Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits.

BACKGROUND: Oral rehydration solutions (ORS) for the treatment of acute diarrhea remain an underutilized therapy in the United States, despite multiple clinical trials confirming their efficacy and safety. Economic barriers to their use have been identified. OBJECTIVE: To determine whether providing ORS to patients at the time of their office visit for acute diarrhea can increase ORS utilization and reduce unscheduled follow-up visits. DESIGN: Randomized, controlled clinical trial. SETTING: Seven health centers of a large health maintenance organization. PARTICIPANTS: Children (N = 479) 0 to 60 months of age with acute diarrhea (at least three watery or loose stools in the previous 24 hours for

Controversies of early discharge of infants from the well-newborn nursery.

A reduced hospital length of stay for normal newborns has become common, largely in an attempt to reduce hospital costs. Although evidence in the literature suggests that this is a safe practice, the overall quality of the studies is weak, and controversy exists regarding the advisability of this practice. A review of the rather modest literature and experience with shortened hospital stays lead us to conclude that early discharge of newborns is safe if it is but one component of a larger program designed to transfer portions of care traditionally provided in the hospital to pre- and postnatal care provided outside the hospital. The early discharge program developed at the Harvard Community Health Plan is presented as an example of such a program, with the hope that this model will provide a useful framework to those who are involved with shortened hospital maternity lengths of stay.

Acute otitis media: who needs posttreatment follow-up?

OBJECTIVE: Because the optimal timing for follow-up of acute otitis media (AOM) is unknown and clinicians' recommendations for timing follow-up are highly variable, a study was conducted to determine which risk factors or symptoms could predict the resolution, recurrence, or persistence of AOM after treatment completion. METHODS: Three hundred four children from a general pediatric practice in a staff-model health maintenance organization, ages 6 months to 4 years diagnosed with AOM were enrolled in a prospective study of the clinical outcome of AOM at 10 to 21 days from diagnosis. Risk factors, symptoms, and parental observations were obtained by questionnaire at both the initial and follow-up visit 10 to 21 days later. At the follow-up visit, the clinical outcome of resolved AOM or persisting AOM was determined by the examining clinician. RESULTS: One hundred eighty-one patients returned for follow-up between 10 to 21 days; 24.9% had AOM at follow-up. Parental impression of resolved ear infection and the absence of symptoms at follow-up identified 97.1% of children with resolved AOM. Other factors associated with increased risk of AOM at follow-up were age < or = 15 months and a family history of recurrent AOM in a sibling. CONCLUSIONS: Because parental judgement of ear status and observation of symptoms appear to accurately identify those children with resolved AOM, a follow-up strategy is proposed in which posttreatment follow-up may be selectively offered to children whose parent(s) feels the infection has not resolved, children whose symptoms persist, or children at higher risk for AOM such as those < or = 15 months or with a family history of recurrent otitis.

Relationship of bacteremia to antipyretic therapy in febrile children.

We undertook a prospective study of children from three to 24 months of age with rectal temperatures of greater than or equal to 40.0 degrees C (104.0 degrees F) to determine if children whose fevers fail to respond to antipyretic therapy are more likely to be bacteremic than children whose fevers are lowered by antipyretic measures. Children from two clinical settings were studied: primarily black lower-class children at an inner-city hospital (n = 188) and primarily white middle-class children at a suburban hospital (n = 45). We found an overall prevalence of bacteremia of 7.3%, which was not statistically different between two hospitals. A response to antipyretic therapy, defined as a decrease in temperature of at least 1 degrees C, was seen in 83.7% of children. Children who did not respond to antipyretics had no more increased prevalence of bacteremia than did responders. We conclude that lack of fever response to antipyretics is not a clinical marker for bacteremia in children.

Patients who leave a pediatric emergency department without treatment.

We describe a population of 296 patients (1.1% of 27,230 pediatric emergency department visits) who left a pediatric ED without treatment during a 12-month period. Most occurred on weekends (n = 120; 41%), registered between 4 PM and midnight (n = 174; 59%), were on public aid (n = 161; 54%), had no known source of health care (n = 188; 64%), and waited less than three hours before leaving (n = 187; 63%). Most were not seriously ill; 12 children (4%) had urgent or emergency problems. Minor trauma was the most common reason for the visit. Two hundred twenty-three (75%) were contacted by telephone two days later. A long waiting time was the most commonly cited reason for leaving (137/231; 59%). One hundred sixteen patients (52%) did not seek other medical care; 36 (16%) went to another hospital ED. Forty-eight hours after leaving without treatment, 112 patients (50%) were well, 65 (29%) had improved, 34 (15%) were unchanged, two (less than 1%) were worse, and seven (3%) had been hospitalized.

Prenatal anticipatory guidance.

This article outlines the purpose and content of the prenatal visit. In question-answer format, the article addresses the most frequently asked questions by the mother and the most relevant issues raised by the pediatrician. It is thus hoped that a flavor of both the process and goals of the prenatal visit will be conveyed.

Effectiveness of a health education program in a lower socioeconomic population. Replication of an ipecac guidance study.

When teaching home safety, we selectively highlight those hazards most likely to injure children at various developmental stages. In one of the few studies evaluating this approach, we successfully taught a middle class population appropriate home use of ipecac syrup. The study reported herein replicated that study in a lower socioeconomic population. Although learning occurred, statistical significance was not quite achieved. While this study does not refute the "targeted" approach, it does demonstrate that characteristics of the population are likely to affect the educational outcome. Impressive statistical improvement may not be demonstrated. Individual realistic goals must be established prior to implementation and evaluation of a program.

The effect of the Tylenol scare on parent's use of over-the-counter drugs.

We administered a questionnaire to determine changes in parental use and administration of over-the-counter (OTC) drugs after cyanide-laced Extra-Strength Tylenol capsules caused the deaths of at least seven people in Illinois in 1982. Three hundred area parents were studied and divided into three equally sized groups on the basis of economic, educational, and professional criteria. After the Tylenol murders, all groups became anxious about the safety of OTC drugs, but intergroup differences were highly significant (p = 0.001). Attitude changes, however, did not necessarily precipitate a change in behavior. Similar percentages of each of the groups who claimed to be adversely affected by the Tylenol scare gave OTC drugs as before.

Treatment of children with posttraumatic transient loss of consciousness.

Recommendations for the treatment of asymptomatic children who have had a brief period of loss of consciousness due to blunt head trauma are anecdotal and vary greatly. The purpose of this study is to define the range of practice in treating children with uncomplicated loss of consciousness by determining: (1) the frequency of "routine" hospitalization for observation and (2) those criteria which, when present, result in hospitalization. A total of 957 pediatricians representing five groups of physicians responded to a nationwide questionnaire survey to determine current treatment practices for uncomplicated loss of consciousness. Of all directors of pediatric emergency rooms and pediatric chief residents, 44% routinely hospitalize all patients who have had loss of consciousness. Academic child neurologists and child neurologists in private practice hospitalize these patients least frequently, 29% and 31%, respectively (P less than 0.05). Of pediatricians in private practice, 38% admit all children with loss of consciousness. Pediatricians from all groups who do not routinely hospitalize all children with uncomplicated loss of consciousness showed similarity in the criteria they use for admission. These variables include: abnormal vital signs (97% to 100%), skull fracture (96% to 100%), suspicion of child abuse (93% to 100%), observation of a change in level of consciousness (92% to 99%), unreliable caretaker at home (91% to 98%), vomiting (90% to 99%), history of a change in level of consciousness (88% to 100%), duration of loss of consciousness (88% to 96%), seizure (77% to 94%), age of child (62% to 75%), child nearly back to normal (32% to 48%), dizziness (22% to 49%), witness of loss of consciousness not reliable (24% to 36%), headache (9% to 16%), and decision deferred to neurosurgeon (2% to 7%).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative study of the prevalence, outcome, and prediction of bacteremia in children.

We undertook a prospective, concurrent comparison of the prevalence, predictability, and outcome of bacteremia in children from 3 to 24 months of age with temperatures greater than or equal to 39.5 degrees C in three diverse clinical settings: primarily black lower-class children at an inner-city hospital (n = 532), primarily white middle-class children at a suburban hospital (n = 160), and primarily white middle-class children in offices of pediatricians in private practice (n = 94). The prevalence of bacteremia for the entire study sample (3.1% to 7.4%) and outpatients only (1.9% to 5.9%) was not statistically different among the three groups. There were no statistically significant differences among the three groups in identifying children with bacteremia (P greater than 0.05). There was no racial, geographic, or socioeconomic predilection for bacteremia in infants. At the first visit, antibiotics were prescribed (most commonly for otitis media) for 23 of the 25 bacteremic patients who were not initially hospitalized. One patient with otitis media developed meningitis. The others had uncomplicated courses and were well by 96 hours (most by 48 hours). In office settings, private practitioners were no better in predicting bacteremia in familiar patients than they were with first-time patients. Information from blood culture did not appear to alter patient management. We conclude, therefore, that routine blood cultures are unnecessary for all highly febrile infants given antibiotics.

The effectiveness of health education on home use of ipecac.

It is widely recommended by pediatricians that syrup of ipecac for secondary prevention of poisoning be kept in homes where there are young children. To evaluate the efficacy of this recommendation we measured mother's gain in knowledge of how to use ipecac safely at home. The study population (n = 78) were primarily middle class mothers bringing their 9-month-old infants to one pediatrician at a health maintenance organization for a well-baby visit. The pediatrician delivered health education on poisonings. A before-after study design was used. The highly significant (p less than 0.001) gain in knowledge demonstrates that parents can learn to use ipecac safely at home. The practitioner should limit safety counseling to selected areas most problematic at each age level, and within each topic, should concentrate on the most salient points.

Will mothers use free household safety devices?

This study was intended to determine if mothers of small children would use free safety devices to help safety-proof their homes. The study population consisted of an experimental group of 101 families receiving general health education on home safety proofing and a control group of 104 families. Each of the 205 families received two types of safety devices: Kindergards (which are plastic locking devices for cabinets and so forth) and covers for electric outlets. The families were given identical instructions on their use. There was significant increase in the use of the outlet covers in both subgroups, with experimental group using them more (P less than .05) than the control group. There was no significantly increased use of the Kindergards.