Respite needs of families receiving palliative care.

AIM: The care of a child with a life-limiting condition proves an emotional, physical and financial strain on the family that provides care for their child. Respite care is one way which allows carers to receive some relief and support in the context of this burden of care. The provision of and the requirements for respite in this context is poorly understood. This survey aims to describe the types of respite care families receive, the respite that they would ideally receive and the barriers that prevent this. METHODS: A cohort of 34 families cared for by the Paediatric Palliative Care Service in Queensland were approached to participate in a 20-question survey about their current respite preferences for future respite, with 20 surveys returned. RESULTS: Three of the families (15%) reported receiving no respite in the previous 12 months. Families who received respite received a combination of formal respite (a structured care provider) and informal respite (family or friends). Ten families (50%) reported that they would want the time of respite changed. Barriers to receiving adequate respite included complexity of care of the child, financial barriers and lack of a respite provider. CONCLUSIONS: There is disparate provision of respite care with the main perceived barrier to attaining 'ideal respite' being the lack of a provider able to meet the complex care needs of their child. The provision of respite across diversity in geography; medical condition; social and cultural needs remains a challenge.

Antidepressants for functional gastrointestinal disorders in children.

QUESTION: Functional gastrointestinal disorders (FGIDs) are complex conditions I see in some of my pediatric patients. The indications for antidepressants such as selective serotonin reuptake inhibitors (SSRIs) do not include treatment of FGIDs; however, some children are prescribed SSRIs for this condition. Are antidepressants effective and safe to use for treating FGIDs in children and adolescents? ANSWER: The pathogenesis of FGIDs is largely idiopathic, and although theories exist to explain why SSRIs might be used to treat FGIDs, there is no conclusive evidence of their effectiveness. No large, well controlled studies have investigated the use of SSRIs to treat FGIDs in the pediatric population. There is also evidence that suggests an increased risk of suicidal thoughts when adolescents use SSRIs. Currently, there is no recommendation to use SSRIs to treat FGIDs in children.

Proton pump inhibitors for irritable infants.

QUESTION: Crying is common in infants; however, caring for infants with inconsolable crying, previously also known as colic or reflux, is often extremely distressing for parents. Is there a benefit to using gastric acid suppression (eg, proton pump inhibitors [PPIs]) in these infants? ANSWER: The use of PPIs in infants and children has increased in recent years. The efficacy of proton pump inhibitors has not been demonstrated in the treatment of irritability and excessive crying in otherwise healthy infants younger than 3 months of age. Conversely, while PPIs are generally well tolerated, there is some evidence to link the use of PPIs with increased susceptibility to acute gastroenteritis, community-acquired pneumonia, and disorders of nutrient absorption and utilization. Irrespective of treatment, crying and irritability in infancy generally improve with time. Proton pump inhibitors do not improve symptoms in the interim.

Staphylococcus aureus decolonization for recurrent skin and soft tissue infections in children.

QUESTION: I see otherwise healthy children in my practice with recurrent staphylococcal skin infections. While I am comfortable with managing each acute infection, what can be done to eradicate Staphylococcus aureus and reduce the chance of recurrent infections? ANSWER: Staphylococcus aureus skin and soft tissue infections (SSTIs) are common in children and are increasing in frequency. Risk factors for the development of staphylococcal SSTIs are colonization with S aureus and recent diagnosis of SSTI in a household member. Current evidence suggests that a combined strategy using hygiene education, nasal mupirocin, and bath washes with chlorhexidine or diluted bleach has the most success in decolonization. However, decolonization appears to only provide temporary reduction in carriage rate. According to the limited research in the ambulatory population, decolonization of a patient does not confer a reduced risk of recurrent infections. Further research and large studies are required to understand the factors in S aureus pathogenesis and whether decolonization of a child and his or her household is of benefit in reducing subsequent S aureus infections.

Acute otitis externa in children.

QUESTION: In the summer months I see many children with uncomplicated acute otitis externa (AOE). I am aware of the multiple ototopical preparations. Which is the best first-line agent to treat AOE, and is there a role for an oral antibiotic? ANSWER: There are no specific Canadian guidelines for the management of AOE. However, current American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated AOE; suggest there is little difference between the various ototopical preparations; and recommend the choice of treatment be based on the specific clinical situation. In practice, this often results in prescribing an antibiotic-steroid formulation for 7 to 10 days. This ototopical treatment option is supported by a recent Cochrane review that has documented the superiority of an antibiotic-steroid combination when compared with placebo or acetic acid in providing clinical resolution of AOE.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.

QUESTION: I have heard about children who have tic disorders that seem to be exacerbated by group A ß-hemolytic streptococcal infection. Should children presenting with this phenomenon receive treatment with antibiotics, receive prophylactic treatment, or use immunomodulators to treat the symptoms? ANSWER: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) constitute a condition that includes neuropsychiatric symptoms, mainly obsessive-compulsive disorder or tic disorders, temporally associated with an immune-mediated response to streptococcal infections. The actual existence of PANDAS as a unique clinical entity is still up for debate, as a temporal association between group A ß-hemolytic streptococcal infections and symptom exacerbations has been difficult to prove thus far. Based on only a few studies, positive results have been found using antibiotic prophylaxis and immunomodulatory therapy in children with PANDAS. At this time, however, evidence does not support a recommendation for long-term antibiotic prophylaxis or immunomodulatory therapy.

Topical nonsteroidal anti-inflammatory drugs for corneal abrasions in children.

QUESTION: Corneal abrasion from minor injury to the eye is common in both adults and children. Some of my colleagues prescribe topical nonsteroidal anti-inflammatory drugs (NSAIDs) for analgesia. How safe is this practice? ANSWER: Topical ophthalmic NSAIDs are a short-term effective treatment of the pain associated with corneal abrasions in children. Rare but serious complications have been reported in adult case-study series. Children with corneal abrasions should have follow-up appointments within 24 to 48 hours to assess healing, complications, and side effects of treatment, particularly if they are using topical NSAIDs.

An incurable itch: head lice.

QUESTION: Head lice infestations continue to be seen frequently in many communities. Some of these children require multiple treatments before eradication. What are the current treatment recommendations for head lice? ANSWER: Head lice (Pediculus humanus capitis) infestations are common, particularly among school-aged children. In order to minimize louse resistance, insecticide usage, and social stigmatization, diagnosis and treatment should be limited to those with live lice on the scalp. Options for management are predominantly topical therapies or physical removal. Large studies comparing the efficacy of these treatments are lacking. Treatment should be repeated in approximately 7 days if topical insecticides are used or every 2 to 3 days for 2 weeks if wet combing is used. Lice resistance patterns vary widely geographically, and resistance is now the most common cause of treatment failure.