Keep spreading it around….some thoughts on cold and flu treatments

I think it is irresponsible to encourage someone who may well have an infectious illness like influenza to take a tablet so they can feel better, return to school and infect a classroom of small children.

Reckitt Benckiser (Australia) Pty Limited the markers of Nurofen Cold and Flu is not the only Pharmaceutical manufacturer who puts profits ahead of common sense and evidence in their marketing,

Pfizer Consumer Healthcare sell the same message at http://www.dimetapp.com.au/tvc.html. Only in this add its okay to contaminate a public swimming pool with your virus!

Johnson & Johnson Pacific Pty Limited would have you take Coldral to keep you soldiering on …. to pass on the cold to all your friends. Go Audrey!

South Australia’s Health Department advises the best way to slow down the spread of influenza is to get vaccinated.  The Influenza Management Guideline for Emergency Departments and General Practice suggests isolation and face masks whilst being assessed. Furthermore, if the patient doesn’t require admission to hospital encourage the patient to stay at home and practice good hand hygiene and cough etiquette. If going outside house, strongly encourage the patient to keep at least 1 metre away from other people and to use cough etiquette. Patting kids on the head in the playground is neither. The NSW Health Department specifically recommends symptomatic people should not attend school, child care, work or public gatherings.

Most people with influenza recover with rest, drinking plenty of fluids and use of paracetamol for the relief of pain and fever.

There are specific prescription-only drugs that may be useful in influenza. These are not antibiotics; antibiotics are not useful for treating viral illnesses such as influenza.

Amantadine and rimantadine are effective only against the influenza A virus and work by by blocking viral replication inside the host cell.  However, they are associated with several toxic effects and with the rapid emergence of drug-resistance. Oseltamivir and zanamivir act against influenza A and B by preventing influenza viral release from infected cells. They work by blocking neuraminidase  and are less likely to cause resistance or serious adverse effects. Because replication of influenza virus reaches its peak within 24 to 72 hours after the onset of the illness, antiviral drugs are needed to be used as early as possible and within the first 48 hours of symptom onset. When initiated within 36 to 48 hours of the onset of symptoms, zanamivir shortened the time until the alleviation of symptoms by 1 to 1.5 days compared with a placebo! Back to work Tuesday rather than Wednesday!!

Is there any clinical evidence that any of these over the counter well marketed do any good? Has Reckitt Benckiser, Pfizer, Johnson &  Johnson or any number of Pharmaceutical companies conducted and published randomised clinical trials proving benefit of these products? It’s not as if there is a lack of suitable subjects.

In a similar vein, Cochrane has shown there is no good evidence for or against the effectiveness of OTC medicines in acute cough. Studies often showed conflicting results with uncertainty regarding clinical relevance.

And if these products don’t do any good can they do harm? Well yes and particularly in children. Sarfstein et al argue in the NEJM (Over the Counter but No Longer under the Radar) that there is no evidence of effectiveness particularly in children and documented harm. Cardiac arrhythmias, hallucinations, convulsions, altered consciousness and encephalopathy are some of the severe side effects. In the US, an FDA review implicated symptomatic cold and flu treatments in 123 deaths of children under six years of age. In Australia the TGA suggested in November 2012 that children under six should not be given these medications.

After the rant how about a bit of science…….

A glance at how the flu-virus interacts with our cells makes it understandable that finding a cure is going to be tricky!

1741-7015-10-104-1Anti-influenza drugs and their biological targets. The relevant viral proteins (color-coded) and old and new drugs targeting them are shown (not drawn to scale). The genomic ribonucleoprotein complex is shown as tightly coiled. Influenza viral RNA synthesis occurs in the infected host nucleus using this ribonucleoprotein as a template, while translation occurs in the cytoplasm. Neuraminidase (NA) and the drug candidate, Fludase, cleave the sialic acid receptor on the cell membrane, as indicated by the cutting scissors. Nonstructural proteins (only NS1 is shown) are not packaged in mature virions. Diverse viral products activate an inflammatory response that can be quelled by the use of anti-inflammatory treatments, such as non-steroidal anti-inflammatory drugs. Potential future drug regimens, targeting influenza-relevant cellular functions, are shown at the bottom. (Influenza virion image credit: Dan Higgins and Doug Jordan, CDC Public Health Photo Library, image #11822). HA: hemagglutinin; IFN: interferon; NA: neuraminidase; NS: nonstructural protein; RNP: ribonucleoprotein.  Barik BMC Medicine 2012 10:104   doi:10.1186/1741-7015-10-104

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Stop sucking the baby

Sometimes you see a paper published and think why was that study done?

I know everything has to be evidence based these days, forget about consensus, and wisdom of the elderly experienced practitioner or just even common sense it would seem.

I have been delivering babies for 10 years or so now and at the start I was taught only to do oronasopharyngeal suction on the perineum if there was meconium. Now I believe that is also been shown to be of little use.

I was a little surprised seeing this paper published in the Lancet from a US study. Also surprising, the paper has 13 authors!

Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial.

Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T, Owen J, Ambalavanan N, Carlo WA. Lancet. 2013 Jul 27;382(9889):326-30. doi: 10.1016/S0140-6736(13)60775-8. Epub 2013 Jun 3.

BACKGROUND: Wiping of the mouth and nose at birth is an alternative method to oronasopharyngeal suction in delivery-room management of neonates, but whether these methods have equivalent effectiveness is unclear.

METHODS: For this randomised equivalency trial, neonates delivered at 35 weeks’ gestation or later at the University of Alabama at Birmingham Hospital, Birmingham, AL, USA, between October, 2010, and November, 2011, were eligible. Before birth, neonates were randomly assigned gentle wiping of the face, mouth (implemented by the paediatric or obstetric resident), and nose with a towel (wipe group) or suction with a bulb syringe of the mouth and nostrils (suction group). The primary outcome was the respiratory rate in the first 24 h after birth. We hypothesised that respiratory rates would differ by fewer than 4 breaths per min between groups. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01197807.

FINDINGS: 506 neonates born at a median of 39 weeks’ gestation (IQR 38-40) were randomised. Three parents withdrew consent and 15 non-vigorous neonates with meconium-stained amniotic fluid were excluded. Among the 488 treated neonates, the mean respiratory rates in the first 24 h were 51 (SD 8) breaths per min in the wipe group and 50 (6) breaths per min in the suction group (difference of means 1 breath per min, 95% CI -2 to 0, p<0·001).

INTERPRETATION: Wiping the nose and mouth has equivalent efficacy to routine use of oronasopharyngeal suction in neonates born at or beyond 35 weeks’ gestation.

My midwife friends tell me babies are delivered a little different in the USA than Australia. But I am glad that my lack of suction over the last 10 years has note caused any harm.

Now going back to sucking away the meconium

It does seem logical that if you have a flat baby which hasn’t made a respiratory effort and its mouth is full of pea soup (puts you off the idea of that for a winter dinner) then sucking it away seems like a good idea before providing some respiratory support.

However there have been studies done which discount this logic. And it is probably based on the preposition that the baby has already inhaled the meconium well before it got into your hands in its journey through the birth canal.

With reference to another Lancet article this time from Argentina

Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial.

Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Lancet. 2004 Aug 14-20;364(9434):597-602.

BACKGROUND:  Meconium aspiration syndrome (MAS) is a life-threatening respiratory disorder in infants born through meconium-stained amniotic fluid (MSAF). Although anecdotal data concerning the efficacy of intrapartum oropharyngeal and nasopharyngeal suctioning of MSAF are conflicting, the procedure is widely used. We aimed to assess the effectiveness of intrapartum suctioning for the prevention of MAS.

METHODS: We designed a randomised controlled trial in 11 hospitals in Argentina and one in the USA. 2514 patients with MSAF of any consistency, gestational age at least 37 weeks, and cephalic presentation were randomly assigned to suctioning of the oropharynx and nasopharynx (including the hypopharynx) before delivery of the shoulders (n=1263), or no suctioning before delivery (n=1251). Postnatal delivery-room management followed Neonatal Resuscitation Program guidelines. The primary outcome was incidence of MAS. Clinicians diagnosing the syndrome and designating other study outcomes were masked to group assignment. An informed consent waiver was used. Analysis was by intention to treat.

FINDINGS: 18 infants in the suction group and 15 in the no suction group did not meet entry criteria after random assignment. 87 in the suction group were not suctioned, and 26 in the no suction group were suctioned. No significant difference between treatment groups was seen in the incidence of MAS (52 [4%] suction vs 47 [4%] no suction; relative risk 0.9, 95% CI 0.6-1.3), need for mechanical ventilation for MAS (24 [2%] vs 18 [1%]; 0.8, 0.4-1.4), mortality (9 [1%] vs 4 [0.3%]; 0.4, 0.1-1.5), or in the duration of ventilation, oxygen treatment, and hospital care.

INTERPRETATION: Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF does not prevent MAS. Consideration should be given to revision of present recommendations.