3 Top Papers You Missed in December 2020
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
Vergano ST. 3 top papers you missed in December 2020. Published online January 4, 2021. Consultant360.
In the past month, 3 important articles have been published that will impact our daily practice of managing pediatric patients. Below is a synopsis of each study, as well as some thought-provoking questions. You can submit your feedback to us at email@example.com.
2020 Updates to the Asthma Management Guidelines1
The most significant publication in the past month is the update to the 2007 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines. The 6 summary tables1 contain the most important guidelines for general pediatricians. Of note, the recommendations for intermittent asthma (step 1) have not changed, and step 2 management for children remains low-dose daily inhaled steroid with as-needed albuterol, although in patients 12 years and older, as-needed use of inhaled steroid and albuterol is equally recommended. The biggest change for general pediatricians is for children and adolescents who have moderate persistent asthma and need step 3 or 4 management. For these patients, SMART (single maintenance and reliever therapy) is recommended, with a combination of inhaled steroid and formoterol, a rapid-onset, and long-acting β-agonist (LABA). For SMART, the same inhaler is used for daily and as-needed therapy. Use of the inhaler as needed provides a rapid-onset LABA and simultaneous increase in dosing of the inhaled corticosteroid.
I was pleased to see that the NHLBI did not recommend inhaled steroids for intermittent asthma, as advocated by new GINA guidelines. In my mind, the patient who wheezes a few times per year and has no severe exacerbations does not need more-aggressive therapy. The new guidelines seem to de-emphasize the use of montelukast, although no formal changes were included. I will likely use less of this leukotriene inhibitor as more information on potential adverse effects has emerged. Finally, I am eager to try SMART and see how it will fit into my management of patients with moderate persistent asthma. Everything above stage 3 or 4 is less relevant to my management, as these children are referred to pulmonologists or allergists.
Please feel free to share your thoughts. What are your opinions of the changes? Have you tried SMART? What has your experience been? The guidelines also specifically state that a short-term increase in inhaled steroid dosing alone for acute exacerbations is not recommended. What are your thoughts?
Fluoride Use in Caries Prevention in the Primary Care Setting2
This updated policy statement from the American Academy of Pediatrics (AAP) reiterates prior recommendations from the AAP Section on Oral Health. The routine application of fluoride varnish is indicated for children at high risk for caries starting at tooth emergence and repeated every 3 months until establishment of a dental home. For children at low risk for dental caries, fluoride varnish application is recommended starting at tooth emergence and repeated every 3 to 6 months until establishment of a dental home. Use of fluoride-containing toothpaste is recommended for all children. An amount the size of a grain of rice is recommended from first tooth eruption until age 3 years, and an amount the size of a pea is recommended at age 3 years or older. Prescription fluoride is recommended for children in households with fluoride-deficient water, regardless of whether tap or bottled water is used for drinking; it is noted that the US Preventive Services Task Force (USPSTF) recommends fluoride supplementation for all such children starting at age 6 months, while the American Dental Association and American Academy of Pediatric Dentistry recommend fluoride supplementation only for children at high risk for dental caries.
In my current practice, our nursing staff routinely administer an oral health risk assessment, and pediatric providers apply fluoride varnish every 3 months to children who are at high risk. It is interesting to read in the AAP statement that, per the Affordable Care Act, payers are required to cover all services recommended by the USPSTF, which include fluoride varnish application for all children up to age 5 years. Perhaps we need to advocate for more consistent coverage by all payers in our area and extend our policy to provide fluoride varnish to all children, regardless of the results of their risk assessment.
I’m interested to hear from you about your practices. Do you perform oral health risk assessments? For whom do you apply fluoride varnish, and at which frequency? Do you have fluoridated water in your community, and if not, to whom do you prescribe fluoride supplementation?
Reasons to Accept Vaccine Refusers in Primary Care3
In this article, the authors argue that the practice of nonacceptance of vaccine refusers is ethically distinct from the policy of dismissing families who persistently refuse vaccinations, a practice that the AAP considers acceptable. They state that some motivations for nonacceptance are “intrinsically immoral” and that nonacceptance of families who refuse vaccination does not treat these families fairly or permit engagement to motivate potential education and change. They conclude, “[E]ven if dismissal were sometimes an ethically acceptable option, wholesale nonacceptance of these families is not."
Having worked for 16 years in a practice that routinely dismissed nonvaccinating families by age 12 months and in another that accepts nonvaccinators, I have some perspective on each policy. In my former practice, only a few families accepted vaccination just to remain in our care. In my current practice, I have successfully changed the opinions of only a few families about vaccines. Anecdotally, neither policy seems more effective in promoting vaccination, and there were more families with whom distrust of the medical establishment led to dismissal in my former practice. Nonetheless, I feel better about accepting all families, sharing my perspectives repeatedly about science and vaccination, and advocating for the optimal care of all children, regardless of their parents’ beliefs.
What does your practice do? Has it been successful? I have never before read of nonacceptance labeled as unethical. What do you think?
Thanks for reading my perspectives and sharing your own. I look forward to bringing you this column on a monthly basis and serving as a catalyst for dialogue among all those in practice caring for our children.
- 2020 Focused Updates to the Asthma Management Guidelines. US Department of Health and Human Services. Published online December 2020. https://www.nhlbi.nih.gov/sites/default/files/publications/AsthmaClinicians-At-a-Glance-508.pdf
- Clark MB, Keels MA, Stayton RL; Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2020;146(6):e2020034637. https://doi.org/10.1542/peds.2020-034637
- Navin MC, Wasserman JA, Opel DJ. Reasons to accept vaccine refusers in primary care. Pediatrics. 2020;146(6):e20201801. https://doi.org/10.1542/peds.2020-1801