Alternating antipyretics: is this an alternative?

OBJECTIVES: To identify current fever management strategies and their basis, and to assess the frequency of alternating acetaminophen and ibuprofen. BACKGROUND: Practicing pediatricians confront the dilemma of elevated temperature and the anxiety this creates for parents. An informal survey of pediatricians revealed a variety of management strategies, including alternating acetaminophen and ibuprofen. There are no scientific data regarding alternating these 2 products. Design. During professional meetings, pediatricians voluntarily filled out a 15-item questionnaire. RESULTS: One hundred sixty-one completed surveys were reviewed. Respondents were mostly general pediatricians (67.7%), with >/=20 years in practice (55.9%). Most respondents chose a temperature of 101(o)F to start antipyretic treatment (61.9%). A small percentage used discomfort alone as the indication (13%). The antipyretic of choice was temperature-dependent in 50% of respondents; 57% used ibuprofen for temperature >/=102 degrees F. Fifty percent of respondents advised parents to alternate acetaminophen and ibuprofen. The method of alternation varied. The most common answers given for choosing a particular antipyretic regime were recommendations of the American Academy of Pediatrics (29%) and opinions of colleagues and mentors (25%). Physicians with <5 years of practice were significantly more likely to alternate antipyretics (69.7%). CONCLUSION: Acetaminophen and ibuprofen are commonly being used in an alternating manner for management of fever. There is presently no scientific evidence that this combination is safe or achieves faster antipyresis than either agent alone. There is evidence that the improper use of these agents may cause harm. Despite 29% of participants citing American Academy of Pediatrics recommendations as the basis for fever management, no such policy or recommendations exist. The observation that this practice is more common in younger practitioners may reflect their continued anxiety about fever (fever phobia). Until properly controlled studies have assessed the risk of combining these 2 products, practitioners should proceed with caution.

A primary care approach to pediatric gastroesophageal reflux.

Gastroesophageal reflux is a common problem that occurs in the pediatric population. Gastroesophageal reflux refers to the retrograde passage of gastric contents into the esophagus. Current thinking implicates transient lower esophageal sphincter relaxations as a major cause for reflux. Infants generally present with symptoms of regurgitation, whereas symptoms of esophagitis are more common in older children. When there are dangerous consequences secondary to gastroesophageal reflux, it is termed gastroesophageal reflux disease (GERD). GERD has been shown to manifest with respiratory symptoms and a pathologic process. A variety of diagnostic procedures are available for the assessment of GERD which include barium swallow, pH probe, scintigraphy, and endoscopy with esophageal biopsy. Medical management of GERD primarily involves prokinetic agents and acid suppression therapy. Surgical therapy, albeit less common, now still has its role in the treatment of GERD.

Does swimming decrease the incidence of otitis media?

To determine the influence of swimming on the incidence of otitis media in children, the authors designed a case control survey involving 32 children, aged 1 to 4 years, who were participating in swimming classes. Thirty control subjects were matched for age, race, and sex. The participants were pooled from the general pediatrics clinic and toddler swimming classes in Nassau County, New York. Parents completed a questionnaire gathering data over a 12-week study period during the winter months. Information was gathered regarding demographics, number of ear infections, history and frequency of swimming during the study period, presence of head submersion, day care center attendance, allergies, chronic medical conditions, otolaryngology consultations, ear surgery, and air travel. Forty-three percent of nonswimmers compared with 19% of swimmers had one or more ear infections during the study period (P < .02). The remaining factors surveyed did not differ significantly between groups. A review of the literature yielded two studies suggesting that swimming may have a beneficial effect on eustachian tube function and may indirectly decrease the occurrence of otitis media. Based on these findings, the authors conclude that there appears to be no basis to the commonly held belief that swimming may induce or exacerbate otitis media. In fact, the converse may be true.

The power of words: communicating effectively with young patients.

Communication skills are the cornerstone of the doctor-patient relationship. This article provides clinically helpful hints to practitioners working with children and families. Specific examples of clinical phrases are presented along with alternative phrases that may enhance the clinical process.

Standards for Pediatric Immunization Practices: an osteopathic physician's commentary and 'reality check'.

The "Standards for Pediatric Immunization Practices," recommended by the National Vaccine Advisory Committee and approved by the US Public Health Service, provides guidance to clinicians as to what the National Vaccine Advisory Committee considers optimal practice. Each of the 18 recommendations reflects the ideal; unfortunately, life in the trenches is less than ideal. Providers must reflect on each point and consider how they might modify their own practices to help us to realize the goal of Healthy People 2000, that is, 90% immunization coverage by the child's second birthday. The Standards are clear. They are reprinted herein from MMWR (April 23, 1993;42[5]). Following each is a response, sort of a reality check, from the author, a practicing clinician and practice administrator.

Impact of pediatricians' attire on children and parents.

To evaluate perceptions of a pediatrician's attire, 50 children and parents in an outpatient facility were shown five photographs of a female or a male physician dressed differently (formal to informal). A list of positive and negative attributes was presented to the parents and children who were to match each picture to the attributes. Parents had a strong positive preference for the formally dressed female (short white coat and skirt), and the formally dressed male (short white coat and tie). More than 50% of the parents least preferred the most informal attire. Children had no clear preferences for males and preferred the female in the blouse and skirt. Children assigned negative attributes to informal attire but not to the same degree as did their parents. This study demonstrates that parents have stronger preferences than do their children. Although children had no strong positive preferences, they may feel negatively about informal attire.

Nursing bottle caries: characteristics of children at risk.

Nursing bottle carries is a pattern of extensive decay in newly erupted maxillary incisors. We examined nutritional, demographic, and behavioral characteristics of children with this condition and age/sex-matched controls, generating a profile of factors associated with increased risk for the development of this disease. Parents of 24 consecutive bottle caries patients seen in a private pediatric dental office completed a questionnaire. Controls were children receiving routine primary pediatric health services at a university based clinical office. Children with bottle caries were more likely to be living in a single parent household (p = 0.005). A higher incidence of sleep difficulties and strong temper also was reported (p = 0.05). Cases were more likely to take the bottle to bed and, to an older age than controls. They received less professional advice regarding weaning as well as less fluoride supplementation (p = 0.025). Clinical recognition of this profile may foster provision of specific anticipatory guidance resulting in primary prevention of this condition.

Minor physical anomalies and learning disability: what is the prenatal component?

The authors performed a case-control study of 60 school children who were examined for a constellation of anomalies suggestive of fetal alcohol exposure. Nonretarded learning disabled children were 7.25 times (95%, confidence interval, 1.05 to 50.0) more likely than controls to have signs consistent with alcohol exposure in fetal life. These data suggest an expanded spectrum of fetal alcohol effects. Early recognition of minor physical anomalies could result in prompt evaluation and treatment of these children.

Setting the referral process in motion: a case study with teaching objectives.

Pediatric collaboration with mental health professionals is necessary due to the high prevalence of behavioral and emotional disorders in this population. Clinicians frequently encounter parental resistance to acceptance and follow-through on recommended mental health services. In addition, physicians may have difficulty recognizing and referring psychosocial problems due to inadequate training or experience. The case presented of a 10-year-old girl with enuresis illustrates the process of referring a patient with a behavioral problem from a general pediatrician to a mental health specialist. The behavioral pediatrician plays a critical role in providing linkage between medical and psychosocial care.