Does oral aciclovir improve clinical outcome in immunocompetent children with primary herpes simplex gingivostomatitis?

A 3 year old previously well boy presents with a fever of 38.6ºc and several ulcers and erosions extending from his lips, along the tongue and cheek, to the back of the throat. The lesions have all appeared within the last 2 days. He has been crying inconsolably over the past 24 hours and is refusing food and drink. Is the use of oral aciclovir is indicated for primary herpes gingivostomatitis in children?

The question has been posed by a team from University Hospital of Wales, in Cardiff. It’s my belief that aciclovir works (based on clinical experience in children with malignant disease) – but the question of ‘is it indicated’ asks more than just ‘does it work’ but ‘should we use it’?

Any views out there?

(You can review the evidence in the report here.)

Acknowledgement:

Image from Wikipedia

A 13 year old boy with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) comes to the clinic with his mother for a review. He was started on atomoxetine 6 weeks prior to this visit for hyperactive/impulsive symptoms and poor concentration. The boy was admitted in the hospital one week ago for changed behaviour, disorientation, irrelevant speech and self-harming behaviour. He was reported as very aggressive and hostile towards other children and adults. In past use of stimulant medication was not considered because of the risk of abuse and drug diversion. Mother correlates this hospitalization due to side effect of atomoxetine. She asks your opinion about increased aggression and hostility related to atomoxetine .

There’s an answer now available … look here

Report by

Somnath Banerjee Associate Specialist in Community Paediatrics, School & Child Health, Ramsgate, Kent.

Hani F Ayyash Consultant Paediatrician, Doncaster Royal Infirmary, Doncaster, South
Yorkshire.

Ahmed Shakir Mohammed F2, Queen Elizabeth the Queen Mother Hospital Margate Kent.

A 7-year-old boy was referred for medical assessment as part of the process of producing a statement of special educational needs. There had been no medical concerns in the past and there was no family history of note. On examination, the boy was noted to be micro cephalic with head circumference on the 0.4^th centile, while his height and weight were on the 50^th centile. Neurological examination was normal. Should this boy be referred for an MRI scan of the brain?

Oh dear, I think I’m turning into a radiologist. “And what …” my mind is crying “will you do differently after I scan your child?” Perhaps I had to visit too many small dark rooms when I was a House Officer (*).

[Edit - May 2008]

Well, there is an answer of sorts … The summary of the literature surrounding this (by Dr Ambika Karthikeyan) found only three papers, all of poor quality, and none of them suggested any useful yield of diagnostic information. Unless we have a specific indication for scanning (or a study is conceived and open in your centre) then “no” to MRI seems like the right answer.

Acknowledgement
Image from Wikipedia

* – House Officer. {Archaic} Pre 2000 AD, an almost-qualified doctor who assessed patients, initiated investigations and formulated clinical management plans.

A 5 year old boy was admitted to a rural New Zealand hospital with 10 day history of abdominal pain. The pain was localised to the RIF with guarding and examination revealed a palpable mass in the RIF. He had previously presented with a 1 day history of severe abdominal pain and fever and had been discharged the following day with a diagnosis of gastroenteritis. He was transferred to the tertiary hospital and a diagnosis was made on ultrasound scan of appendiceal mass with abscess. His condition was stable. He was commenced on conservative management and supportive care with intravenous (iv) antibiotics followed by a 2 week course of oral antibiotics. He responded well to conservative management and was scheduled for appendectomy after an interval of 6-8 weeks. You wonder whether it is necessary, now he is well, for him to have an appendectomy.

Is it reasonable to leave someone with an appendix just ready to become inflamed again? Or should the poor little thing be left alone, rather than expose the peritoneum to the risks of the open air and a surgeon’s gloves?

Mark Fisher and Maud Meates-Dennis from University of Otago, Christchurch have decided to look for an answer…

… and they found one – it’s online here

During a routine clinic follow-up, a patient with an indwelling ventriculo-peritoneal shunt enquires whether prophylactic antibiotics are necessary prior to routine dental hygiene work. He produces a letter from his dentist enquiring the same.

Dr Max Nathan of Morriston Hospital, Swansea, UK has had this happen … has it happened to you? And what did you do?

(I think it raises some interesting questions – how much do we need to worry vs how much do we need to know about ‘something’ before we act? If you already advise to take, what would it take to stop you? If you advise to avoid, how much data would you need to change your mind?)

[Edit - 27 March 2008]

Since first posting,  in February, the BNF committee has produced new guidance highlighting the ineffectiveness of antibacterial prophylaxis for preventing bacterial endocarditis. This accords with the findings of Dr Nathan and colleagues.

A 3 year old boy presents to the Emergency Department with a limp. He has been reluctant to weight bear on his right leg during the day and has a temperature of 37.9°C. Hip examination is painful. What clinical or laboratory tests could help discriminate between septic arthritis and transient synovitis?

Of course, you could just ring up orthopaedics and ask them to take him to theatre and wash out the hip – but you may not win many friends that way. How do you decide there is enough ‘clinical suspicion’ to make the call?

Well, you’re fortunate to have a team of orthopaedic surgeon and paediatrician have answered this question for you. [EDIT - Jan 2009]

If you can’t wait for their answer, you might want to post your own here though … [EDIT - Jan 2009] Or now you can read their thoughts here

(Image from the files of the Royal College of Surgeons, Edinburgh)

Length of stay for ‘well’ near term (30-36 week gestation) babies varies between units and between countries, with the UK average being discharge at 36+2 weeks corrected. What strategies are in place in your unit to help these ‘small but well’ babies get out of precious neonatal cots into their own lovingly decorated cribs at home? And more to the Archimedes point – is there any evidence these interventions work?

The team at Northwick Park have both reviewed their own practice and the evidence that underlies it here; what do you think of their answers?

Authors:

Nivedita Bajaj, Richard Nicholl; Neonatal Unit, Northwick Park, Harrow HA1 3UJ.

The photo is used under the creativecommons2.0 licence, originals to be found here

Is the frequency of recurrent chest infections, in children with chronic neurological problems, reduced by prophylactic Azithromycin?
You see Jonny, an 8 yr old boy with severe dystonic CP as a result of his premature birth at 26 wks gestation with another chest infection. He is mainly gastrostomy fed and had a Nissen’s fundoplication 5 yrs ago at the same time his gastrostomy was inserted. He has copious secretions and a poor cough reflex; these are made worse by Nitrazepam he requires for his dystonia. Evidence from previous barium studies and swallow assessments show that he chronically aspirates his secretions. He has no symptoms of upper airway obstruction. He has had increasingly frequent lower respiratory tract infections over the last year, requiring admission and intra-venous antibiotics (a total of four times in 2006). His weight and height have fallen from the 10th to the 3rd percentile. A chest x-ray shows chronic changes suggestive of underlying bronchiectasis. Immune function and Sweat test are normal. He awaits a CT scan. He has daily physiotherapy and regular suction and usually produces copious muco-purulent secretions. He is on maximal anti-reflux medication already. Would prophylactic Azithromycin reduce his risk of further LRTI? Or might it increase growth of multi resistant organisms within his sputum?

Structured Clinical Question

Do children with chronic lung disease (not Broncho-pulmonary Dysplasia) and/or bronchiectasis (subject), who are prescribed long term azithromycin as prophylaxis (intervention) have a reduction in frequency of respiratory exacerbations (outcome) without a change in the bacterial flora found on sputum culture (outcome).

The answer isn’t as straightforward as it seems: read here.

Should gonadotropin releasing hormone analogue be administered to prevent premature ovarian failure in young women with systemic lupus erythematosus on cyclophosphamide therapy?
A 15 year old girl with acute renal failure was found to have class IV systemic lupus erythematosus (SLE) nephritis on renal biopsy. A decision was taken to start her on the routine National Institute Health protocol of pulsed methyl-prednisolone and monthly intravenous cyclophosphamide (CYC) (0.5–1.0 g/m² of body surface area). With her post pubertal status and the possibility of CYC induced gonadal toxicity, the question was raised as to whether she should be put on gonadotropin releasing hormone analogue ( GnRH-a ) therapy for ovarian protection.

It’s probably a while since you last thought of fertility issues in respect of your patients, but as more and more teenage and young adult patients come under the caring hands of paediatric doctors, it’ll be a nudge to relearn all the O&G you missed in medical school. What about those patients who receive alkylating agents, which may affect their fertility, and the options available for them? In young men, sperm banking is a option (although sadly not widely offered to the most obvious group – teenagers and young adults with a new cancer diagnosis according to this paper), but for women the options are more scarce.

The answer – as judged by the authors below – can be found here. Do you agree?

Dr Rajiv Sinha (Fellow, Paediatric Nephrology) and Dr Janis M Dionne (Clinical Assistant Professor, Paediatric Nephrology) from British Columbia’s Children’s Hospital, Vancouver.

A 7 year old boy is admitted to the General Paediatric ward with a community acquired pneumonia affecting the right lower lobe. It is suggested on the ward round that we arrange chest physiotherapy to try and reduce the length of his hospital stay. We wonder if there is evidence to support the use of physiotherapy in this case.

Clinical Bottom Line

1) There is no evidence that chest physiotherapy is of benefit in the treatment of children with community acquired pneumonia. (Level C)

2) There is some evidence that chest physiotherapy may prolong duration of fever in children with community acquired pneumonia. (Level C)

Read more

Author

Dr Francis J Gilchrist

Paediatric SpR

Burnley General Hospital