Near-fatal pediatric methemoglobinemia secondary to intentional sodium nitrite ingestion.

Methemoglobinemia is the result of inappropriate oxidation of hemoglobin iron groups, leading to a failure of oxygen transport and delivery, resulting in a clinical state of refractory hypoxia. Methemoglobin levels above 70% are often considered fatal. Acquired methemoglobinemia can be caused by a variety of substances, including sodium nitrite, a commercially available food preservative and color fixative. This report describes a patient presenting with a methemoglobin level of 83% secondary to intentional sodium nitrite ingestion. The methemoglobin level recorded is amongst some of the highest found in surviving patients.

Managing an acute asthma exacerbation in children.

Children and youth with acute asthma exacerbations frequently present to an emergency department with signs of respiratory distress. The most severe episodes are potentially life-threatening. Effective treatment depends on the accurate and rapid assessment of disease severity at presentation. This statement addresses the assessment, management, and disposition of paediatric patients with a known diagnosis of asthma who present with an acute asthma exacerbation. Guidance includes the assessment of asthma severity, treatment considerations, proper discharge planning, follow-up, and prescription for inhaled corticosteroids to prevent exacerbation and decrease chronic morbidity.

La prise en charge des exacerbations aiguës de l'asthme chez les enfants.

Les enfants et les adolescents atteints d'exacerbations aiguës de l'asthme se rendent souvent à l'urgence à cause de signes de détresse respiratoire. Les épisodes les plus graves ont un potentiel mortel. Pour que les traitements soient efficaces, le patient doit faire l'objet d'une évaluation exacte et rapide de la gravité de la crise d'asthme. Le présent document de principes traite de l'évaluation, de la prise en charge et de la disposition des patients pédiatriques ayant un diagnostic connu d'asthme qui consultent à cause d'une exacerbation aiguë. Les directives portent sur l'évaluation de la gravité de l'asthme, les considérations thérapeutiques, le plan de congé approprié, le suivi et la prescription de corticostéroïdes inhalés pour éviter de nouvelles exacerbations et limiter la morbidité chronique.

Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A Network Meta-analysis.

CONTEXT: Uncertainty exists as to which treatments are most effective for bronchiolitis, with considerable practice variation within and across health care sites. OBJECTIVE: A network meta-analysis to compare the effectiveness of common treatments for bronchiolitis in children aged ≤2 years. DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to September 1, 2019. STUDY SELECTION: A total 150 randomized controlled trials comparing a placebo or active comparator with any bronchodilator, glucocorticoid steroid, hypertonic saline solution, antibiotic, helium-oxygen therapy, or high-flow oxygen therapy were included. DATA EXTRACTION: Data were extracted by 1 reviewer and independently verified. Primary outcomes were admission rate on day 1 and by day 7 and hospital length of stay. Strength of evidence was assessed by using Confidence in Network Meta-Analysis . RESULTS: Nebulized epinephrine (odds ratio: 0.64, 95% confidence interval [CI]: 0.44 to 0.93, low confidence) and nebulized hypertonic saline plus salbutamol (odds ratio: 0.44, 95% CI: 0.23 to 0.84, low confidence) reduced the admission rate on day 1. No treatment significantly reduced the admission rate on day 7. Nebulized hypertonic saline (mean difference: -0.64 days, 95% CI: -1.01 to -0.26, low confidence) and nebulized hypertonic saline plus epinephrine (mean difference: -0.91 days, 95% CI: -1.14 to -0.40, low confidence) reduced hospital length of stay. LIMITATIONS: Because we did not report adverse events in this analysis, we cannot make inferences about the safety of these treatments. CONCLUSIONS: Although hypertonic saline alone, or combined with epinephrine, may reduce an infant's stay in the hospital, poor strength of evidence necessitates additional rigorous trials.

Severe alcohol intoxication among Canadian Youth: A 2-year surveillance study.

PURPOSE: To obtain data on Canadian youth, aged 11 to 15 years, presenting to paediatric emergency departments, with severe alcohol intoxication and to describe demographics, presentations to hospital, concurrent substance use, comorbidities, and short-term outcomes of admission to emergency departments. METHODS: Between March 2013 and February 2015, through the established methodology of the Canadian Paediatric Surveillance Program, Canadian paediatricians and paediatric subspecialists were surveyed monthly to identify cases of young adolescents presenting to paediatric emergency departments across Canada with severe alcohol intoxication. Those that identified cases were subsequently sent a detailed questionnaire. The detailed questionnaires were then screened to ensure the reported cases met the study's inclusion criteria. RESULTS: A total of 39 cases (18 females and 21 males) were included in the final analysis. Overall, results indicate over 90% of presenting youth had consumed spirits, 39% had concurrent substance use and 46% experienced serious medical morbidity. Almost two-thirds of youth were admitted to hospital for a period ranging from 10 hours to 5 days; 12 youth required intubation. Follow-up referrals were provided to two-thirds of youth, with variable supports given. No statistically significant differences between sexes were noted for blood alcohol level or concurrent substance use. CONCLUSION: Although rates of alcohol use in adolescents have been steadily decreasing, results from this surveillance study suggest that severe intoxication arising from the use of alcohol alone, and with concurrent substance use, results in significant immediate health consequences in young adolescents. Results from this study also highlight characteristics of patients, initial treatments and initial referrals across Canadian paediatric healthcare facilities, the results of which highlight variability and may aid in the guidance of a future longitudinal study, prevention strategies, and public health messaging.

Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis.

OBJECTIVE: Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children. DESIGN: Systematic review of primary studies. DATA SOURCES: Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017. ELIGIBILITY CRITERIA: Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days. DATA EXTRACTION AND SYNTHESIS: One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose. RESULTS: Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events. CONCLUSIONS: Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.

Parents' and caretakers' perceptions and concerns about accessibility of antenatal services by pregnant teenagers in Mbarara Municipality, Uganda.

BACKGROUND: Uganda has one of the highest teenage pregnancy rates in Sub-Saharan Africa and the world. About a quarter of teenagers become pregnant annually. This is much higher than the global rate of 11%. When a teenager becomes pregnant, caring responsibilities are usually shared between the teenage mother and the baby's grandmother. Previous research has largely focused on the experiences of teenagers, leaving out the parents and caregivers. This paper describes parents and caretakers' perceptions and concerns about accessibility of antenatal services by pregnant teenagers in three divisions of Mbarara Municipality in southwestern Uganda. METHODS: This was a qualitative cross-sectional descriptive study. Thirty in-depth interviews with parents and caregivers were conducted. The study was conducted in the Nyamitanga, Kakoba and Kamukuzi divisions in Mbarara Municipality, southwestern Uganda. Data analysis was done manually by identifying emergent themes which were then coded and organized into concepts which were later developed into explanations. RESULTS: According to parents and other caregivers, teenage pregnancy is considered a significant challenge both for themselves and for the teenagers. Often, pregnant teenagers lack information on the available antenatal care services. They struggle with stigma and also lack social and financial support from parents. In addition, the teenagers lack support from reproductive health workers. The parents and caregivers also struggle with the stigma of their children's pregnancy and are often unaware of any available teenager friendly ANC services. CONCLUSIONS: Parents and caregivers find it difficult to cope with their children's pregnancy. They are not aware of any existing teenager-friendly antenatal services, yet antenatal services specifically targeting teenagers are necessary. In planning programs for antenatal services, parents and caregivers also need to be equipped with knowledge and skills required for them to guide and support the pregnant teenagers.

Prehospital dexamethasone administration in children with croup: a medical record review.

OBJECTIVES: Croup is one of the most common childhood respiratory illnesses. Early dexamethasone administration in croup can improve patient outcomes. The objective of this study was to assess the clinical impact of prehospital administration of dexamethasone to children with croup. METHODS: A medical record review that included children between 6 months and 6 years, who were brought via emergency medical services (EMS) to the emergency department (ED) with a final diagnosis of croup, between January 2010 and December 2012, was conducted. Data were collected regarding prehospital management and ED management, length of stay (LOS), final disposition, and patient demographics. RESULTS: A total of 188 patients with an ED diagnosis of croup were enrolled, 35.1% (66/188) of whom received a prehospital diagnosis of croup. The mean age of the participants was 32.96±17.18 months and 10.6% (20/188) were given dexamethasone in the prehospital setting by EMS, while 30.3% (57/188) were given epinephrine nebulizations. Out of the 66 patients with a prehospital diagnosis of croup, 10.6% (7/66) were given dexamethasone by EMS. In ED, dexamethasone was administered to 88.3% (166/188) while 29.8% of participants (56/188) received epinephrine nebulizations. There was no significant difference in ED LOS between those who received prehospital dexamethasone (2.6±1.6 hours, n=18) and those who did not (3.3±2.7 hours, n=159) (P=0.514). The number of in-hospital epinephrine doses per patient was significantly influenced by the administration of prehospital dexamethasone (P=0.010). CONCLUSIONS: Prehospital administration of dexamethasone results in less ED epinephrine use and may reflect dexamethasone's positive influence on the severity and short-term persistence of croup symptoms.

Single-Use Detergent Sacs: A Retrospective Multicenter Canadian Review of Emergency Department Cases.

BACKGROUND: Single-use detergent sacs (SUDS) are widely used in North America and Europe with emerging literature on their toxicity. This is the first Canadian multicenter study aimed to quantify and compare SUDS exposures to traditional detergent exposures. METHODS: A retrospective review of the Canadian Hospitals Injury Reporting and Prevention Program databases was conducted at the Hospital for Sick Children in Toronto, Alberta Children's Hospital in Calgary and the Stollery Children's Hospital in Edmonton. All exposures presenting to these 3 centers between 2009 and 2014 were identified, a case form was completed, and data were analyzed. RESULTS: Forty cases of SUDS exposure were identified alongside 35 cases of traditional detergent exposure during the study period resulting in an incidence of 3.16 SUDS exposures per million children per year presenting to tertiary pediatric emergency departments (EDs). In contrast, traditional detergent exposures had an incidence of 2.78 exposures per million children per year presenting to tertiary pediatric EDs over the study period. Although there was no change in incidence of exposure to traditional detergent over the study period, there was an increase in the incidence of SUDS exposures from 2010 to 2013, with a decrease seen in 2014. There was no significant difference seen in age, sex, location of exposure, transportation to hospital, morbidity, or mortality associated with SUDS exposures compared with traditional detergent exposure. Although not statistically more likely to cause long-term complications, SUDS-exposed children required more follow-up visits to health care providers than traditional detergents. CONCLUSIONS: This multicenter study is the first to establish the incidence of SUDS and traditional detergent exposure in 3 Canadian cities. Overall, the frequency of exposure to detergents-both traditional and SUDS-is very low. Given the increase in SUDS exposure seen from 2011 to 2013, alongside larger sales of SUDS, continued efforts are required to monitor exposures, and reduce potential exposures to SUDS and traditional detergents in the future.

Antenatal services for pregnant teenagers in Mbarara Municipality, Southwestern Uganda: health workers and community leaders' views.

BACKGROUND: Globally, about 11% of all annual births involve adolescents aged 15-19 years. Uganda has one of the highest teenage pregnancy rates in Sub-Saharan Africa. This study assessed stakeholders' views concerning factors affecting availability, accessibility and utilization of teenager friendly antenatal services in Mbarara Municipality, southwestern Uganda. METHOD: This was a cross-sectional descriptive study utilizing Key Informant Interviews (KIIs). It was conducted in three divisions of Mbarara Municipality. The KIIs were held six Village Health Team (VHT) members, three gynecologists, six midwives, three Community leaders (LC 3 Secretaries for women affairs), one police officer from the Family and Child protection unit at Mbarara Police and three Traditional Birth Attendants (TBAs). Data analysis was done manually by identifying emergent themes which were later coded and organized into concepts which were later developed into explanations. RESULTS: Reproductive health stakeholders generally considered teenage pregnancy to be among the high risk pregnancies that need to be handled with care. In addition, the reproductive health workers described their experience with teenagers as challenging due to their limited skills when it comes to addressing adolescent-specific needs. Adolescent-friendly services were defined as those that could provide privacy, enough time and patience when dealing with teenagers. With this description, there were no teenager-friendly antenatal services in Mbarara municipality at the time of the study. There is need for proactive steps to establish these services if the needs of this subgroup are to be met. CONCLUSION: There are no teenager friendly antenatal services in Mbarara municipality and few teenagers access and utilise the available general antenatal services. There is need for specialized training for health workers who deal with pregnant teens in Mbarara Municipality in order for them to provide teenager friendly services.

High-fidelity simulation in pediatric emergency medicine: a national survey of facilitator comfort and practice.

OBJECTIVES: High-fidelity simulation (HFS) is widely used in pediatric emergency medicine (PEM) training and a competent facilitator is vital for effective learning. This survey describes the characteristics, comfort, practices, and need of PEM physicians as HFS facilitators. METHODS: A descriptive cross-sectional survey was electronically distributed to Pediatric Emergency Research Canada physician members, representing 14 academic pediatric emergency departments nationally. RESULTS: The response rate was 66.6% (92/138); 63% (56/89) of PEM physicians taught HFS. Junior attending physicians (P = 0.011) and those with an education focus (P = 0.005) were more comfortable in using HFS. Sixty-eight percent (38/56) described their facilitator training as formal. Generally, facilitators felt comfortable in running simulations (weighted mean scale, 1.53 [<2 = comfortable] on a 5-point rating scale). Facilitators with formal training used verbal confidentiality agreements more frequently (P = 0.008), spent less time running the scenario (P < 0.05) and spent more time in debriefing (P < 0.05) than those without formal training. Sixty-three percent (n = 56) of facilitators identified debriefing as the most stressful aspect of HFS. Their main barrier to HFS teaching was lack of protected teaching time (mean scale, 2.02 [>2 = barrier]). Seventy-six percent (35/46) of respondents desired online and printable facilitator information. Seventy percent (35/51) thought the ideal time for formal facilitator training was during fellowship. CONCLUSIONS: High-fidelity simulation is a widely used educational modality, and more attention must be paid to the needs of the facilitator in order to optimize the educational experience. Standardized facilitator training, focused particularly on effective debriefing techniques, would help improve facilitator comfort with HFS.

Multifaceted support for a new medical school in Nepal devoted to rural health by a Canadian Faculty of Medicine and Dentistry.

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals' natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.