A randomized trial of magnesium in the emergency department treatment of children with asthma.

STUDY OBJECTIVE: Magnesium sulfate has been shown to benefit asthmatic children and adults with poor responses to initial beta(2)-agonist therapy in the emergency department. We sought to determine whether the routine early administration of high-dose magnesium would benefit moderate to severely ill children with acute asthma. METHODS: This was a randomized, double-blind, placebo-controlled trial of 54 children 1 to 18 years of age who presented to the ED of a tertiary care children's hospital with a moderate to severe asthma exacerbation. After receiving a nebulized albuterol treatment (0.15 mg/kg) and methylprednisolone (1 mg/kg), patients were randomly assigned to receive either 75 mg/kg of magnesium sulfate (maximum 2.5 g) or placebo. Thereafter, all patients were treated with frequent nebulized albuterol following a structured protocol. The main outcome was degree of improvement as assessed by Pulmonary Index scores over 120 minutes. Secondary outcomes included hospitalization rates and time required to meet discharge criteria. RESULTS: The mean change in Pulmonary Index score from baseline to 120 minutes was 2.83 for the magnesium group compared with 2.66 for the placebo group (95% confidence interval -1. 24 to 1.60). Eleven (46%) of 24 magnesium-treated patients were hospitalized compared with 16 (53%) of 30 in the placebo group (95% confidence interval -19% to 34%). There were no statistically significant differences between the groups with respect to time required to meet discharge criteria. CONCLUSION: The routine administration of high-dose magnesium to moderate to severely ill children with asthma, as an adjunct to initial treatment with albuterol and corticosteroids, was not efficacious.

Appendicitis in childhood.

Ultrasonography, CT scanning, and prolonged observation may improve diagnostic accuracy of appendicitis in children with atypical presentations. This article describes diagnostic pitfalls, including early presentation and abnormal appendiceal location.

Oral versus intravenous corticosteroids in children hospitalized with asthma.

BACKGROUND: Previous studies have demonstrated that in the emergency treatment of an asthma exacerbation, corticosteroids used in conjunction with beta-agonists result in lower hospitalization rates for children and adults. Furthermore, orally administered corticosteroids have been found to be effective in the treatment of outpatients with asthma. However, similar data in inpatients is lacking. OBJECTIVE: The purpose of this study was to determine the efficacy of oral prednisone versus intravenous methylprednisolone in equivalent doses for the treatment of an acute asthma exacerbation in hospitalized children. METHODS: We conducted a randomized, double-blind, double-placebo study comparing oral prednisone at 2 mg/kg/dose (maximum 120 mg/dose) twice daily versus intravenous methylprednisolone at 1 mg/kg/dose (maximum 60 mg/dose) four times daily in a group of patients 2 through 18 years of age hospitalized for an acute asthma exacerbation. All patients were assessed by a clinical asthma score 3 times a day. The main study outcome was length of hospitalization; total length of stay and time elapsed before beta-agonists could be administered at 6-hour intervals. Duration of supplemental oxygen administration and peak flow measurements were secondary outcome measures. RESULTS: Sixty-six patients were evaluated. Children in the prednisone group had a mean length of stay of 70 hours compared with 78 hours for the methylprednisolone group (P =.52). Children in the prednisone group were successfully weaned to beta-agonists in 6-hour intervals after 59 hours compared with 68 hours for the methylprednisolone group (P =.47). Patients receiving prednisone required supplemental oxygen for 30 hours compared with 52 hours for the methylprednisolone group (P =.04). CONCLUSION: There was no difference in length of hospital stay between asthmatic patients receiving oral prednisone and those receiving intravenous methylprednisolone. Because hospitalization charges are approximately 10 times greater for intravenous methylprednisolone compared with oral prednisone, the use of oral prednisone to treat inpatients with acute asthma would result in substantial savings.

Noncompliance with scheduled revisits to a pediatric emergency department.

OBJECTIVES: To determine the incidence of, the risk factors associated with, and the consequences of noncompliance (NC) with a scheduled revisit to a pediatric emergency department (ED). DESIGN: A prospective, inceptive cohort study. SETTING: An urban pediatric ED. PATIENTS: A sample of 179 children. INTERVENTIONS: Interviews of parents and physicians. RESULTS: Overall, 91 (51%) of the parents were noncompliant, and just 21% were noncompliant because "the child was better." Of the 124 patients who ED physicians believed were "certain to return," 57 (46%) were noncompliant. Six factors were associated with NC: (1) the parent believed that the child was not severely ill (relative risk [RR], 2.92; 95% confidence interval [CI], 1.31-6.49); (2) the parent was judged to be unable to recognize a clinical deterioration of the child (RR, 1.95; 95% CI, 1.55-2.45); (3) the parent did not own a car (RR, 1.77; 95% CI, 1.23-2.54); (4) the parent was younger than 21 years (RR, 1.48; 95% CI, 1.12-1.95); (5) no laboratory testing was performed during the initial ED visit (RR, 1.36; 95% CI, 1.03-1.80); and (6) the parent was judged "not certain" to return (RR, 1.34; 95% CI, 1.01-1.78). CONCLUSIONS: The high rate and the lack of predictability of NC with a scheduled revisit to an ED should influence patient disposition decisions. The factors associated with NC in this study may serve as a model for identifying parents who are at a high risk of NC and as a foundation for interventions designed to improve compliance.

Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children.

STUDY OBJECTIVE: To compare nebulized dexamethasone with oral prednisone in the treatment of children with asthma. DESIGN: A randomized, double-blind, double-placebo study. SETTING: An urban pediatric emergency department. PARTICIPANTS: Patients aged 1 to 17 years with acute asthma. INTERVENTIONS: Patients with moderate asthma exacerbation received frequent aerosolized albuterol and either 1.5 mg/kg of nebulized dexamethasone or 2 mg/kg of oral prednisone. RESULTS: A total of 111 children was evaluated; 21% of those treated with dexamethasone required hospitalization, compared with 31% of those treated with prednisone (P = .26). A significantly greater proportion of dexamethasone-treated children were discharged home within 2 hours (23% versus 7%, P = .02). In the dexamethasone group, 8% who received the drug by mouthpiece were hospitalized compared with 33% who received it by face mask (P = .06). Fewer children treated with dexamethasone vomited (0% versus 15%, P = .001) and fewer relapsed within 48 hours of ED discharge (0% versus 16%, P = .008). CONCLUSION: Nebulized dexamethasone was as effective as oral prednisone in the ED treatment of moderately ill children with acute asthma and was associated with more rapid clinical improvement, more reliable drug delivery, and fewer relapses.

Effect of emergency department immunization on compliance with primary care.

The purpose of this study was to determine whether immunization of children during treatment in an Emergency Department (ED) affects subsequent compliance with primary care. This cohort study of children immunized in the ED and matched controls was conducted in the ED and the pediatric clinic in an urban, tertiary care, pediatric hospital. Forty children were enrolled in study and control groups. There were no differences in age, race, sex, insurance status, temperature on arrival, and discharge diagnoses between groups. The immunization status by parental report and as documented in the clinic records was similar for immunized and control patients. There was no difference in attendance at health maintenance visits during the six months after the ED visit between immunized and control patients. No differences in receipt of immunizations or in immunization status were noted after six months. The sample size has adequate power to conclude that the difference in subsequent compliance with primary care between immunized and control patients is less than 50%. Parents reported their child's immunization status incorrectly in 23% of cases. Patients receiving measles immunization in the ED had already been immunized in 18% of cases. Unnecessary subsequent immunization of study patients occurred in 28% of cases. In conclusion, immunization in an ED does not have a large effect on subsequent compliance with primary care. In the ED, parents are an unreliable source of information about immunization status. An immunization database could reduce the frequency of inappropriate immunization.

Gonococcal conjunctivitis in prepubertal children.

Four prepubertal children had confirmed gonococcal conjunctivitis. All were febrile and had hyperpurulent conjunctival discharge with periorbital inflammation. Cultures of pharyngeal, rectal, and genital specimens on selective media excluded infection at other sites. Detailed social evaluation revealed no evidence or suspicion of sexual abuse. Isolated gonococcal conjunctivitis occurs in prepubertal children. Unlike gonococcal infections at other locations, a nonsexual mode of transmission may exist. However, a careful physical examination and detailed social evaluation, looking for signs of sexual abuse, must be obtained in any prepubertal child with a gonococcal infection.