March 2014, VOLUME4 /ISSUE 2

It Doesn’t Have to be EviDense

  1. Eric Biondi, MD
  1. Division of Pediatric Hospital Medicine, University of Rochester, Rochester, New York
  1. Address correspondence to Eric Biondi, MD, University of Rochester, 601 Elmwood Ave, Box 667, Rochester, NY 14642. E-mail: eric_biondi{at}urmc.rochester.edu
  • Evidence-based Medicine

The Headbone’s Connected to the…GI Tract?

You just admitted a child with a headache. These patients present a particularly challenging dilemma because the differential diagnosis can be broad and the wide array of testing options (which can be both harmful and expensive) may leave you wondering, “Do I watch and wait, or go looking for things?”

The study.

The goal of this case-control examination, conducted in France and Italy, was to determine whether an association exists between infantile colic and migraine headaches. Consecutive children aged 6 to 18 years, who presented to 1 of 3 emergency departments and were diagnosed with migraine or tension-type (according to criteria of the International Headache Classification, 2nd edition) primary headaches between April and June 2012, were enrolled. Control subjects were similar-aged children presenting to the same centers for minor trauma. All parents completed rigorous, criteria-based questionnaires to determine whether their child had a history of infantile colic.

The key findings.

A total of 328 cases (208 with migraine and 120 with tension headaches) and 471 control subjects took part in the study. Characteristics between migraine cases and control subjects were generally similar, although the migraine group was slightly older (10.1 vs 9.0 years; P = .001). Prevalence of a history of colic in the migraine, tension headache, and control groups was 72.6%, 35.0%, and 26.5%, respectively. Logistic regression demonstrated an associated odds ratio between infantile colic and migraine of 6.61 (95% confidence interval: 4.38–10.00); this association was not found for colic or tension-type headaches.

Why do we care?

The first step to narrowing a broad differential diagnosis is a careful history and physical examination. Perhaps this additional point in the history might help you to build a case for migraine while avoiding further testing.

In the words of the expert…

“The most immediate practical use of this information for pediatric hospitalists would be to help in the identification of risk factors for children admitted with headaches. Migraines are very common in children, but often a pediatrician is faced with a large potential differential diagnosis. Similar to children with a history of motion sickness or a strong family history of migraine, a provider could evaluate for a history of infantile colic when considering risk factors for migraine in a particular patient. The idea of using migraine preventative treatments in infants with colic is interesting, but would take substantial investigation before being considered for clinical practice.”

– Dr Robert Stone, attending pediatric neurologist, University of Rochester

Citation: Romanello S, Spiri D, Marcuzzi E, et al. Association between childhood migraine and history of infantile colic. JAMA. 2013;309(15):1607–1612

Not Merely Clowning Around

Okay, the pun was embarrassingly easy. So, is this study really about clowns? Well, technically, yes. But we should probably all pay attention to techniques that ease stressful or painful situations for hospitalized children. Maybe you don’t have ready access to professional hospital clowns, but you can probably extrapolate the data here. And I bet you haven’t seen this study.

The study.

A recent qualitative meta-analysis focused on a 7-year project funded by the Swedish Childhood Cancer Foundation attempted to closely examine encounters between hospital clowns and sick children. The analysis combines the semi-structured interviews of 51 participants (13 hospital clowns, 20 staff members, 9 children, and 9 parents) conducted over the 3 individual studies included in the larger project. Interview topics were varied but generally focused on interpersonal relationships, roles, and the value of the encounters.

The key findings.

Three main benefits to hospitalized children emerged from the interviews. First, the children enjoyed being provided a quality of care that transcends boundaries. Although it can be achieved in a variety of ways, allowing the children to explore the “lighter side of life” and to express their own wishes provided clear benefit. Second, providing a nondemanding quality of care, one that is free from obligation and requires nothing in return (read that as “joy without demands”), was found to help patients and siblings alike. Third, clowns provided a “positive counterweight” by serving as a distraction that downplayed medical care in difficult situations.

Why do we care?

Great question, because if your institution is anything like mine, it’s unlikely that you have a local hospital clown on speed dial. However, what the data here suggest, to me at least, is that distraction can be a powerful tool in a children’s hospital. Your hospital likely employs certified Child Life Specialists (full disclosure: I’m married to one) who are specifically trained in using distraction techniques for children. They are not merely the gatekeepers of the playrooms; they have often undergone extensive training in caring for the psychosocial needs of children regardless of medical condition. For painful procedures or simply stressful times in the hospital, these data suggest that distraction can help patients to cope.

Why this article?

Because it’s probably something that you haven’t read and something that could actually affect your practice in a consistently remarkable way.

Straight from the author’s mouth…

“My message in all my articles - the hospital clowns and their important work with very sick children in the hospital. It ´s my hope that my articles will increase our psychological understanding of the hospital clowns´ work in terms of: joy without demands, hopefulness, well-being, magical attachment and humor attunement between the hospital clowns and the ailing children.”

– Dr Lotta Linge, author (recently retired from academics)

Citation: Linge L. Joyful and serious intentions in the work of hospital clowns: a meta-analysis based on a 7-year research project conducted in three parts. Int J Qual Stud Health Well-being. 2013;8:1–8

Deficiency: The D Stands For D

I bet you’ve had a patient with asthma this week. And I bet you didn’t give him or her vitamin D. And if you’re anything like me, you didn’t even know the 2 were related.

The study.

This 2013 randomized trial from India aimed to define the therapeutic role of vitamin D in children with moderate to severe bronchial asthma as an adjunct to standard preventative treatment. One hundred children aged 5 to 13 years visiting an asthma clinic were randomized to receive either oral vitamin D3 (60 000 IU) once a month for 6 months or placebo. They were assessed at monthly visits. The primary outcome measure was a change in the Global Initiative for Asthma severity score.

The key findings.

Treatment groups were similar in almost all measured demographic characteristics and in severity of asthma at enrollment. An intention-to-treat analysis found that by the 6-month follow-up, patients in the treatment group had more improvements in asthma severity (P = .016), decreased frequency of acute exacerbations (P = .011), improved peak expiratory flow rates (P < .001), and fewer emergency department visits (P = .015) than the placebo group.

Why do we care?

True, larger trials are needed to define the role of vitamin D in asthma. But as a pilot study, these data are pretty provocative. Stay tuned; I’m guessing we’re going to hear more about this treatment in the near future.

Why this article?

There is some evidence to indicate that severe asthma and vitamin D deficiency are related. But here is a randomized, double-blind, placebo-controlled trial that suggests adding vitamin D to a treatment regimen can dramatically improve asthma control.

Straight from the author’s mouth…

“Asthma poses a therapeutic challenge despite availability of a varied armamentarium. Our study should motivate researchers to conduct larger and preferably multicenter trials with vitamin D levels done before and after the intervention to define its role in asthma and other atopic disorders.”

– Dr Madhu Shrikrishan Yadav, lead author

Citation: Yadav M, Mittal K. Effect of vitamin supplementation on moderate to severe bronchial asthma [published online ahead of print November 6, 2013]. Indian J Pediatr.


  • FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.

  • FUNDING: No external funding.

  • POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.