such as the Pediatric Symptom Checklist), but the group was unable to find good studies using these as screening tools for pediatric anxiety disorders. I am interested to hear your thoughts!

Firearm-Related Injuries and Deaths in Children and Youth4

In its policy statement published in Pediatrics this month, the American Academy of Pediatrics (AAP) updates its approach to firearm-related injuries and deaths. In a strategy analogous to motor vehicle-related injuries and deaths, the AAP proposes intense efforts on harm reduction. Harm reduction entails the idea that if we cannot eliminate all firearms (just as we cannot eliminate cars), we should focus on minimizing the chances that children and adolescents can be injured or killed by them. The major risks highlighted in the statement include accidental injuries in younger children and suicides and homicides in adolescents and young adults.

Harm-reduction strategies include interventions at the clinician, community, legislative, and research levels. For individual practitioners, discussions related to safe storage of firearms, risks of firearm injuries within the home, and use of firearms as a means of self-harm should be addressed with families at well visits. For community advocates, implementation of community-based violence prevention programs and hospital-based violence intervention programs are important strategies to decrease the alarming increase of firearm-related injuries. Legislative action and firearm-related research remain critical in the public health response to this crisis.

According to the policy, reasonable recommendations for anticipatory guidance should focus on the safe storage of firearms and ammunition. Although it can be challenging, the AAP encourages a non-judgmental and non-political approach to anticipatory guidance. It offers model language for such a discussion, suggesting a statement like: "Having a loaded or unlocked gun in your house increases the risk of injury or death to all family members, including children, whether by accident or on purpose. I urge you to store your unloaded guns in a locked box or safe, separate from the locked ammunition, and out of the reach of children."

And finally, this article from September, which has taken on new importance given the surge of hospital admissions for bronchiolitis this month:

Home Care for Bronchiolitis5

This systematic review, published in the September issue of Pediatrics, examines the feasibility, acceptability, safety, and cost of home care for infants with bronchiolitis. After reviewing 1312 studies, the authors identify 10 that meet inclusion criteria. They note that indications for bronchiolitis hospitalization include hypoxia, dehydration, and observation for clinical deterioration. Potential home interventions for these infants include home oxygen therapy, home enteral feeding, and remote monitoring. Of the 10 studies included in the review, all 10 examined home oxygen therapy.

Noting that hypoxia is more likely at higher elevations than at sea level, the authors find that seven of their 10 studies examined home oxygen therapy at high altitudes. They conclude that evidence suggests home oxygen therapy at high altitude is feasible, acceptable, and safe. However, they find insufficient evidence to form conclusions on home oxygen therapy at sea level. None of the studies in their review addresses home enteral feeding or remote monitoring. Of the 1257 individual patients included in the 10 studies, three required admission to a pediatric intensive care unit, one required intubation, and no infants died.

Some of the studies in the review discharged patients home directly from the Emergency Department, others after a brief observation hospitalization, and the rest after a longer hospitalization that still required oxygen therapy. If the safety and feasibility of home oxygen therapy could be more thoroughly assured, we could change the standard of care for some of the infants who are less sick and admitted with bronchiolitis and potentially alleviate the stresses on hospital resources during seasonal respiratory syncytial virus outbreaks, such as those occurring now in the United States.

References:

  1. Mangione CM, Barry MJ, Nicholson WK, et al; US Preventive Services Task Force. Screening for anxiety in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(14):1438-1444. doi:10.1001/jama.2022.16936
  2. National survey of children’s health. United States Census Bureau. September 26, 2022. Accessed November 10, 2022. https://www.census.gov/programs-surveys/nsch.html
  3. Viswanathan M, Wallace IF, Cook Middleton J, et al. Screening for anxiety in children and adolescents: evidence report and systematic review for the US preventive services task force. JAMA. 2022;328(14):1445-1455. doi:10.1001/jama.2022.16303
  4. Lee LK, Fleegler EW, Goyal MK, et al; injury violence and poison prevention co. Firearm-related injuries and deaths in children and youth: injury prevention and harm reduction. Pediatrics. 2022. doi:10.1542/peds.2022-060070
  5. Lawrence J, Walpola R, Boyce SL, Bryant PA, Sharma A, Hiscock H. Home care for bronchiolitis: a systematic review. Pediatrics. 2022;150(4):e2022056603. doi10.1542/peds.2022-056603