Evidence-based Tips and Tricks for Pediatricians

Educational Objectives

The goal of this program is to improve management of common pediatric conditions through incorporation of novel evidence-based interventions. After hearing and assimilating this program, the clinician will be better able to:

1. Reduce pain among children with primary herpetic gingivostomatitis.
2. Compare use of diluted apple juice vs electrolyte maintenance solution for oral rehydration.

Summary

Challenges in translational medicine: a common misconception is that a large study is always necessary to bring about change in medical practice; smaller studies with notable outcomes can also provide impactful guidance; when a substantial difference exists between treatments, a smaller study can reveal significant results; larger studies are only necessary to detect very subtle differences; a study involving only 45 children with herpes simplex virus (HSV) meningitis revealed 6 mo acyclovir prophylaxis led to significantly improved mental developmental outcomes (Kimberlin et al [2011]), and this simple intervention has become standard practice; however, a randomized controlled trial conducted on 68,000 infants noted similar risk for intussusception among patients vaccinated vs unvaccinated against rotavirus (Vesikari et al [2006]); a significant element of advancing medical practice is to be open to trying interventions when evidence suggests potential benefit and minimal risk; when considering new interventions, clinicians should weigh the existing evidence and discuss options with patients and their families to ensure informed shared decision-making

Rectal ibuprofen for pain relief: Maunuksela et al (1992) demonstrated decreased heart rates (HRs), pain scores, and postoperative opioid use, plus better recovery among children who received rectal ibuprofen vs placebo; rectally administer 5 mL liquid ibuprofen (drawing up 5 mL ibuprofen after first drawing 5 mL air) using a 14-G suction catheter and a syringe needle; compared with oral ibuprofen, rectal ibuprofen avoids first-pass metabolism and enhances drug delivery to peripheral tissues; while teaching the technique may require extra time (and be unconventional), rectal ibuprofen is cost-effective, readily accessible, and empowers parents to manage pain in young children with primary herpetic gingivostomatitis (PHGS)

Honey: may be good for a child with PHGS who, despite pain management, is not drinking and is beyond the 3-day administration period for acyclovir; compared with acyclovir alone, Abdel-Naby Awad et al (2018) found that the addition of 5 mL honey every 4 hr decreased the mean number of days of oral lesions, drooling, and eating difficulties among children with PHGS; honey is more effective than diphenhydramine and similarly effective to dextromethorphan for managing cough (Oduwole et al 2012) and avoids the risks for side effects and potential misuse associated with dextromethorphan; one study demonstrated that honey reduced hospital length of stay; honey is safe for children ≥1 yr of age (children <1 yr of age are at risk for botulism)

Diluted apple juice for gastroenteritis: the standard approach for patients with gastroenteritis with stable blood pressure who otherwise appear well is an oral hydration challenge; though liquid electrolyte solution is normally prescribed, diluted apple juice (more palatable than liquid electrolyte solution) is more effective for in-office oral hydration challenges and can also reduce hospitalization rates; Freedman et al (2016) demonstrated a lower treatment failure rate and decreased need for intravenous (IV) hydration among children with gastroenteritis treated with diluted apple juice vs electrolyte maintenance solution; these findings suggest that using diluted apple juice for an oral hydration challenge could lower hospitalization rates and the need for IV fluids; however, this approach does require caution because it is dangerous if families solely rely on juice for hydration in severe cases

Probiotics for functional abdominal pain: a 12-yr-old girl presents with recurring, nonspecific abdominal pain; extensive diagnostic imaging revealed no structural abnormalities; psychiatry and various therapies were tried with limited success; a Cochrane review by Wallace et al (2023) found that probiotics are more effective than placebo for resolving symptoms associated with functional abdominal pain; this review suggests that probiotics and synbiotics are more efficacious than placebo in achieving treatment success; avoid probiotics and synbiotics in children with implanted hardware

Aprepitant for cannabis hyperemesis syndrome (CHS): while the primary treatment for CHS is cannabis cessation, a supplementary treatment option may be aprepitant, an antiemetic typically used for postoperative nausea; although the use for CHS is supported by minimal clinical evidence, anecdotal experience suggests aprepitant can effectively reduce the duration of symptoms and shorten hospital stays; the speaker prescribes 125 mg of aprepitant by mouth on day 1, followed by 80 mg on days 2 and 3; aprepitant costs ≈$800 for uninsured patients, but is safe for children

Readings

Abdel-Naby Awad OG, Hamad AH. Honey can help in herpes simplex gingivostomatitis in children: prospective randomized double blind placebo controlled clinical trial. Am J Otolaryngol. 2018;39(6):759-763. doi:10.1016/j.amjoto.2018.09.007; Cone DC, Lewis RJ. Should this study change my practice? Acad Emerg Med. 2003;10(5):417-22. doi:10.1111/j.1553-2712.2003.tb00621.x; Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-74. doi:10.1001/jama.2016.5352; Maunuksela EL, Ryhänen P, Janhunen L. Efficacy of rectal ibuprofen in controlling postoperative pain in children. Can J Anaesth. 1992;39:226–30. doi:10.1007/BF03008781; Oduwole O, Meremikwu MM, Oyo-Ita A, et al. Honey for acute cough in children. Cochrane Database Syst Rev. 2012;(3):CD007094. doi:10.1002/14651858.CD007094.pub3. Update in: Cochrane Database Syst Rev. 2014;(12):CD007094. doi:10.1002/14651858.CD007094.pub4; Parvataneni S, Varela L, Vemuri-Reddy SM, et al. Emerging role of aprepitant in cannabis hyperemesis syndrome. Cureus. 2019;11(6):e4825. doi:10.7759/cureus.4825; Wallace C, Gordon M, Sinopoulou V, et al. Probiotics for management of functional abdominal pain disorders in children. Cochrane Database Syst Rev. 2023;2(2):CD012849. doi:10.1002/14651858.CD012849.pub2.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Alverson was recorded at the 10th Annual Hot Topics in Pediatrics 2024, held July 18-20, 2024, in Lake Buena Vista, FL, and presented by Nemours Children's Health. For information about upcoming CME activities from this presenter, please visit https://ce.nemours.org. Audio Digest thanks Dr. Alverson and Nemours Children's Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PD704802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.