Year in Review: Top Recent Articles in Pediatrics

Educational Objectives

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

1. Exert caution when prescribing melatonin in pediatric patients.
2. Promote penicillin allergy delabeling.
3. Prescribe treatment for patients with food allergies.

Summary

Melatonin

Background: an endogenous neurohormone which regulates the sleep-wake cycle; prescribed for insomnia in adults and primary sleep disorders in children; melatonin is classified as a dietary supplement (not a medication) by the US Food and Drug Administration

Evidence: Cohen et al (2023) — found that over-the-counter melatonin supplements contain 74% to 347% of the labeled melatonin quantity, and some of the products contain cannabidiol; calls for pediatric melatonin ingestions to US Poison Control centers have increased 530% from 2012 to 2021; Hartstein et al (2024) — reported an 18.5% prevalence of melatonin use among school-aged children over the prior 30 days; preteens demonstrated similar use prevalence, but with a bimodal pattern (weekly or daily use); doses ranged from 0.25 mg to 10 mg, and gummies were the most popular form; though preschoolers demonstrated the lowest use prevalence, they tended to have consistent use over a period of months; even among older children, long-term use spanned 18 to 21 mo

Recommendations: more specific data suggest that children with autism have lower serum melatonin levels than their siblings; emphasize sleep hygiene over long-term melatonin use; consider melatonin for short-term use, paired with healthy sleep routines; start with the lowest dose; families should exert caution with gummies to prevent overdose, ensure safe storage, and choose supplements with third-party verification

Oral antibiotic therapy for febrile urinary tract infection: Montini et al (2024) — demonstrated noninferiority of 5 days vs 10 days of therapy with regard to recurrence rate, clinical recovery, adverse events, and antibiotic resistance; SCOUT trial (Zaoutis et al [2024]) — though initial data suggested that patients prescribed short-course therapy do not fare as well as patients prescribed standard-course therapy, ad hoc analysis revealed no significant differences in outcomes

Obesity

Medication therapy: though semaglutide has demonstrated significant success in obesity treatment, concerns exist regarding potential for lifelong use; a 14-day course of teplizumab can delay or prevent type 1 diabetes in children ≥8 yr of age with ≥2 specific antibodies and abnormal glucose tolerance testing

Prevention: Armstrong et al (2024) — after a period of decline, the rate of obesity among children 2 to 4 yr of age has risen to 2%; 90% of children who become obese by 3 yr of age remain obese as teenagers; Resnicow et al (2024) — compared with usual care, children <6 yr of age who received motivational interviewing gained more weight

Antiviral therapy for influenza: the American Academy of Pediatrics recommends antiviral treatment for children <5 yr of age with influenza not only to reduce complications, but also to protect vulnerable populations from severe outcomes; while antivirals can cause mild gastrointestinal (GI) side effects, neuropsychological concerns are rare; per Antoon et al (2023), 49% to 67% of all children with influenza receive antiviral therapy, though only 34% of children 2 to 5 yr of age and 37% of children <2 yr of age receive antiviral therapy

Penicillin allergy label (PAL)

Background: affects 4% to 10% of children; the median age for PAL is 1.3 yr, and 75% of cases are recorded by 3 yr of age; however, >95% of children with PAL do not actually have immunoglobulin E (IgE)-mediated hypersensitivity; rather, they have viral rashes, hives, diarrhea (not a contraindication), or positive family history of PAL; inaccurate PAL leads to increased use of broad-spectrum antibiotics (BSAs), resulting in more infections with Clostridioides difficile or vancomycin-resistant enterococci, plus adverse drug reactions

Joerger et al (2023): while ≈5% of children received a PAL (primarily for amoxicillin), only 14% of those children were delabeled over time; compared with children without PAL, children with PAL experienced more adverse drug reactions and received more second-line BSAs (eg, cefdinir, azithromycin) for outpatient treatment of respiratory infections, though experienced no differences with regard to clinical outcomes

Journal of Allergy and Clinical Immunology guidelines (Khan et al [2022]): emphasize that delabeling can be done in primary care, the emergency department (ED), and inpatient settings; delabeling is appropriate for patients who have tolerated penicillin since their initial reaction or cannot recall those details, provided the reaction was not anaphylaxis; delabeling is safe for patients who experience a delayed rash (mainly hives) after the first day or experienced a nonsevere reaction >10 yr ago; family history or diarrhea alone are not valid reasons for PAL

Recommendations for delabeling: ask what antibiotic was prescribed, when it was prescribed, and whether the child received it again; contraindications for office-based delabeling include severe reactions (eg, anaphylaxis, serious delayed hypersensitivity, serum sickness, toxic epidermal necrolysis, immediate swelling or hives); screen eligible patients and obtain consent before performing challenge testing, which involves administering 10% of the dose (maximum total dose 500 mg/10 mL), waiting 15 min, giving the remaining dose, and observing for 1 hr

Croup: common and usually mild; accounts for 3% to 5% of ED visits; treatment primarily involves a single oral dose of dexamethasone, effective within 30 min; humidified air or mist therapy is no longer recommended, and no evidence supports its use; Siebert et al (2024) found that ≈50% of patients who received 30 min of cold air exposure, as an adjunct to oral dexamethasone, experienced significant reduction of the intensity of mild-to-moderate croup symptoms, compared with patients not exposed to cold air (23.7%); no differences were noted with 60 min of cold air exposure

Multiple food allergies: food allergies affect ≈8% of children and ≈10% of adults, with increasing rates of anaphylaxis; omalizumab, an anti-IgE monoclonal antibody approved for severe allergic asthma and urticaria, is approved for treatment of multiple food allergies

Wood et al (2024): found that 67% of patients treated with subcutaneous omalizumab tolerated 600 mg of peanut protein (≈2 peanuts), compared with 7% treated with placebo, with similar improvements for cashews, eggs, milk, and walnuts; ≈50% of patients who received omalizumab maintained tolerance to increasing doses of allergens, even with multiple allergens

Omalizumab: omalizumab treats various IgE-mediated food allergies by providing protection against accidental exposures; omalizumab does not cure the allergies, potentially requiring lifelong use; annual costs are determined by IgE levels and weight; the initial 3 doses should be administered in an allergist’s office, and subsequent doses can be administered at home; reassess efficacy after 20 wk to determine whether continuation is appropriate; consider a treatment break of ≥4 mo, with allergen rechallenge, for patients with milk or egg allergy

Readings

Antoon JW, Sarker J, Abdelaziz A, et al. Trends in outpatient influenza antiviral use among children and adolescents in the United States. Pediatrics. 2023;152(6):e2023061960. doi:10.1542/peds.2023-061960; Armstrong SC, Skinner AC. Severe obesity in toddlers: a canary in the coal mine for the health of future generations. Pediatrics. 2024;153(1):e2023063799. doi:10.1542/peds.2023-063799; Casale TB, Fiocchi A, Greenhawt M. A practical guide for implementing omalizumab therapy for food allergy. J Allergy Clin Immunol. 2024;153(6):1510-1517. doi:10.1016/j.jaci.2024.03.019; Cohen PA, Avula B, Wang YH, et al. Quantity of melatonin and CBD in melatonin gummies sold in the US. JAMA. 2023 Apr 25;329(16):1401-1402. doi: 10.1001/jama.2023.2296; Hartstein LE, Garrison MM, Lewin D, et al. Characteristics of melatonin use among US children and adolescents. JAMA Pediatr. 2024 Jan 1;178(1):91-93. doi:10.1001/jamapediatrics.2023.4749; Joerger T, Taylor MG, Li Y, et al. Impact of penicillin allergy labels on children treated for outpatient respiratory infections. J Pediatric Infect Dis Soc. 2023;12(2):92-98. doi:10.1093/jpids/piac125; Khan DA, Banerji A, Blumenthal KG, et al. Drug allergy: a 2022 practice parameter update. J Allergy Clin Immunol. 2022;150(6):1333-1393. doi:10.1016/j.jaci.2022.08.028; Montini G, Tessitore A, Console K, et al. Short oral antibiotic therapy for pediatric febrile urinary tract infections: a randomized trial. Pediatrics. 2024;153(1):e2023062598. doi:10.1542/peds.2023-062598; Resnicow K, Delacroix E, Sonneville KR, et al. Outcome of BMI2+: motivational interviewing to reduce BMI through primary care AAP PROS practices. Pediatrics. 2024;153(2):e2023062462. doi:10.1542/peds.2023-062462; Shenoy P, Etcheverry A, Ia J, et al. Melatonin use in pediatrics: a clinical review on indications, multisystem effects, and toxicity. Children (Basel). 2024;11(3):323. doi:10.3390/children11030323; Siebert JN, Salomon C, Taddeo I, et al. Outdoor cold air versus room temperature exposure for croup symptoms: a randomized controlled trial. Pediatrics. 2023;152(3):e2023061365. doi:10.1542/peds.2023-061365. Erratum in: Pediatrics. 2024;153(3):e2023065508. doi:10.1542/peds.2023-065508; Wood RA, Togias A, Sicherer SH, et al. Omalizumab for the treatment of multiple food allergies. N Engl J Med. 2024;390(10):889-899. doi:10.1056/NEJMoa2312382; Zaoutis T, Shaikh N, Fisher BT, et al. Short-course therapy for urinary tract infections in children: the SCOUT randomized clinical trial. JAMA Pediatr. 2023;177(8):782-789. doi:10.1001/jamapediatrics.2023.1979. Erratum in: JAMA Pediatr. 2024;178(6):630. doi:10.1001/jamapediatrics.2024.0973.

Disclosures

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

Acknowledgements

Dr. Tomaszewski, and Dr. Walter were recorded at the 10th Annual Hot Topics in Pediatrics 2024, held July 18-20, 2024, in Lake Buena Vista, FL, and presented by the Nemours Foundation. For information on upcoming CME activities from this presenter, please visit https://ce.nemours.org. Audio Digest thanks the speakers and the Nemours Foundation 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 1.25 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 1.25 CE contact hours.

Lecture ID:

PD704402

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.