Escoliosis idiopática del adolescente. ¿Algo nuevo sobre el cribado?

AVC | Artículos Valorados Críticamente

Dunn J, Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Lin JS. Screening for adolescent idiopathic scoliosis: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319:173-87.

Revisores: Orejón de Luna G1, Puebla Molina SF2.

1CS General Ricardos. Madrid. España. 
2Intensivista Pediátrico. Magíster en Epidemiología Clínica. Hospital San Juan de Dios de La Serena. Chile. 

Correspondencia: Gloria Orejón de Luna. Correo electrónico: gloriaglo04@gmail.com

Palabras clave: adolescente; cribado; escoliosis idiopática

Fecha de recepción: 03/09/2018

 

Fecha de aceptación: 17/09/2018

 

Fecha de publicación: 03/10/2018

Resumen Estructurado

Objetivo: evaluar los beneficios del cribado en la detección precoz de la escoliosis idiopática del adolescente (EIA).

Diseño: revisión sistemática basada en 6 preguntas: si el cribado de la escoliosis idiopática del adolescente (EIA) mejora los resultados en salud del niño o el adulto o en el grado de gravedad de la EIA, cuán preciso es el cribado en la detección de la EIA, si el tratamiento de la EIA cuyo ángulo de Cobb es menor de 50° mejora los resultados en salud en la edad infantil o adulta o en la gravedad de la EIA, si existe asociación entre la gravedad de la EIA y los resultados de salud en la edad adulta, si existe daño con el cribado de la EIA y si existe daño en el tratamiento de la IEA en adolescentes que tienen un ángulo de Cobb de menos de 50°.

Fuente de datos: se realizó una búsqueda sistemática de artículos publicados entre enero de 1966 y el 20 de octubre de 2016 en las bases de datos de los registros de ensayos clínicos controlados de Cochrane, OVID Medline, ERIC (Eric.ed.gov), PubMed y Cumulative Index to Nursing and Allied Health Literature (CINAHL). La búsqueda fue complementada en la plataforma de la Organización Mundial de la Salud (OMS) y en ClinicalTrial.gov.

Selección de estudios: dos revisores evaluaron de forma independiente 8230 títulos y resúmenes y 1088 artículos según los criterios de inclusión preestablecidos. Las discrepancias se resolvieron por consenso. Para la pregunta de detección, la población de interés fueron niños asintomáticos entre 10 y 18 años, utilizando cualquier medición objetiva, siendo la más comúnmente usada el test de Adams. Para la pregunta de tratamiento los criterios de inclusión fueron niños y adolescentes de 10 a 18 años con el diagnóstico de EIA con un ángulo de Cobb de entre 10° y 50° al momento del diagnóstico. Se excluyeron niños con curvas con ángulos mayores a 50° porque estos pacientes son susceptibles de ser detectados clínicamente. Dependiendo de la pregunta, se incluyeron los diseños adecuados para contestar cada pregunta.

Extracción de datos: se extrajeron los datos pertinentes de cada estudio y se construyeron tablas de evidencias estandarizadas adaptadas para cada pregunta y diseño de estudio. Se realiza una síntesis narrativa de los resultados. Por la heterogeneidad en los estudios no fue posible realizar un metanálisis.

Resultados: no se encontraron estudios para responder la primera pregunta. La precisión del cribado aumentó con el número de test usados. Sensibilidad del 93,8% y especificidad del 92,2%, con un valor predictivo positivo del 81%, usando test de Adams, escoliómetro y topografía de Moiré. En un estudio usando test de Adams y escoliómetro, la precisión fue más baja. Sensibilidad del 71,1% y especificidad del 97,1%. El tratamiento ortopédico mostró beneficio respecto a los controles en un estudio prospectivo controlado, mejorando en 5-6° la progresión de la escoliosis. No hubo diferencias en los resultados de calidad de vida entre diferentes tratamientos ortopédicos. Dos ensayos clínicos aleatorizados evaluaron los ejercicios, demostrando mejoría significativa a los 12 meses de vida, comparando ejercicios específicos con ejercicios generales. Hubo una reducción en el ángulo de Cobb de 4,9° respecto al grupo control, que fue de 2,8°; estas diferencias son estadísticamente significativas. Se observó mejoría significativa en el ángulo de la curva de la escoliosis, 0,67° frente a 1,38° (p <0,05) a los 12 meses de observación como en la percepción de calidad de vida. Hubo diferencias no significativas en la asociación de la gravedad de la EIA y los resultados de salud en la edad adulta. No se encontraron estudios para evaluar daño al realizar el cribado. Un estudio de buena calidad metodológica de 242 adolescentes reportó dolores y molestias derivados de la terapia ortopédica. Las tasas de ansiedad y depresión fueron bajas y similares en ambos grupos.

Conclusión: no hay suficiente evidencia para hacer una recomendación sobre la realización del cribado sistemático y universal de la escoliosis idiopática del adolescente.

Conflicto de intereses: no existe.

Fuente de financiación: Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.

Comentario Crítico

Justificación: la escoliosis idiopática del adolescente es la desviación tridimensional de la columna vertebral en pacientes de más de 10 años, no causada por ninguna patología subyacente, de más de 10° de ángulo de Cobb y que generalmente se asocia a rotación vertebral1-4. Desde hace tiempo, existe una importante controversia sobre la eficacia e indicación de realizar cribado de la EIA1,5. Por una parte, se ha visto que el tratamiento precoz de la EIA, sobre todo antes de completar la maduración ósea, previene la progresión de la misma, evitando deformidades permanentes de la columna. Pero, por otra, no se ha encontrado una clara evidencia para recomendar un cribado sistemático y universal de la EIA3-5. Por todo ello y teniendo en cuenta que la escoliosis genera una gran ansiedad en los adolescentes y sus familias, parece interesante actualizar la posible indicación de dicho cribado.

Validez o rigor científico: es una revisión sistemática realizada bajo los criterios de GRADE. Sus objetivos están bien definidos. Se ha realizado una búsqueda bibliográfica exhaustiva, especificando claramente los criterios de inclusión y exclusión, que fueron adecuados para los objetivos del estudio. La evaluación de la calidad también fue adecuada.

Importancia clínica: el cribado es una intervención que se realiza en población sana y su principal objetivo debe ser mejorar los resultados de salud de la población a la que va dirigido, por lo que es importante que en el estudio se haya valorado la eficacia del tratamiento de la EIA. Si tomamos en cuenta que la prevalencia de la EIA es de 5,2%, probabilidad preprueba, y el valor predictivo positivo es de 86,54% (probabilidad posprueba)*, la información ganada es de 81 puntos porcentuales y si la prueba es negativa se descarta prácticamente el diagnóstico, fundamentalmente en los estudios de cohorte donde el cribado se realizó usando el test de Adams, escoliómetro y topografía de Moiré. En estas variables, los resultados no fueron tan alentadores, encontrando diferencias poco significativas entre el grupo de intervención y el grupo control, aunque el tratamiento con corsé o ejercicio parece disminuir la evolución de la curvatura en los adolescentes. No hubo evidencia de que el cribado de la EIA mejorase el pronóstico en la edad adulta. Otros estudios coinciden con estos mismos resultados, incluso asegurando que los riesgos de un cribado universal de la EIA son superiores a los beneficios, ya que al tener un VPP bajo, aumentaría el diagnóstico de falsos positivos, la realización de pruebas innecesarias y la ansiedad por la enfermedad en los adolescentes y sus familias1,2,5. Otros autores, aunque reconocen que no hay evidencia de que sea eficaz, recomiendan realizar el cribado de rutina sobre todo para detectar los pacientes con factores de riesgo (adolescentes que no han completado maduración ósea con curvas de más de 20° de ángulo de Cobb) para poder realizar un seguimiento y tratamiento adecuado3.

Aplicabilidad en la práctica clínica: a la vista de los resultados, podemos decir que la controversia en cuanto a la realización del cribado de EIA no se ha solucionado. Sin embargo, esta revisión aporta más argumentos para no indicar la realización del cribado sistemático y universal en la población adolescente. Lo que sí parece estar indicado es realizar un seguimiento y tratamiento adecuado en los adolescentes con curvas escolióticas moderadas o graves. El hecho de que en la revisión sistemática se excluyeran los estudios no realizados en la población general o en centros de Atención Primaria, hace que los resultados sean más concluyentes para su aplicabilidad en este ámbito.

Conflicto de intereses de los autores del comentario: no existe.

BIBLIOGRAFÍA

1. Esparza Olcina MJ. Cribado de la escoliosis idiopática del adolescente. En: Recomendaciones PrevInfad/PAPPS [en línea] [actualizado en junio de 2014, consultado el 27/09/2018]. Disponible en: http://previnfad.aepap.org/monografia/escoliosis
2. Plaszewski M, Bettany-Saltikov J. Are current scoliosis school screening recommendations evidence-based and up to date? A best evidence synthesis uymbrella review. Eur Spine J. 2014;23:2572-85.
3. Burton MS. Diagnosis and treatment of adolescent idiopathic scoliosis. Pediatr Ann. 2013;42:224-8.
4. El-Hawary R, Chukwunyerenwa CH. Update on evaluation and treatment of scoliosis. Pediatr Clin N Am. 2014;61:1223-41.
5. Duerloo JA, Verkek PH. To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature. Public Health. 2015;129:1267-72.

Cómo citar este artículo

Orejón de Luna G, Puebla Molina SG. Escoliosis idiopática del adolescente. ¿Algo nuevo sobre el cribado? Evid Pediatr. 2018;14:17.

Screening for Celiac Disease: A Systematic Review for the U.S. Preventive Services Task Force Agency for Healthcare Research and Quality U.S. Department of Health and Human Services

Agency for Healthcare Research and Quality U.S. Department of Health and Human Services.
Evidence Synthesis Number 144. AHRQ Publication No. 14-05215-EF-1. May 2016.

Background: Unrecognized celiac disease (CD) may have adverse effects on morbidity and mortality. Purpose: To review the evidence on screening for CD in asymptomatic adults, adolescents, and children 3 years of age and older for the United States Preventive Services Task Force.
Data Sources: Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to February 2016).
Study Selection: Randomized clinical trials, cohort studies, and case-control studies of screening versus no screening, one screening strategy versus another, treatment versus no treatment, or immediate versus delayed treatment that evaluated clinical outcomes; and studies on diagnostic accuracy of serological tests for CD.
Data Extraction: One investigator abstracted data, a second checked data for accuracy, and two investigators independently assessed study quality using predefined criteria. Data Synthesis (Results): We identified no trials of screening for CD. One recent, good-quality systematic review found serological tests to be accurate for diagnosing CD, but two studies conducted in asymptomatic populations reported lower sensitivity than in studies not restricted to asymptomatic populations. One fair-quality, small (n=40), Finnish treatment trial of screendetected, asymptomatic adults with positive serological findings found initiation of a gluten-free diet associated with small improvement in gastrointestinal symptoms versus no gluten-free diet (less than 1 point on a 1 to 7 scale) at 1 year, with no differences on most measures of quality of life. No withdrawals due to adverse events occurred during the trial.
Limitations: Limited or no evidence for all key questions; limited to English language studies. Conclusions: More research is needed to understand the effectiveness of screening and treatment for CD in asymptomatic adults, adolescents, and children; accuracy of screening tests; and optimal screening strategies.

Screening programmes for developmental dysplasia of the hip in newborn infants (Review)

Shorter D, Hong T, Osborn DA

The Cochrane Collaboration and published in The Cochrane Library
2011, Issue 9. http://www.thecochranelibrary.com

Background
Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.
Objectives
To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.
Search methods
Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.
Selection criteria
Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.
Data collection and analysis
Three independent review authors assessed study eligibility and quality, and extracted data.
Main results
No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.
One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.
One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.
Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.
Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.
One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.
Authors’ conclusions
There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.

Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: U.S. Preventive Services Task Force Recommendation Statement

O'Connor E(1), Gaynes BN, Burda BU, Soh C, Whitlock EP.

Ann Intern Med. 2013 May 21;158(10):741-54. 

http://annals.org/article.aspx?articleid=1872851

-------------------------------------------------------------------------------------------------

[Description: Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for suicide risk.

Methods: The USPSTF reviewed the evidence on the accuracy and reliability of instruments used to screen for increased suicide risk, benefits and harms of screening for increased suicide risk, and benefits and harms of treatments to prevent suicide.

Population: This recommendation applies to adolescents, adults, and older adults in the general population who do not have an identified psychiatric disorder.

Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting. (I statement)]


-------------------------------------------------------------------------------------------------




BACKGROUND: In 2009, suicide accounted for 36 897 deaths in the United States.

PURPOSE: To review the accuracy of screening instruments and the efficacy and

safety of screening for and treatment of suicide risk in populations and settings
relevant to primary care.

DATA SOURCES: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of 

Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a

surveillance search of MEDLINE for additional screening trials (July to December 
2012).

STUDY SELECTION: Fair- or good-quality English-language studies that assessed the

accuracy of screening instruments in primary care or similar populations and
trials of suicide prevention interventions in primary or mental health care


settings.

DATA EXTRACTION: One investigator abstracted data; a second checked the
abstraction. Two investigators rated study quality.

DATA SYNTHESIS: Evidence was insufficient to determine the benefits of screening 

in primary care populations; very limited evidence identified no serious harms.
Minimal evidence suggested that screening tools can identify some adults at


increased risk for suicide in primary care, but accuracy was lower in studi


eMinimal evidence limited to high-risk populations suggested poor

performance of screening instruments in adolescents. Trial evidence showed that

psychotherapy reduced suicide attempts in high-risk adults but not adolescents.

Most trials were insufficiently powered to detect effects on deaths.

LIMITATION: Treatment evidence was derived from high-risk rather than

screening-detected populations. Evidence relevant to adolescents, older adults,
and racial or ethnic minorities was limited.

CONCLUSION: Primary care-feasible screening tools might help to identify some

adults at increased risk for suicide but have limited ability to detect suicide

risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk 

adults, but effective interventions for high-risk adolescents are not yet proven.

PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Informe SESPAS

Promoción de la salud y prevención en tiempos de crisis: el rol del sector sanitario. Informe SESPAS 2014

Este artículo revisa la evolución de los estilos de vida e identifica algunas prioridades y líneas de mejora en prevención y promoción de la salud en el momento actual de crisis económica. Se utilizan diversas fuentes, incluida una encuesta a 30 expertos/as en salud pública y atención primaria. Entre 2006 y 2012 no se detectan grandes cambios en estilos de vida, salvo un descenso en el consumo habitual de alcohol. Desciende ligeramente el consumo de drogas ilegales, pero aumenta el de psicofármacos. La mayoría de los/las expertos/as considera que debe mejorarse la toma de decisiones sobre cribados poblacionales y vacunas, incluyendo el análisis del coste de oportunidad, y mayor transparencia e independencia de los/las profesionales implicados/as. La prevención está contribuyendo a la medicalización de la vida, pero hay opiniones divididas sobre la necesidad de algunas actividades preventivas. Las prioridades en prevención están en el ámbito de la salud mental y de la infección por el virus de la inmunodeficiencia humana en grupos vulnerables. La mayoría de los/las expertos/as considera que las intervenciones de promoción de la salud tienen potencial para mitigar los efectos de la crisis, y que son grupos prioritarios la infancia, las personas desempleadas y otros grupos vulnerables. Son intervenciones prioritarias las actividades comunitarias en colaboración con ayuntamientos y otros sectores, la abogacía y la promoción de la salud mental. Se considera deseable un mayor uso de la legislación y de los medios de comunicación como herramientas de promoción. Es importante clarificar el rol del sector sanitario en las actividades intersectoriales, y reconocer las limitaciones, puesto que los determinantes sociales de salud dependen de otros sectores. Se advierte asimismo del riesgo derivado de los recortes y de las políticas que inciden negativamente en las condiciones de vida.

Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement.

U.S. Preventive Services Task Force (USPSTF). Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Nov 5;159(9):613-9. [12 references] PubMed  Description: Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for high blood pressure in children and adolescents. Methods: The USPSTF reviewed the evidence on screening and diagnostic accuracy of screening tests for blood pressure in children and adolescents, the effectiveness and harms of treatment of screen-detected primary childhood hypertension, and the association of hypertension with markers of cardiovascular disease in childhood and adulthood. Population: This recommendation applies to children and adolescents who do not have symptoms of hypertension. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood.

Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force

O`Connor E, Gaynes BN, Burda BU, et al. Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013 Apr 23. doi: 10.7326/0003-4819-158-10-201305210-00642. (Review) PMID: 23609101

BACKGROUND: In 2009, suicide accounted for 36 897 deaths in the United States.
PURPOSE: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care.
DATA SOURCES: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012).
STUDY SELECTION: Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings.
DATA EXTRACTION: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.
DATA SYNTHESIS: Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths.
LIMITATIONS: Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.
CONCLUSION: Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Large-Scale Use of the Modified Checklist for Autism in Low-Risk Toddlers

1. Colby Chlebowski, PhD^a, 
2. Diana L. Robins, PhD^b, 
3. Marianne L. Barton, PhD^c, and 
4. Deborah Fein, PhD^c,^d

1. ^aDepartment of Psychiatry, University of California, San Diego, San Diego, California;
2. ^bDepartment of Psychology, Georgia State University, Atlanta, Georgia;
3. ^cDepartments of Psychology and
4. ^dPediatrics, University of Connecticut, Storrs, Connecticut

ABSTRACT

OBJECTIVE: The purpose of the study was to examine use of the Modified Checklist for Autism in Toddlers (M-CHAT) as an autism-specific screening instrument in a large, geographically diverse pediatrics-based sample.

METHODS: The M-CHAT and the M-CHAT Follow-Up (M-CHAT/F) were used to screen 18 989 toddlers at pediatric well-child visits in 2 US geographic regions. Pediatricians directly referred children to ascertain potential missed screening cases. Screen-positive children received the M-CHAT/F; children who continued to screen positive after the M-CHAT/F received a diagnostic evaluation.

RESULTS: Results indicated that 54% of children who screened positive on the M-CHAT and M-CHAT/F presented with an autism spectrum disorder (ASD), and 98% presented with clinically significant developmental concerns warranting intervention. An M-CHAT total score cutoff of ≥3 identifies nearly all screen-positive cases, and for ease of scoring the use of only the M-CHAT total score cutoff is recommended. An M-CHAT total score of 7 serves as an appropriate clinical cutoff, and providers can bypass the M-CHAT/F and refer immediately to evaluation and intervention if a child obtains a score of ≥7.

CONCLUSIONS: This study provides empirical support for the utility of population screening for ASD with the use of the M-CHAT in a primary care setting. Results suggest that the M-CHAT continues to be an effective screening instrument for ASD when the 2-step screening process is used. The M-CHAT is widely used at pediatric offices, and this study provides updated results to facilitate use and scoring of the M-CHAT by clinical providers.

http://pediatrics.aappublications.org/content/131/4/e1121.abstract

Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants

1. Shorter D, Hong T, Osborn DA.
2. Evid.-Based Child Health. 2013;8(1):11–54.

Article first published online: 9 JAN 2013. DOI: 10.1002/ebch.1891

Abstract

Background

Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.

Objectives

To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.

Search methods

Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.

Selection criteria

Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.

Data collection and analysis

Three independent review authors assessed study eligibility and quality, and extracted data.

Main results

No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.

One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.

One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.

Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.

Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.

One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.

Authors' conclusions

There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.

USPSTF Perspective on Evidence-Based Preventive Recommendations for Children

Published online July 2, 2012 Pediatrics Vol. 130 No. 2 August 1, 2012
pp. e399 -e407
(doi: 10.1542/peds.2011-2087)

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge.
This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.

Identification of developmental-behavioral problems in primary care: a systematic review.

Pediatrics. 2011 Aug;128(2):356-63. Epub 2011 Jul 4.

Sheldrick RC, Merchant S, Perrin EC.

CONTEXT: Recent mandates and recommendations for formal screening programs are based on the claim that pediatric care providers underidentify children with developmental-behavioral disorders, yet the research to support this claim has not been systematically reviewed.

OBJECTIVE: To review research literature for studies regarding pediatric primary care providers' identification of developmental-behavioral problems in children.

METHODS: On the basis of a Medline search conducted on September 22, 2010, using relevant key words, we identified 539 articles for review. We included studies that (1) were conducted in the United States, (2) were published in peer-reviewed journals, (3) included data that addressed pediatric care providers' identification of developmental-behavioral problems in individual patients, (4) included an independent assessment of patients' developmental-behavioral problems, such as diagnostic interviews or validated screening instruments, and (5) reported data sufficient to calculate sensitivity and specificity. Studies were not limited by sample size. Eleven articles met these criteria. We used Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria to evaluate study quality. Although the studies were similar in many ways, heterogeneous methodology precluded a meta-analysis.

RESULTS: Sensitivities for pediatric care providers ranged from 14% to 54%, and specificities ranged from 69% to 100%. The authors of 1 outlier study reported a sensitivity of 85% and a specificity of 61%.

CONCLUSIONS: Pediatricians are often the first point of entry into developmental and mental health systems. Knowing their accuracy in identifying children with developmental-behavioral disabilities is essential for implementing optimal evaluation programs and achieving timely identification. Moreover, these statistics are important to consider when planning large-scale screening programs.

PMID: 21727101  [PubMed - in process]

Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age)

Robert D. Baker, MD, PhD, Frank R. Greer, MD and The Committee on Nutrition
PEDIATRICS Vol. 126 No. 5 November 2010, pp. 1040-1050 (doi:10.1542/peds.2010-2576)

Recommendations
Major Recommendations
Given that iron is the world's most common single-nutrient deficiency and there is some evidence of adverse effects of both iron deficiency (ID) and iron-deficiency anemia (IDA) on cognitive and behavioral development, it is important to minimize ID and IDA in infants and toddlers without waiting for unequivocal evidence. Controversies remain regarding the timing and methods used for screening for ID/IDA as well as regarding the use of iron supplements to prevent ID/IDA. Although further study is required to generate higher levels of evidence to settle these controversies, the currently available evidence supports the following recommendations.

Term, healthy infants have sufficient iron for at least the first 4 months of life. Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID after 4 completed months of age. Therefore, at 4 months of age, breastfed infants should be supplemented with 1 mg/kg per day of oral iron beginning at 4 months of age until appropriate iron-containing complementary foods (including iron-fortified cereals) are introduced in the diet (see Table 3 in the original guideline document). For partially breastfed infants, the proportion of human milk versus formula is uncertain; therefore, beginning at 4 months of age, partially breastfed infants (more than half of their daily feedings as human milk) who are not receiving iron containing complementary foods should also receive 1 mg/kg per day of supplemental iron.
For formula-fed infants, the iron needs for the first 12 months of life can be met by a standard infant formula (iron content: 12 mg/dL) and the introduction of iron-containing complementary foods after 4 to 6 months of age, including iron-fortified cereals (see Table 3 in the original guideline document). Whole milk should not be used before 12 completed months of age.
The iron intake between 6 and 12 months of age should be 11 mg/day. When infants are given complementary foods, red meat and vegetables with higher iron content should be introduced early (see Table 3 in the original guideline document). To augment the iron supply, liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods.
Toddlers 1 through 3 years of age should have an iron intake of 7 mg/day. This would be best delivered by eating red meats, cereals fortified with iron, vegetables that contain iron, and fruits with vitamin C, which augments the absorption of iron (see Tables 3 and 4 in the original guideline document). For toddlers not receiving this iron intake, liquid supplements are suitable for children 12 through 36 months of age, and chewable multivitamins can be used for children 3 years and older.
All preterm infants should have an iron intake of at least 2 mg/kg per day through 12 months of age, which is the amount of iron supplied by iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron. An exception to this practice would include infants who have received an iron load from multiple transfusions of packed red blood cells.
Universal screening for anemia should be performed at approximately 12 months of age with determination of hemoglobin (Hb) concentration and an assessment of risk factors associated with ID/IDA. These risk factors would include low socioeconomic status (especially children of Mexican American descent [see Table 1 in the original guideline document]), a history of prematurity or low birth weight, exposure to lead, exclusive breastfeeding beyond 4 months of age without supplemental iron, and weaning to whole milk or complementary foods that do not include iron-fortified cereals or foods naturally rich in iron (see Table 3 in the original guideline document). Additional risk factors are the feeding problems, poor growth, and inadequate nutrition typically seen in infants with special health care needs. For infants and toddlers (1–3 years of age), additional screening can be performed at any time if there is a risk of ID/IDA, including inadequate dietary iron intake.
If the Hb level is less than 11.0 mg/dL at 12 months of age, then further evaluation for IDA is required to establish it as a cause of anemia. If there is a high risk of dietary ID as described in point 6 above, then further testing for ID should be performed, given the potential adverse effects on neurodevelopmental outcomes. Additional screening tests for ID or IDA should include measurement of:
Serum ferritin (SF) and C-reactive protein (CRP) levels
Reticulocyte hemoglobin content (CHr) concentration
If a child has mild anemia (Hb level of 10-11 mg/dL) and can be closely monitored, an alternative method of diagnosis would be to document a 1 g/dL increase in plasma Hb concentration after 1 month of appropriate iron-replacement therapy, especially if the history indicates that the diet is likely to be iron deficient.
Use of the serum transferrin receptor 1 (TfR1) assay as screening for ID is promising, and the American Academy of Pediatrics (AAP) supports the development of TfR1 standards for use of this assay in infants and children.
If IDA (or any anemia) or ID has been confirmed by history and laboratory evidence, a means of carefully tracking and following infants and toddlers with a diagnosis of ID/IDA should be implemented. Electronic health records could be used not only to generate reminder messages to screen for IDA and ID at 12 months of age but also to document that IDA and ID have been adequately treated once diagnosed.

Identification and management of familial hypercholesterolaemia

Identification and management of familial hypercholesterolaemia.

Excelente guía de la prestigiosa NICE, editada en 2008. recomendable para pediatras y médicos de familia:

1 Guidance..................................................................................................6
1.1 Diagnosis...........................................................................................6
1.2 Identifying people with FH using cascade testing..............................9
1.3 Management....................................................................................10
1.4 Information needs and support........................................................20
1.5 Ongoing assessment and monitoring..............................................22

Y más y más