Hyperglycemia is not a poor prognostic sign in head-injured children.

Hyperglycemia among adult trauma patients with head injuries is a recognized phenomenon which has been shown to be associated with a poor prognosis when it takes the form of nonketotic hyperosmolar hyperglycemia. It is not known to what extent a similar phenomenon occurs in pediatric patients, although it is known that a child's physiologic response to injury, particularly to neurologic injury, is often different than an adult's. This study was undertaken to characterize the hyperglycemic response of children with closed head injury compared to children with a non-head injury, and to measure the extent to which the presence of hyperglycemia is associated with a poor outcome among children with severe head injury. Records for all children ages 2 to 12 years admitted to a major regional trauma center with closed head injury over a 6-year period were compared to the records of a control group of children hospitalized for a non-head injury. The hyperglycemic response was more common among those with head trauma, occurring in 40% compared to 5% of the controls (p less than 0.001); however, the level of hyperglycemia could not be associated with any indicator of outcome. The entity known as nonketotic hyperosmolar hyperglycemia did not occur in any of these patients. Apparently, the hyperglycemia associated with closed head injury in children is transient, does not need to be treated with insulin therapy, and in contrast to what has been demonstrated in adult trauma patients, does not predict patient outcome.

Garlic burns: a naturopathic remedy gone awry.

We report the case of a child who sustained partial thickness burns from a garlic-petroleum jelly plaster, which had been applied at the direction of a naturopathic physician. A review of the literature reveals that "garlic burns" have not previously been reported, although medicinal properties of garlic have been investigated by physicians and biochemists. The pediatrician caring for children in an area where naturopathic medicine is routinely practiced should be aware of the potential side effects of plasters, poultices, and other "natural" remedies in children.

Poor prediction of positive computed tomographic scans by clinical criteria in symptomatic pediatric head trauma.

A retrospective study of 98 children who received CT scanning for head trauma was conducted to determine whether clinical signs would accurately identify patients needing CT scans. The clinical findings of Glasgow Coma Scale score of 12 or less, altered consciousness on admission, and focal abnormalities on neurologic examination were each significantly associated with abnormal findings on CT scans (P less than .01). However, 31% of the 51 patients with Glasgow Coma Scale scores greater than 12 had abnormal CT scan findings. No clinical findings, alone or in combination, accurately identified all patients with abnormal findings on CT scans.

Contact burns of the hand.

Contact burns of the hand in children present difficult management questions. Because visual inspection of the acute wound often fails to distinguish major burns requiring inpatient treatment from minor burns amenable to outpatient therapy, we sought to identify characteristics of patients that would aid in decision making at the time the burn patient is seen. During the 5-year period, 1980 to 1984, 32 children less than 14 years of age were admitted to our medical center with contact burns of the hand. Patients were divided into two groups: those with major burns requiring greater than or equal to seven days of hospitalization (n = 16) and those with minor burns requiring less than seven days of hospitalization (n = 16). Compared with patients in the minor burn group, patients in the major burn group were hospitalized longer (16.9 v 2.8 days), were more likely to require surgical excision and grafting (63% v 0%), and had more extensive follow-up (5.3 v 2.5 visits). There were no significant differences between the two groups with regard to percentage of area burned, age, sex, primary admission v referral, and cause of burn. These data support the recommendation that all such burns be managed initially on an inpatient basis.

Fever as a predictor of infection in burned children.

Although children with burns often develop fevers, we have found no reports characterizing the course and duration of these fevers. To evaluate the predictive value of fever as an indicator of infection in burned children, we reviewed the hospital charts of all 223 children admitted to a regional burn center in the years 1979 through 1982. The highest temperature reading for each 8-hour period of the child's hospitalization was recorded. The highest mean temperature in burned children occurred at 38 to 96 hours after the burn injury; the peak temperatures appeared at the same time, regardless of whether the child had an infection. All of the 23 children with infections (100%) and 145 of the 200 without infections (73%) had a recorded temperature reading of 38.2 degrees C or higher within 2 weeks after their burn injury. When children less than 4 years, or children with more than 20% total body surface area burns were considered alone, the presence of a temperature greater than 38.2 degrees C was not significant in differentiating those with infections. Fever is not a specific predictor of infection in burned children; in children less than 4 years of age and in children with more than 20% burns, fever has no predictive value for the presence of infection. The physical examination is a reliable source of information about wound infection, sepsis, or other childhood infections, and should be the primary tool used in making the diagnosis of infection in burned children.

Why obtain arterial blood gases, chest x-rays, and clotting studies in injured children? Experience in a regional trauma center.

We conducted a retrospective study to determine the frequency with which arterial blood gases, chest x-rays, and blood clotting studies are obtained while caring for pediatric trauma victims in a regional trauma center, and if the clinician can predict which studies may be abnormal. Arterial blood gases were obtained in 35% of pediatric trauma victims, chest x-rays in 48%, and clotting studies in 56%. We found that abnormalities in arterial blood gases were correlated with closed head injury, intubation in the field, and sex of the patient, while abnormalities on chest x-ray correlated with closed head trauma and intubation in the field. Abnormalities in clotting studies correlated only with intubation in the field. Obtaining a chest x-ray on a pediatric trauma victim with an Injury Severity Score of less than 10 will yield little information. The utility of routine laboratory tests in pediatric trauma victims may vary significantly from that of laboratory tests in adult trauma victims.

Extremity injuries in children: predictive value of clinical findings.

This study sought to identify clinical predictors of extremity fracture in children with trauma. There were 189 children 1 to 15 years of age with 209 extremity injuries seen during a 9-month period. Gross deformity and point tenderness were the best predictors of upper extremity fracture; these two findings correctly identified 81% of children with fractures and 82% of these without fractures. Gross deformity and pain on motion best predicted lower extremity fracture, with 97% of children with fractures correctly identified. The study showed that physical examination is predictive of fractures in extremity injuries of children, regardless of age. In the absence of the specific physical findings identified by the study, the probability of diagnosing a fracture by roentgenographic findings is low.

Pediatric patients in a regional burn center.

Because scald burns are reported to be the leading cause of burn injuries to children, little is written about other etiologies of burn injury in the pediatric literature. To test the hypothesis that burns from other etiologies are more serious and require longer hospitalizations than scald burns, a retrospective chart review was undertaken. The charts of all patients less than 16 years of age who were admitted to Harborview Medical Center Burn Unit in the years 1979 to 1984 were reviewed. Four hundred sixty-four children were admitted to the regional burn center during that time. We found that children under four years of age are at greatest risk for being hospitalized for thermal injury, that the burn most commonly occurs inside the home between 6 PM and midnight, and that scalds are the most common etiology for thermal injuries in children (54%). However, 46% of the burns resulting in admission to our burn center were from etiologies other than scald injury. There was no significant correlation between etiology of the burns and length of hospital stay, rate of infection, or need for excision and grafting. Thermal injuries to children from any etiology are serious; pediatric health care providers should be aware that children may be burned in a variety of ways and should direct some of their well-child visit time to the topic of burn prevention in the home.

The status of research in ambulatory pediatrics.

To investigate the status of clinical research in ambulatory pediatrics and to characterize those environments that produce the most research activities and receive funding for research, a questionnaire survey was undertaken of all ambulatory pediatrics programs in the United States and Canada (N = 143). Our response rate was 68%. We found that divisions of ambulatory pediatrics that conduct clinical research have more faculty with formal research training, faculty with more time devoted to research endeavors, a designated research coordinator, research funding, and regular research seminars. Divisions of ambulatory pediatrics that have funding for research have more faculty with formal research training, fellows, a designated research coordinator, and regular research seminars. Funding for research is a more influential factor in producing clinical research than the number of faculty members in the division. The most frequently mentioned barrier to doing research was lack of time. Divisions of ambulatory pediatrics must continue to stress formal research training, faculty time set aside for research, and skills in grant writing if they hope to compete for academic recognition in the years ahead.

Emergency department management of children with acute isoniazid poisoning.

We suggest that the following therapeutic regimen be followed in cases of isoniazid poisoning in children. In cases of intractable seizure activity in a child which remains unexplained, consider isoniazid poisoning. Give pyridoxine as an intravenous bolus to all children in whom isoniazid toxicity is suspected, who exhibit seizure activity and are known to have been exposed to isoniazid, or who have a history of ingesting one gram or more of isoniazid. It should be given on a gram-for-gram basis, and the clinician need not await serum isoniazid levels before administering pyridoxine. It can be safely given at a rate of five grams per three minutes in a 50 ml volume. In fact, serum isoniazid determinations are not available in many emergency departments and have not been shown to correlate closely with symptomatology. When available, serum isoniazid levels at best are subject to variability owing to sampling procedures (serum protein must be removed within two hours of sampling). The result is that serum isoniazid levels play only a minor role in the emergency department management of isoniazid poisoning. To potentiate the antidotal effects of pyridoxine, diazepam (0.1 mg/kg) may be given intravenously, preferably at a second intravenous site. Because the lactic acidosis seen after seizures resolves spontaneously, and because metabolic alkalosis may result following excess lactate loading, administration of bicarbonate is usually not necessary, and may be harmful in some cases. After pyridoxine treatment, syrup of ipecac may be given to empty the stomach.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of computer-assisted instruction (CAI) in an outpatient pediatrics clinic.

This prospective study was done to measure the effectiveness of a CAI program in teaching outpatient pediatrics to third-year medical students, as measured by their scores on the mandatory pediatrics examination taken at the end of their pediatrics rotation. A significant difference was found between the number of students receiving Honors vs. Satisfactory scores on their examinations between those who worked at our hospital before vs. after the CAI program became available; there was also a statistically significant difference between the number of students who received Honors on their pediatrics examinations when comparing the Harborview-after-computer group to the Other-locations-after-computer group. Such a CAI program appears to be an effective learning aid for medical students doing their outpatient pediatrics rotations. It affords information about costs to the patient, is omnipresent and is an effective alternative to either lecture or reading as a method of learning.

Smoke inhalation and carbon monoxide poisoning in children.

This article reviews the mechanisms of pulmonary injury associated with smoke inhalation and the pathophysiology of carbon monoxide poisoning. In addition, the temporal stages of pulmonary injury and evaluation and treatment of the pediatric patient are discussed. Maintaining a high index of suspicion when treating the victim of a house fire or other closed-space thermal injury will allow the emergency clinician to offer the most effective therapy to the child in the first four hours after thermal injury.

Intestinal parasites in Southeast Asian refugee children.

To determine the predictability of pediatric stool-parasite patterns among various Southeast Asian ethnic groups, I collected data from medical and microbiology laboratory records on all Southeast Asian refugee children who had a stool specimen examined for ova and parasites over a 21-month period. For most of the children, the specimen was examined as part of routine "health screening." The patterns of infection by ethnic group for those Vietnamese and Laotian children living in Seattle differ from the patterns seen in other geographic areas.

gamma-Aminobutyric acid in CSF of children with febrile seizures.

Previous studies have suggested that levels of cerebrospinal fluid (CSF) gamma-aminobutyric acid (GABA) may be decreased in children with febrile seizures. We used gas chromatography and mass spectrometry to measure CSF GABA levels in 14 children with febrile seizures. The results were compared with the GABA levels in six children with first-time afebrile seizures, three with recurrent febrile seizures, and 13 controls (febrile children undergoing lumbar puncture to rule out meningitis). Children with central nervous system infections or known neurologic disease were excluded. The CSF GABA levels in children with febrile seizures were not significantly different from those in controls and children with afebrile or recurrent febrile seizures. In the control group, CSF GABA levels correlated with increasing age. There was no correlation with severity of febrile response in any group. The results indicated that the CSF GABA level may not be abnormal in patients with first-time febrile convulsions.

The significance of Babinski signs in children with head trauma.

A prospective study was undertaken to investigate the significance of Babinski signs in children with head trauma. Thirty-eight children between the ages of 1 and 15 were studied. Twenty-four of the children were admitted to the hospital for observation; 14 were sent home, with 24-hour follow-up in the pediatrics clinic. Of the 24 children admitted, six were believed to have altered CNS status or other focal findings on examination in the emergency department, and 18 were judged by two independent observers to have Babinski signs, either unilateral or bilateral, as their only neurological finding. Twelve hours after admission, all 18 children who had been admitted on the basis of Babinski signs alone had downgoing toes and they continued to have Babinski signs. The isolated presence of Babinski signs in a child with a history of head injury is not indicative of poor neurological outcome. An otherwise asymptomatic child who presents with a history of head injury and a solitary finding of Babinski sign(s) may be observed safely at home rather than being admitted to the hospital for observation.

Developmental milestones in abused children, and their improvement with a family-oriented approach to the treatment of child abuse.

Few objective measures of the efficacy of intervention programs in the treatment of child abuse exist. One such measure may be improvement in the developmental delays often seen in abused children. Using the Learning Assessment Profile, we tested 53 abused children, ages 2.5-5 years, just before and after involvement in our Family Development Center Program (FDC). The FDC emphasizes therapy-group-interaction for parents, where alternative ways of expressing anger are explored. Children attend daily preschool classes, and take occasional outside field trips. Of the 53 children tested 42 (79%) showed greater than expected developmental skills gains. Six children demonstrated no improvement in developmental skills, four of whom had severe developmental delays in one or two areas. Fine motor and language skills were significantly delayed for the group as a whole; these areas showed the greatest improvement after FDC. There did not appear to be an overall association between increased improvement in developmental skills and length of time in the FDC program, although certain subgroups of children appeared to improve with time while others appeared to lose ground. A five-year follow-up study of these children is presently underway. We conclude that a program which involves both parent and child, and focuses on their interaction, appears to be effective in dealing with abusive families; monitoring developmental levels in the abused children is one means of assessing their progress in such a program. Further controlled prospective trials are needed in this area.

Interaction of theophylline with erythromycin base in a patient with seizure activity.

A pediatric patient who was taking carefully monitored doses of theophylline for chronic asthma, was placed on erythromycin base for bronchitis. She subsequently developed theophylline toxicity which caused her to experience seizure activity. Any patient taking a theophylline preparation who is then placed on ANY of the available erythromycin compounds must have close monitoring of serum theophylline levels.