Bacterial blood cultures in children with sickle cell disease.

BACKGROUND: Children with sickle cell disease (SCD) are considered at risk for bacteremia, especially when they present to the emergency department (ED) with fever. OBJECTIVE: We aimed to determine the incidence of bacteremia in children with SCD presenting with or without fever to a pediatric ED. METHODS: A retrospective chart review of 692 pediatric ED visits of children with SCD during a 2-year period was conducted. RESULTS: Seven blood cultures (6 homozygous and 1 heterozygous) had bacterial growth (1.3%; 95% confidence interval, 0.5-2.1), 3 of which were among febrile children (1.7%; 95% confidence interval, 0-3.6). All identified microorganisms are part of the normal skin or oral flora and could represent contamination. None of the patients had growth of the Streptococcus pneumoniae species. CONCLUSION: A very low rate of bacterial growth and no S pneumoniae were found. The absence of S pneumoniae in our cohort can be associated with the addition of the 7-valent pneumococcal conjugate vaccine.

Measuring tissue oxygen saturation via spectrometer in children.

BACKGROUND: : Near-infrared spectroscopy is a new noninvasive method of monitoring oxygen saturation at a tissue level. The purpose of this study was to evaluate new near-infrared tissue spectrometer InSpectra (Hutchinson Technology Inc.) in children and to determine preferable areas of the body to measure tissue oxygen saturation (StO2). METHODS: : Prospective study at a pediatric emergency department. Children aged 0 years to 17 years with no respiratory distress participated in this study. StO2 on deltoid muscle, thenar eminence, forearm, calf, bicep, and tricep was measured at triage with a 25-mm probe. RESULTS: : A total of 310 patients were recruited. The mean age of participants was 6.8 years +/- 4.4 years and 53% were males. Average StO2 was 84% (95% confidence interval, 81-87%) on the bicep muscle, 83.5% (95% confidence interval, 82-85%) on the deltoid muscle and significantly (p < 0.05) lower on other areas. Variation of StO2 was lower on the bicep, deltoid, and thenar muscles. Regression analysis showed significant linear relationship between patients' age and StO2 measured on the thenar eminence (beta = 0.3, R = 0.08, p < 0.001) and between patients' weight and StO2 on the thenar eminence (beta = 0.3, R = 0.07, p < 0.001). StO2 in febrile patients was similar to afebrile children, except thenar eminence where StO2 was significantly lower (p = 0.002). Less than 5% reported any type of pain or cried during StO2 measurement, which did not differ from pulse oximetry. CONCLUSION: : Bicep and deltoid muscles are the most appropriate areas to measure StO2 using the 25-mm transducer in children of different ages. The use of near-infrared spectroscopy on the thenar eminence, which is usually used for measurement in adults, has varied results in children depending on the age, weight, and presence of fever.

Admission and length of stay due to painful vasoocclusive crisis in children.

PURPOSE: To identify demographic, clinical, and laboratory characteristics associated with admission and a longer length of stay (LOS) due to vasoocclusive crisis (VOC) in children with sickle cell disease (SCD). METHODS: Retrospective chart review at a large tertiary pediatric center. Patients younger than 18 years with VOC due to SCD presenting to the emergency department were included. We performed multivariate regression analyses to predict characteristics associated with admission and LOS of 4 days or more. RESULTS: A total of 428 visits for VOC were documented in 2005 to 2006. In a multivariate regression analysis higher pain score at triage (P < .001), older age (P = .04), and increased systolic blood pressure (P = .02) were predictors of admission. Higher pain score at triage (P = .046), older age (P = .002), increased polymorphonuclear count (P = .02), and homozygous SCD type (P = .03) were associated with prolonged hospital LOS. CONCLUSION: These characteristics will help healthcare providers predict and plan admission and management of children with SCD.

Potential vitamin-drug interactions in children: at a pediatric emergency department.

BACKGROUND: A significant increase in vitamin use has been observed in recent years and interactions between vitamins and medications have been reported. OBJECTIVE: To determine the frequency and types of potential interactions between vitamins and medications in children arriving at a large tertiary, pediatric emergency department. We also compared family characteristics of children with potential interactions with those of children with no potential interactions, in order to determine children at a higher risk. METHODS: A cross-sectional study in which a survey was conducted of parents/caregivers and/or patients aged 0-18 years registered at a large pediatric emergency department in Canada. A total of 1804 families underwent a face-to-face interview. The main outcome measure was the rate of potential vitamin interactions in the preceding 3 months. RESULTS: A considerable number of patients (11% of our cohort) had potential vitamin-medication interactions in the preceding 3 months, which could theoretically result in adverse events, and over one-third of these children had more than one potential interaction. Patients with potential interactions and their parents were significantly older (p < 0.001 for the child and mother, p = 0.02 for the father), the children were much more likely to have a chronic illness (p < 0.001) and concurrently receive prescribed or over-the-counter medication (p < 0.001), and more children with potential interactions were completely immunized (p = 0.02). The child's sex, parental education, employment status, family income, and primary language spoken at home were not associated with potential interactions. CONCLUSIONS: Taking into account the high rate of potential vitamin-drug interactions, especially among older children and patients with chronic illness, parents and healthcare providers need to balance the potential benefit of concurrent vitamin-medication use with its potential harms.

Should weight-loss supplements be used for pediatric obesity?

QUESTION: In my clinic I have a large population of overweight and obese children. There is a range of weight-loss supplements marketed for the adult population. What natural health products for treatment of obesity are effective and can be used in children? ANSWER: Weight-loss supplements lack sufficient data supporting their efficacy and safety, even in adults. Most weight-loss supplements cannot be recommended at this time for children. Options for obese adolescents include increasing consumption of fibre with diet or using fibre supplements, such as glucomannan. Dietary fibres can also prevent side effects of orlistat, the only medication available for treatment of obese adolescents.

Predictors for admission of children with periorbital cellulitis presenting to the pediatric emergency department.

OBJECTIVES: To identify demographic and clinical characteristics associated with admission because of periorbital cellulitis (PC) in children. METHODS: Records of children aged 0 to 18 years with PC who visited our tertiary emergency department (ED) in 2004 were reviewed. We calculated a cumulative number of local ocular symptoms in patients that included swelling/edema, redness/erythema, presence of discharge, pain, conjunctival injection, and shut eye. A binary logistic regression analysis was performed to identify predictors of admission for PC. RESULTS: A total of 89 children were included in the analysis; 39 (44%) of them were admitted to the ward. A cumulative number of local symptoms associated with PC and temperature in the ED served as significant predictors of hospitalization (odds ratio, 2.5; P = 0.005; and odds ratio, 2.0; P = 0.04, respectively). Among individual local symptoms, only swelling/edema was found to significantly predict admission in univariate analysis (P = 0.03). Considerable variation was documented in intravenous and oral antibiotics prescribed in the ED. CONCLUSIONS: Combination of local ocular symptoms and body temperature are positively associated with admission from the ED. Future research should concentrate on evaluating the suggested score we used in this cohort to validate it and evaluate its generalizability. Devising such scoring can help clinicians determine guidelines for admission of children with PC.

Potential interactions of drug-natural health products and natural health products-natural health products among children.

OBJECTIVE: To determine the frequency of concurrent use of conventional medications and natural health products (NHP) and their potential interactions in children arriving at an emergency department. STUDY DESIGN: A survey of parents and patients 0 to 18 years at a large pediatric ED in Toronto, Ontario, Canada. RESULTS: A total of 1804 families were interviewed in this study. Concurrent drug-NHP use was documented in 355 (20%) of patients and 269 (15%) of NHP users were receiving more than one NHP simultaneously. Theoretically possible NHP-drug or NHP-NHP interactions in the preceding 3 months were identified in 285 (16%) children. There were 35 different NHP-medication interaction pairs and 41 NHP-NHP interaction pairs. NHP-medication interactions were predominantly pharmacokinetic (modified absorption, 35%); potential NHP-NHP interactions were mostly pharmacodynamic (increased risk of bleeding, 47%). CONCLUSIONS: Medications are used concurrently with NHP in every fifth pediatric patient in the emergency department and many NHP users are receiving more than 1 NHP simultaneously. One quarter of all paired medication-NHP or NHP-NHP could potentially cause interactions. Although we can not confirm that these were true interactions resulting in clinical symptoms, parents and health care providers need to balance the potential benefit of concurrent NHP-medication use with its potential harms.

Predictors for opioid analgesia administration in children with abdominal pain presenting to the emergency department.

OBJECTIVES: Abdominal pain is one of the most common symptoms in children. The aim of this study was to determine the rate of opioid analgesia in children with abdominal pain presenting to the pediatric Emergency Department (ED) and to identify factors associated with administration of opioids. METHODS: We retrospectively reviewed all charts of patients with abdominal pain < 7 days presenting to the ED of a tertiary pediatric hospital over a 3-month period. Demographic and illness-related variables were recorded, and the primary outcome variable was whether opioid analgesia was used to relieve abdominal pain. We analyzed the data with a univariate analysis and a multivariate stepwise regression analysis to determine independent influences on the rate of opioid prescribing. RESULTS: Of 582 children included in the analysis, 53 (9%) received opioid analgesia. Pain in the right lower quadrant on examination, documentation of a pain score in triage, and the level of acuity as determined by the triage nurse were predictors of administration of opioids by the physician. Thirty-four (77%) of the opioids given were below the recommended dose for the child. CONCLUSIONS: Few pediatric patients with abdominal pain are treated with pain medications. The decision to use opioid analgesia for acute abdominal pain in the pediatric ED is influenced by acuity level, pain score documentation in triage, and location of abdominal pain. Efforts should be made to educate physicians on the appropriate administration and dose of opioids in children with abdominal pain in the ED.

Hypnosis for treatment of pain in children.

QUESTION: Many children suffer from chronic and painful illnesses. Hypnosis was found to be effective for analgesia in adults. Is it effective for managing pain in children? ANSWER: Children can be easier to hypnotize than adults. Studies have shown clinical hypnosis and self-hypnosis to be effective as adjunct treatments for children in pain. Examples include painful medical procedures, such as bone marrow aspiration and lumbar puncture in pediatric cancer patients, postoperative pain and anxiety in children undergoing surgery, and chronic headache.

Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries.

PURPOSE: The purpose of the study was to document prehospital analgesia (PA) for children with extremity injuries at home or en route to the hospital, as assessed by research personnel at the pediatric emergency department. METHODS: Two parallel groups of patients with fractures or soft-tissue injuries (STIs) were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. Parents or children were interviewed, pain assessed, and data from the emergency department charts collected. RESULTS: A total of 310 patients were recruited; their mean age was 10.2 years, and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and STI. Of the patients, 78% had PA, 73% received first aid (icing, immobilization), and 37% had medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures. CONCLUSION: Most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.

Physician pain reminder as an intervention to enhance analgesia for extremity and clavicle injuries in pediatric emergency.

UNLABELLED: The purpose of this study was to document analgesic use for limb and clavicle injuries in the pediatric emergency department (ED) and to determine whether a physician-oriented pain scale form on the patient's chart would enhance the administration of analgesia. Patients 3 to 18 years old were recruited prospectively in our tertiary pediatric ED in Toronto. The study included 4 crossover periods, 2 with the pain scale form on the patient's chart and 2 without. A total of 310 patients were recruited, mean age was 10 years, 64% were boys, and 62% had sustained fractures. The mean pain score was 4.4. Only 90 (29%) patients received an analgesic in the ED, and 65 (72%) of them were ordered by a physician. Only 24 (20%) in the study group and 22 (14%) in the control group received sufficient analgesia (P = .13). The median time to physician-initiated analgesia after arrival was 2.0 hours (1.0 to 3.3 hours), without a significant difference between groups. Pain control was 4-fold more appropriate in children receiving opioids versus nonopioids. Physician pain reminders did not enhance, and other measures should be taken to increase the dispensing of analgesia. PERSPECTIVE: This is the first study to evaluate whether the addition of a physician-oriented pain-scale form on the chart of patients with injuries improves administration of analgesia in the ED. We found that physicians do not give sufficient analgesia even with this reminder form.

Treating infants' colic.

QUESTION: Young parents often visit my office because their infants are crying inconsolably. Results of physical examination are unremarkable, so colic is the most likely cause. Colic has been known for many years, but I am unaware of any good remedy for it. Are there any modern, effective, safe methods of managing colic? ANSWER: In most cases, colic is a "noisy phenomenon"for which there is no good explanation or treatment. Changing babies' feedings rarely helps, and effective pharmacologic remedies are as yet unavailable. Several behavioural and complementary therapies have been suggested, but they have not been found effective. Addressing parental concerns and explaining about colic is the best solution until the colic goes away.