Pediatric injuries in emergency room, Ramathibodi Hospital.

The purposes of this study were to analyze the epidemiological data of child injuries from the computerized data system of the emergency room at Ramathibodi Hospital from June 1995 to May 1996 and assess the accuracy of triage system for child injury cases. Among 14,427 pediatric patients, 1,023 patients (7%) were injured. Most were under 5 years of age (48%), and most were male. Twenty-five per cent of cases were triaged as true emergency cases. Twelve per cent were disposed on an admission or referral by physicians. The negative predictive value of triage system to classify as a non-urgent was 91 per cent. Common causes of injury included falls (38%), inanimate force (19%), transportation (14%), and animal bite (12%). Older age group had significantly more severe injuries than younger (p = 0.002). However, only the transportation injuries were significantly more severe than other types (p = 0.003). The present ER-based injury surveillance system is useful to describe the basic epidemiology of pediatric injuries and to evaluate the triage system. However, for injury prevention purposes, the injury surveillance system should include more data of injury circumstances, associated environment and products.

Cyanide poisoning, 2 cases report and treatment review.

Two patients, a 4-year-old girl and her brother 1 1/2 year-old, with cyanide poisoning are reported. They vomited and became comatose 9 hours after ingestion of boiled cassava. At a community hospital, they were intubated and given ventilatory support. The girl was transferred to Ramathibodi Intensive Care Unit. At 19 hours after ingestion, sodium nitrite and sodium thiosulfate were given as well as other supportive treatment. She recovered with normal breathing on the next day. The boy was referred to Ramathibodi 4 hours later. On arrival, he appeared normal except for the bitter almond breathe. Only supportive treatment was given. Their blood cyanide levels on arrival were 0.56 and 0.32 microgram/ml (normal value < 0.3 microgram/ml) respectively confirming the diagnosis of cyanide poisoning. Other abnormal laboratory findings included metabolic acidosis and lactic acidemia. The pathogenesis and management of cyanide poisoning are reviewed.

Blood lead level in Bangkok children.

Lead poisoning is one of the most harmful pollutant in children since it permanently effects the growth and intelligence. OBJECTIVE: To evaluate the lead problem in Bangkok children and identify risk factors and impact associated with high lead levels (> 10 micrograms/dL). MATERIALS AND METHODS: The longitudinal study (N = 84) followed blood lead levels at birth, 6, 12, 18 and 24 months of age. Also multiple cross-sectional studies comprising of children under 15 years of age attending the outpatient clinic, Ramathibodi Hospital (N = 511), kindergartens (N = 60) and secondary school students (N = 377) in Bangkok were conducted. The control for under 2 year-old children (N = 188) were those attending Metapracharak Hospital, Nakornprathom Province. Physical examinations were performed by pediatricians. Blood lead levels were assessed by Atomic Absorption Spectrometry. Questionnaires to identify risk factors were completed by parents of under 2-year-old children. Standford Binet tests were performed by psychologists for assessing the IQ in the longitudinal group at 2 years of age. RESULTS: The mean blood lead levels were increasing with age from 5.57 +/- 2.31 micrograms/dL at birth, to 4.75 +/- 3.25 micrograms/dL at 2 years of age, 6.74 +/- 2.02 micrograms/dL in kindergartens, and 9.03 +/- 3.65 micrograms/dL in secondary school students. They were in the acceptable range. However, the proportion of blood lead higher than 10 micrograms/dL were increasing from 1 to 6, 10 per cent at birth to 6 per cent at 2 years of age, 10 per cent in kindergartens and 35 per cent in secondary school students. The mean lead level in Bangkok children under 2 years of age was higher than those of the control group in Nakornprathom province, but not statistically significant. In addition, there was no identified significant risk factor except that the high lead group had a higher mean age and larger family size than those in the low lead group. In the kindergartens and secondary school, males had higher lead levels than females in the same age group. CONCLUSION: The blood lead levels in Bangkok children were not as high as expected. On the contrary, they tended to decrease following the reduction of ambient lead levels due to unleaded gasoline usage.

Risk factors associated with morbidity and mortality of pneumonia in Thai children under 5 years.

ARI is the most common cause of illness and death in children under 5 years of age. Pneumonia is the leading cause of death. This prospective study was part of an ARIC project conducted to identify risk factors associated with mortality and morbidity of community acquired pneumonia in Thai children younger than 5 years of age. Study subjects were 267 moderately severe pneumonia who were admitted to hospital. Fifteen percent required a ventilator and were categorized as severe cases. Nine patients (3.4%) died and were categorized in the fatal group. From univariate analysis only, risk factors of fatal pneumonia were lower body weight (p = 0.04), paternal age less than 35 year (OR = 6.1, p = 0.01), underlying heart disease (OR = 12.1, p = 0.0000) and protein energy malnutrition (OR = 7.9, p = 0.0087). Predictors on admission to predict fatal outcome were rapid respiratory rate > 50/minute (OR = 4.1, p = 0.03), gallop rhythm (OR = 11, p = 0.04), enlarged liver (OR = 13.2, p = 0.001), and cyanosis (OR = 12, p = 0.0006). Significant factors associated with severe pneumonia after multiple logistic regression were underlying heart disease (OR = 4.04, 95% CI 1-15.4), enlarged liver (OR = 4.31, 95% CI 1.2-15.2) and cyanosis (OR = 5, 95% CI 0.8-28.7). This information should create awareness in physicians who are responsible for young children with pneumonia. Early recognition and intervention may prevent deaths and complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Laboratory investigation utilization in pediatric out-patient department Ramathibodi Hospital.

HYPOTHESES: Laboratory investigations are inappropriately utilized in the Pediatric OPD of Ramathibodi Hospital and this is due to lack of knowledge and unawareness of the cost of tests. OBJECTIVES: 1) To obtain information on laboratory utilization. 2) To evaluate the appropriateness of the residents' test ordering behavior. 3) To estimate the cost of unnecessary tests. 4) To reduce the utilization by combined education, feedback, and peer-review strategies. STUDY DESIGN: Randomized controlled trial carried out from January 1987 to May 1988, consisting of pre-intervention period (Jan-May 1987). intervention period (June-November 1987), and post-intervention period (July 1987-May 1988). STUDY POPULATION: There were 3 intervention groups and 3 control control groups which were stratified by level of seniority as 10 first year residents (R1I vs R1C), 8 second year residents (R2I vs R2C), and 18 staff (SI vs SC). INTERVENTION: For the residents, education on diagnostic tests, chart audit and feedback on their test ordering behavior were provided twice a week. The second year residents also played an active role in giving comments on the first year residents' performances. For the staff, the strategy used was peer-review. The simulated cases derived from the actual medical records serviced by the residents were reviewed and rated, according to the appropriateness of the residents' test ordering behavior, from 0 (poor) to 10 (excellent). A score of less than 5 was considered to indicate inappropriate ordering behavior. OUTCOME: 1) Numbers and cost of tests per patient for each group. 2) The achievement of a score indicating appropriate test ordering behavior of the resident groups. STATISTICAL ANALYSIS: Kruskal-Wallis test, Mann Whitney test, Wilcoxon test and Chi-square test. RESULTS: 1. The utilization pattern was not correlated to the level of seniority of the physicians. 2. There was inappropriate laboratory utilization in this group of residents: overutilization defined as should not be ordered (26.9%), and underutilization defined as should have been ordered (17.7%). Most of the inappropriateness occurred in the ordering of microbiology (50%) and special blood chemistry (40%). 3. Only the number of tests per patient ordered by the R2I group was significantly lower than that of the R2C group in the late post-intervention period. The cost of tests per patient ordered by the R2C group was significantly increased as compared to their baseline. This suggested that the combination of education, chart audit and active feedback strategies was more effective than each strategy alone. 4. The appropriateness of the test ordering behavior of the resident intervention groups improved during the post-intervention period, although the change was not statistically significant. The control groups' behavior was statistically worse. This suggested that the strategy prevented the inappropriateness of test ordering behavior. 5. With the intervention, the overutilization significantly decreased while the underutilization increased. The underutilization might be a consequence of cost containment on laboratory utilization. 6. The cost of unnecessary tests accounted for 17.6 per cent of the total cost of tests ordered by the residents.

Correlation of roentgenologic diagnosis and etiologic agents of pneumonia in thai children under 5 years of age.

An attempt to distinguish between viral and bacterial pneumonia from radiographs is usually difficult unless there is a pathognomonic type of infiltration such as parahilar peribronchial infiltration commonly seen in viral pneumonia which can be usually be differentiated easily from that of bacterial pneumonia. Percentage of agreement of roentgenographic diagnosis for bacterial pneumonia, viral pneumonia and mixed infection is about 53, 73.3 and 63.9 per cent respectively.

Childhood trauma, country report (Thailand).

In Thailand, each year approximately 15,000 people die from accidents, a figure exceeded only by cardiovascular diseases. Motor vehicle accidents (MVA) is the principal cause of death and injuries in children of all ages except preschool group. In 1988 there were 554,452 cases of injuries out of which 10,031 died from MVA. In Bangkok alone MVA accounts for an average of 300 childhood and teenage death and 1,900 cases of injuries each year. Falls, burns and poisonings are relatively high in children less than 4 years old while MVA and injuries from sharp and blunt objects of both accidental and non-accidental cases increase with age and become the two leading causes of injury in older children. The sex ratio (F:M) in preschool ages are 1:1.4 and 1:2 in preteen. Poisonings, though less common, are considered to be very important because of their severity. Drugs, hydrocarbon, insecticides, lead and corrosive substances are leading agents. As for injuries caused by animals, 150 cases of rabies were reported each year while around 5,000 cases of snake bites were found in 1987 and 20 per cent of the victims were children. The study from Ramathibodi Hospital revealed that the majority of accidents (65-72%) occur at home and 20 per cent in the street in children younger than 12 years. Peak incidence were found between 5-9 pm. During weekend and holidays the incidence is higher. Ninety-five per cent of the accidents reported were mild cases, 15 per cent moderate, 3 per cent severe and less than 1 per cent caused death.

Serum bilirubin levels in breast-fed vs formula-fed infants during the first 3-5 days of life.

Breast feeding seems to be a cause of neonatal jaundice during the first five days of life; the mechanism of which needs further study. Thai infants appear to exhibit a higher level of "physiological jaundice" bilirubin level than Caucasians.

Epidemiology and risk factors of injury in Thai children.

A case-control study was carried out to identify risk factors of injury in 200 children (mean age 6.68 +/- 3.9 years) attending the Emergency Room, Ramathibodi Hospital from April to August 1987. Traffic and falls were the most common causes of injuries in all age groups. Falls, traffic and sport injuries were responsible for the age-specific injury in infants, 1-10 years and more than 10 year-old children respectively. Most of the injuries occurred at home and on the street, during school term, working day, and between 3-8 pm. Twenty two percent of them needed hospitalization. Another 200 patients, matched sex and age range (mean age 6.38 +/- 3.8 year) from the general out patient department were selected as controls. Parents or care providers were interviewed. The result showed that boys, children older than 6 years of age not attending school, higher rank of order of the child in the family, large family size, the more care providers at the time, parental education lower than primary school level and low family income were risk factors of injury in these children (OR = 1.8, 2.4, 1.6-2.7, 1.7-3.3, 6.2, 2.1, 1.8 and 2.4 respectively).

Oral rehydration therapy in a rural area, northern Thailand.

A cross-sectional sampling survey of mothers' practice of ORT in Amphoe Bunpotphesai in the northern part of Thailand included 1,619 children under five. Two hundred and six children were reported to have 223 diarrheal episodes. The incidence of diarrhea in children under five was 3.4 episodes per child per year. When children had diarrhea 65.5 per cent of mothers sought help from health providers, 25.2 per cent treated their children with drugs bought from stores, 2.3 per cent used herbal medicine and 6.1 per cent did not treat their children. 50.7 per cent of diarrheal episodes mother gave ORT, using ORS 19.7, commercial electrolytes mixture 16.6 and home available fluid 14.4 per cent. The accuracy of dilution of electrolytes powder from the packets was checked in 80 incidences. 31.8 and 27.8 per cent of mothers made correct dilution of ORS and commercial electrolytes products respectively. Health providers carried both ORS and commercial electrolytes packets. ORS added to a glass of water was found in 13.6 per cent which was 3 times concentrated. Commercial electrolytes products were too dilute in 72.2 per cent. 17.5 per cent of mothers divided electrolytes powder to add in one spoon of water to treat their children as one drug dose. Data showed that the ORT use rate was 50.7 per cent. Home available fluid was used by 14.4 per cent. ORT should be further promoted to control diarrheal diseases and health providers should give instructions to every mother or child minder on how to dispense ORS or electrolytes packets for appropriate dilution and use.

Childhood accidents.

Injuries and poisoning are increasingly common causes of mortality, mobidity, and disability in children all over the world; not to speak of the socio-economic cost and human suffering involved. By trying to change the perception of unavoidable or unpreventable accidents to injury syndromes which have an 'agent-host-environment' model as any disease, we can understand better the epidemiology of injuries. All kinds of energy can injure children who by nature are at risk. Their curiosity, limited knowledge, developmental ability at a certain age, in addition to some anatomical disadvantages increase childhood injury-rates. Boys have a higher rate than girls in every age group which may be due to higher exposure to risk, as well as their more aggressive and overactive behaviour. Under inappropriate adult supervision and unsafe environment, tragedies will always happen. Maternal factors, including age, education, physical and mental health, directly effect childhood injury rates. Other environmental factors are home and neighbouring safety, parent's type of work, and socio-economic status. Without knowledge of how important injuries are, how they occur, and which population is at risk, one will never find how to prevent injuries at all.