HEADS UP

Abstract

There is no doubt that paracetamol overdose, whether accidental or self-administered, is hepatotoxic. It is controversial whether or not liver injury occurs rarely with therapeutic dosing (up to 75 mg/kg/day), as claimed by some authors. A meta-analysis of 62 studies that enrolled a defined paediatric population who received at least 24 h of paracetamol (acetaminophen in the USA) was searched for reports of any major or minor hepatic adverse events. Five of a total of 32 414 children had minor and 5 had major hepatic adverse events associated with paracetamol use; the two who stopped paracetamol because of raised transaminases had proven viral hepatitis. The causality was rated as possible for all 10 cases. No child had symptoms or signs of liver disease, none needed antidote or liver transplant, and none died. Hepatotoxicity is very rarely reported in association with therapeutic paracetamol dosing, viral hepatitis may be contributory in some cases and evidence of causality is weak. Link: http://pediatrics.aappublications.org/cgi/reprint/126/6/e1430 Reviewer: David Isaacs [email protected] High-frequency oscillatory ventilation (HFOV) has its advocates and its detractors. Are there subgroups of babies for whom HFOV is superior to conventional ventilation? A systematic review and meta-analysis of 3229 participants in 10 randomised controlled trials compared HFOV with conventional ventilation. The relative risk for HFOV compared with conventional ventilation for the primary outcomes was: death or bronchopulmonary dysplasia at 36 weeks gestation = 0.95 (95% confidence interval 0.88–1.03); death or severe adverse neurological event = 1.00 (0.88–1.13); or any of these outcomes = 0.98 (0.91–1.05). No subgroup of infants, whether analysed by gestational age, birthweight for gestation, initial severity of lung disease or antenatal corticosteroid exposure, was shown to have more or less benefit from HFOV. Reviewer: David Isaacs ([email protected]) The choking game or the fainting game (also known by a wide variety of local slang names such as Blackout, jeu du foulard, Würgespiel, Doctor death and Rocket Ride) is a game played for many years by school children with the intention of inducing temporary syncope and euphoria by cutting off oxygen to the brain. Children are thought to use this to get high without drugs, rather than for sexual gratification. Boys often use strangulation, while girls tend to use chest compression or hyperventilation. A 2008 survey by the Centers for Disease Control reported 82 deaths attributed to the choking game in the USA from 1995 to 2007, mostly of boys aged 11–16 (see Figure).1 A survey of Oregon 13-year-olds found that 36.2% had heard of the choking game, 30.4% had heard of someone participating and 5.7% had participated.2 A survey of US paediatricians and family practitioners found that only 68.1% had heard of the choking game, knowledge of the warning signs was sketchy and less than 2% talked about it to adolescents.3 This is a common, potentially fatal childhood activity. Paediatricians should be aware of the signs, should be vigilant and might consider warning adolescents of the dangers. Link: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5706a1.htm Link: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5901a1.htm http://pediatrics.aappublications.org/cgi/reprint/125/1/82.pdf Reviewer: David Isaacs ([email protected]) The benefits of antibiotics in acute otitis media remain controversial. Two randomised, placebo controlled trials of amoxycillin/clavulanate for otitis media examined symptom resolution. A US study1 of children age 6–24 months found that 10 days of antibiotic achieved symptom resolution in 20%, 41% and 67% on days 2, 4 and 7 of treatment, respectively, compared with 14%, 36% and 53% in the placebo group. After 7 days, two thirds of treated children had resolved compared with half without treatment (absolute risk reduction 14%, number needed to treat = 7). On the downside, antibiotics commonly caused diarrhoea (24% vs. 7% with placebo) and ‘diaper-area dermatitis’ (47% vs. 16% in the placebo group). One child in the placebo group developed mastoiditis. A Finnish study2 of children age 6–35 months found that 7 days of amoxycillin/clavulanate resulted in 18.6% of treatment failure (see Figure) compared with 44.9% in the placebo group (absolute risk reduction 26.3%, number needed to treat = 3.8). Diarrhoea developed in 47.8% of children receiving amoxycillin/clavulanate and 26.6% with placebo. An editorial in the same issue3 concludes: ‘Is acute otitis media a treatable disease? The investigators . . . have provided the best data yet to answer the question, and the answer is yes; more young children with a certain diagnosis of acute otitis media recover more quickly when they are treated with an appropriate antimicrobial agent.’ But are the treatment effects that impressive, is amoxycillin/clavulanate the most appropriate agent and is the diarrhoea worth it? In Australia, antibiotic guidelines recommend a wait-and-see approach for non-toxic children >6 months old with acute otitis media and amoxycillin as first-line treatment for toxic children.4 Reviewer: Phil Britton ([email protected]) and David Isaacs ([email protected])