Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellowship directors.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends oral rehydration therapy (ORT) for management of uncomplicated childhood gastroenteritis with mild-moderate dehydration. However, ORT is widely underused relative to their recommendations. We compared ORT use by directors of Pediatric Emergency Medicine (PEM) fellowship training programs with AAP recommendations, and sought to identify their barriers to ORT. METHODS: Mail/fax survey of the directors of U.S. and Canadian PEM fellowship programs. The survey included 10 scenarios of mild or moderately dehydrated children with gastroenteritis, a personal innovativeness scale, self-assessment of ORT experience and knowledge, and open-ended questions regarding perceived barriers to ORT use. RESULTS: 60/67 (89.6%) PEM fellowship program directors responded. All reported experience with and knowledge about ORT. Only 10/58 (17.2%) believe ORT is usually better than intravenous (i.v.) rehydration in all 10 clinical scenarios, and only 4/58 (6.7%) usually use ORT in all 10 scenarios. 18/58 (31%) usually use ORT for all mildly but no moderately dehydrated children. ORT use did not correlate with personal innovativeness scores. Important barriers cited by respondents include additional time requirements for ORT relative to i.v. rehydration (76.7%) and expectation of i.v. rehydration by parents (41.7%) or primary care physicians (10%). CONCLUSIONS: Relative to AAP recommendations, PEM fellowship directors underuse ORT, especially for moderately dehydrated children. Physician innovativeness does not influence ORT use. Further study of effectiveness, length of stay, staff requirements, and ORT acceptance in the emergency department setting, especially in children with moderate dehydration, may influence ORT use.

Is oral albuterol effective for acute cough in non-asthmatic children?

Fifty-nine non-asthmatic children with acute cough were randomized to receive oral albuterol or placebo for 7 d. There was a similar, rapid rate of resolution of acute cough for the two groups, but more shaking or trembling in those treated with albuterol (5/30 vs 0/29; p = 0.05). In ambulatory children with acute cough who have no history of asthma and a normal chest examination, oral albuterol does not reduce the frequency or duration of cough.

Comparison of two regimens of feeding and oral electrolyte solutions in infants with diarrhea.

BACKGROUND: Glucose-based oral rehydration solutions (ORS) available in the United States do not appear to reduce the severity or duration of diarrhea. The use of cereal-derived ORS and cereal-based feedings appears to diminish the severity of illness in studies conducted in the developing world. To our knowledge, no controlled trials of cereal-derived ORS or cereal-based feedings have been performed in the United States. METHODS: We performed a randomized, double-blind trial of two ORS feeding regimens in outpatients with diarrhea. Patients aged 2-13 months with acute watery diarrhea were enrolled. Subjects received standard glucose-based ORS in alternation with soy-based, lactose-free infant formula (Group 1) or rice syrup solid containing ORS in alternation with rice-based, lactose-free infant formula (Group 2). Subjects were visited at home daily to determine the severity of illness and characteristics of the stool. RESULTS: After the first 2 days, significantly more Group 1 subjects continued to have diarrhea than did Group 2 subjects (median duration of diarrhea 3 vs. 2 days) as demonstrated by Kaplan-Meier survival curves (p = 0.04). CONCLUSION: We conclude that infants fed a regimen consisting of rice syrup solid containing ORS and rice formula resolved their diarrhea sooner than did infants fed a regimen of standard glucose-based ORS and formula. The relative contributions of ORS and formula to this more rapid recovery can be elucidated by further studies.

Pediatric poisonings.

In a general exposition of clinical and laboratory issues in the emergency management of poisoning in the pediatric patient I briefly discuss the epidemiology of poisonings in the child population, the categories of poisons to which children are exposed most frequently, and clinical and laboratory considerations, focusing on the importance of understanding the pharmacological properties of the compound involved. I review diagnostic and therapeutic decision-making in light of the characteristics of the known or suspected chemical involved. Finally, the information presented is integrated in a discussion of two cases of poisoned patients in a hospital emergency department.

Hydrolyzed lactalbumin-based oral rehydration solution for acute diarrhoea in infants.

The addition of different organic substrates to standard glucose oral rehydration solution (G-ORS) has been shown to improve the intestinal absorption of sodium and water, and thereby decrease stool losses. Therefore, we evaluated, in infants with acute diarrhoea, the safety and efficacy of three oral rehydration solutions (ORS) which had the same concentrations of electrolytes (with sodium 60 mmol/l) but different substrates of proteins and carbohydrates. One solution (LAD-ORS) contained hydrolyzed lactalbumin (LAD) with maltodextrin and sucrose, a second (MS-ORS) was identical but without LAD and a third (G-ORS) was standard glucose ORS. The three solutions were compared in a double-blind, randomized trial in 74 hospitalized well-nourished children in Panama and the United States. All three oral rehydration solutions were equally efficacious and safe in these children, 54% of whom were infected with rotavirus. There was no suggestion that hydrolyzed lactalbumin or maltodextrin provided any advantage over glucose-ORS in terms of stool output or in duration of diarrhoea. We conclude that all three solutions are efficacious in the therapy of acute diarrhoea in infants.

Barriers to use of oral rehydration therapy.

OBJECTIVE: To identify potential barriers to the use of oral rehydration therapy (ORT) by pediatric practitioners. DESIGN: Cross-sectional, anonymous, self-administered survey of physicians' ORT knowledge, attitudes, and practice. SETTING: A national continuing medical education conference. PARTICIPANTS: One hundred four general pediatricians primarily in private practice (66%) who completed training after 1980 (76%). MEASUREMENTS AND RESULTS: Most respondents (83%) reported that ORT plays an important role in their management of dehydration. However, compliance with guidelines from the American Academy of Pediatrics for use of oral therapy is limited: 30% withhold ORT in children with vomiting or moderate dehydration, 50% fail to advise prompt refeeding, and only 3% advise use of a spoon or syringe. The degree of importance of ORT in physicians' practice was negatively associated with reported lack of convenience of ORT administration in the practice setting (P < .001), support staff preference for intravenous versus ORT (P < .001), need for additional training of support staff to implement ORT (P < .01), and likelihood of reimbursement for intravenous versus ORT (P = .07). Notably, degree of importance of ORT was not associated with physician ORT knowledge. CONCLUSION: Efforts to improve use of ORT should be expanded beyond physician education and focus on such barriers as support staff limitations and financial constraints.

Injuries sustained during flipping--a new fad activity.

This article describes a small series of injuries resulting from a new fad activity among children in Baltimore. "Flipping" involves jumping from an elevated surface and executing an aerial flip, with the intent to land upright. Because this activity takes place frequently on hard surfaces such as concrete, injuries often result. The spectrum of injuries is described and categorized, and injuries are compared with those received during similar activities, such as break dancing or skateboarding, and with playground injuries. Pediatricians and emergency physicians should be aware of the potential for injury in this activity.

Oral rehydration therapy.

Acute gastroenteritis is a leading cause of visits to physicians among children in the United States. Oral rehydration therapy has prevented or reversed dehydration among millions of children in developing countries. Although most U.S. health care providers are familiar with oral rehydration therapy, its proper use is still not widespread in industrialized nations. Viral pathogens in diarrheal illness can destroy absorptive cells at the intestinal villous tip while leaving secretory cells intact. Oral rehydration therapy takes advantage of the remaining intact absorptive cells, is less invasive than intravenous rehydration and allows parents to be involved in their children's care. This article outlines how to select patients for oral rehydration therapy, what fluids to use and how to implement therapy.

Use of ciprofloxacin in an infant with ventriculitis.

Ciprofloxacin was used successfully in a neonate with ventriculitis caused by a multiply resistant strain of Enterobacter cloacae. Limited pharmacokinetic data indicated that adequate concentrations of drug could be attained in cerebrospinal fluid.

Children with Haemophilus influenzae bacteremia initially treated as outpatients: outcome in 85 American Indian children.

Eighty-five American Indian children less than 16 years of age with Haemophilus influenzae bacteremia were retrospectively determined to have been treated as outpatients after their initial evaluation. We hoped to determine the proportion that developed new foci, the time interval to this development and whether age or temperature at presentation predicted outcome. Fifty-one (60%) presented with nonfocal findings. Seventy-two (85%) were treated with antibiotics at the initial visit. Although 49 (58%) of the patients were never hospitalized, a new focus was identified in 25 (29%), including 13 (15%) with a final diagnosis of meningitis. The new foci were identified within 6 days of presentation (median, 2 days). An additional 15 (18%) patients had no new focus but were febrile and/or ill at follow-up. All patients with meningitis or a second positive culture were hospitalized at the first follow-up visit. Age and temperature at presentation did not help predict outcome. All patients with H. influenzae bacteremia require prompt reevaluation and close follow-up by an experienced physician.

Persistent urinary antigen excretion in infants vaccinated with Haemophilus influenzae type b capsular polysaccharide conjugated with outer membrane protein from Neisseria meningitidis.

Testing for urinary excretion of capsular polysaccharide antigen was carried out in 40 four-month-old Navajo infants who had received injections of a Haemophilus influenzae type b Neisseria meningitidis outer membrane protein conjugate vaccine (PedvaxHIB; Merck, Sharp and Dohme Research Laboratories) as part of an ongoing efficacy trial of the vaccine. Urine from 12 placebo recipients was also analyzed. Urine samples were collected on the day of injection (the first voided urine following the injection) and 3, 7, 10, 14, 21 and 30 days later. All vaccine recipients had at least 1 positive specimen. Vaccine recipients excreted antigen for a median period of 14 days after injection. On the first day 54% of vaccinees excreted antigen. Antigen was excreted by 89% of vaccinees on Day 3, 79% on Day 7, 82% on Day 10, 64% on Day 14, 56% on Day 21 and 41% on Day 30. Urine from placebo recipients tested positive in 12% on Day 1, 18% on Day 3, none on Day 7, 14% on Day 10, 11% on Day 14, 10% on Day 21 and none on Day 30. The rate of positive test results was significantly higher among vaccine recipients than among controls. Physicians should not rely on urinary antigen detection tests for predicting the presence of invasive disease caused by H. influenzae type b in infants for at least 30 days after injections with this conjugate vaccine, and possibly longer.

The efficacy in Navajo infants of a conjugate vaccine consisting of Haemophilus influenzae type b polysaccharide and Neisseria meningitidis outer-membrane protein complex.

BACKGROUND AND METHODS: Several conjugate vaccines against Haemophilus influenzae type b have been developed in the search for one that induces protection even in young infants. We evaluated the safety and efficacy of a conjugate vaccine that links the H. influenzae type b capsular polysaccharide to the outer-membrane protein complex (OMPC) of Neisseria meningitidis serogroup B. We conducted a double-blind, placebo, controlled trial in Navajo infants, who are at high risk for systemic infections caused by H. influenzae type b. The infants were randomly assigned to receive the first dose of vaccine or placebo at 42 to 90 days of age and the second at 70 to 146 days of age. RESULTS: Of the infants in the trial, 2588 were assigned to receive the vaccine and 2602 to receive placebo. The mean follow-up was 269 days in the vaccine group and 267 days in the placebo group. Before the age of 18 months, there was 1 systemic H. influenzae type b infection in the vaccine group, as compared with 22 in the placebo group (P less than 0.001; point estimate of efficacy, 95 percent; 95 percent confidence interval, 72 to 99 percent). Of the 22 H. influenzae type b infections in the placebo group, 13 were meningitis. Among the children who received both doses, there was 1 H. influenzae type b infection in the vaccine group (n = 2056) and 14 in the placebo group (n = 2105) (P less than 0.001; point estimate of efficacy, 93 percent; 95 percent confidence interval, 53 to 98 percent). The single infection in the vaccine group occurred at 15 1/2 months of age in an infant with osteomyelitis. Between the first and second doses there were no H. influenzae type b infections in the vaccine group and eight in the placebo group (P less than 0.005; point estimate of efficacy, 100 percent; 95 percent confidence interval, 41 to 100 percent). CONCLUSIONS: The H. influenzae type b OMPC vaccine, administered at 2 and 4 months of age, is safe and induces a high rate of protection against invasive disease caused by H. influenzae type b in infants under the age of 18 months. Protection begins after the first dose.

Role of a soy-based lactose-free formula in the outpatient management of diarrhea.

The introduction of a soy-based, lactose-free formula during the acute phase of diarrheal illness in infants has been shown to reduce stool output and duration of diarrhea in hospitalized patients. In the United States, most infants with acute diarrhea are treated as outpatients. In the present study, infants with diarrhea who were treated as outpatients were randomly assigned to receive either a soy-based, lactose-free formula alternating with oral rehydration solution from the beginning of therapy ("early feeding") or oral rehydration solution alone for the first 24 hours of therapy, followed by a soy-based, lactose-free formula alternating with oral rehydration solution (control group). Twenty-nine infants were randomly assigned to the early-feeding group and 27 to the control group. Twenty-one (72%) of 29 in the early-feeding group resolved their diarrhea at the end of 48 hours of therapy compared with 12 (44%) of 27 in the group fed oral rehydration solution only (P = .02). It is concluded that the introduction of a soy-based, lactose-free formula from the beginning of therapy for acute diarrhea in children treated as outpatients is safe and may shorten duration of diarrhea while maintaining adequate caloric intake.

A comparison of rice-based oral rehydration solution and "early feeding" for the treatment of acute diarrhea in infants.

To compare the use of rice-based oral rehydration solution (R-ORS), with the introduction of food immediately after rehydration ("early feeding"), using standard glucose-based oral rehydration solution (G-ORS) in the management of acute diarrhea, we conducted a four-cell randomized, controlled trial among 200 hospitalized Egyptian infants between 3 and 18 months of age. During the rehydration phase (first 4 hours), three groups were given G-ORS and a fourth group was given R-ORS. During the subsequent maintenance phase, the control group was given a soy-based, lactose-free formula (G-ORS + SF), a second group (G-ORS + RF) was given a rice-based formula, and a third group (G-ORS + rice) was given boiled rice. The fourth group (R-ORS + SF) continued to receive R-ORS for the first 24 hours of the maintenance period, followed by a soy-based lactose-free formula. During the first and second 24 hours of the maintenance period, infants in the three treatment groups had a lower mean stool output in comparison with the control group (p = 0.006 and 0.03, respectively). The mean total stool output in the R-ORS + SF group was significantly lower than in the control group (p = 0.02). There were no statistically significant differences among the four groups in the mean duration of diarrhea. We conclude that (1) infants who were given R-ORS had reduced total stool output (by 35%) compared with the control group and (2) feeding of boiled rice or a rice-based formula immediately after rehydration therapy was as efficacious as treatment with R-ORS alone for 24 hours, followed by feeding with a soy-based, lactose-free formula.