Category: Pediatrics

Discharging Bronchiolitis on Home Oxygen

This is another one of those window-to-the-future articles, where an enterprising department has taken a commonplace disease with a relatively high admission rate and tried to change the status quo.

As they note, bronchiolitis is the #1 cause of admission for children < 1 year, it accounts for 150,000 admissions annually, and costs $500 million.  One of the key clinical features that keeps otherwise well-appearing children in the hospital is hypoxia, specifically < 90% saturation by pulse oximetry as recommended by the American Academy of Pediatrics.

This is a retrospective chart review that essentially says “we did this and we like it.”  4,194 relevant charts were reviewed, 57% of which were discharged without home oxygen, 15% were discharged on oxygen, and 28% were admitted.  Of the discharged patients, 4% of the no-home-oxygen patients returned for eventual admission compared with 6% of the discharge-on-oxygen patients.  Overall, this led to a 25% relative decrease in admissions for bronchiolitis at their institution, compared to historical controls.

More confirmatory study is needed – it’s a little different at mile-high Denver than the rest of the U.S. – but this may be a promising way to reduce admissions for bronchiolitis.  It is also suggestive of what is likely the new future of cost-containment medicine, at least where the malpractice environment will tolerate it – an increasing proportion of higher-risk discharges with, in theory, closer follow-up that saves money in the long run.

“Discharged on Supplemental Oxygen From an Emergency Department in Patients With Bronchiolitis”
http://www.ncbi.nlm.nih.gov/pubmed/22331343

Eat Your Vegetables!

This may be a candidate for an IgNobel Prize, published as a research letter in JAMA: how to get schoolchildren to eat their vegetables!

Control group: normal lunch trays.  Intervention group: lunch trays with compartments specifically labeled with photographs of green beans and carrots.  Results: success!  Green bean choice went from 6.3% of children to 14.8% of children, and carrot choice went from 11.6% to 36.8%.  Amount of green bean and carrot consumption was stable on an individual basis, resulting in an overal net consumption of both green beans and carrots by their cohort.

Of course, this was only a single day intervention – my guess is the effect would fatigue – but, at least, for one day, children ate more vegetables.

This has far-reaching implications for Emergency Medicine.

“Photographs in Lunch Tray Compartments and Vegetable Consumption Among Children in Elementary School Cafeterias”
http://jama.ama-assn.org/content/early/2012/01/31/jama.2012.170.full

Half of Fractures Received No Analgesia

One of the new CMS quality measures involves measuring time to receipt of pain medication for patients diagnosed with long bone fractures.  While this isn’t the most exciting quality measure in terms of outcomes, it is probably a reasonable expectation that fractures receive pain control, and it might be a plausible surrogate marker for overall Emergency Department operations – at least, until the powers that be focus solely on these few measures at the expense of other clinical operations.

This article is a retrospective review of all pediatric long bone fractures evaluated at their facility.  They used the electronic medical record to track the timing of any “adequate” pain medication.  They have a specific weight-based definition of “adequate” for IV narcotics, PO narcotics, and non-narcotic analgesics, and they specifically break down pain medication received within 1 hour of arrival.

They identified 773 cases in their records, and by their definitions, 75 patients received an “adequate” dose of pain medication within 1 hour.  One can quibble with their definition of “adequate” because there is a range of pain needs that don’t necessarily require maximal dosing.  But, you cannot quibble with the fact that 353 children received no pain medication at all within an hour of ED arrival (or prior to ED arrival).  Certainly, some individual factors at play would result in reasonable delays to pain medication, but definitely not nearly half.

“Analgesic Administration in the Emergency Department for Children Requiring Hospitalization for Long-Bone Fracture”
http://www.ncbi.nlm.nih.gov/pubmed/22270501

Dosing Errors With IV Acetaminophen

As a follow-up to the recent posting regarding IV acetaminophen, this recent article in Pediatrics highlights a few case reports regarding overdose.

According to the authors, the most frequent error in administration when the order is written in milligrams, but the medication order is administered in milliliters – a 10-fold overdose.  All of the patients in this series received n-acetylcysteine infusion, and none appeared to suffer significant liver injury specifically attributed to the overdose.

Another lovely demonstration of the potential for iatrogenic injury in healthcare.  Even the most apparently benign orders can have unanticipated harmful consequences, and a demonstration how intravenous administration is at higher risk.

“Intravenous Acetaminophen in the United States: Iatrogenic Dosing Errors”
http://pediatrics.aappublications.org/content/early/2012/01/18/peds.2011-2345.abstract

Happy Holidays!

Holiday break – intermittent and ineloquent blogging will be the norm.  I count 209 blog posts for the year – more than enough to keep anyone busy reading the archives.

But, if you’re done with those, Life In The Fast Lane has a lovely Christmas-themed blog post with great articles including:

“What was wrong with Tiny Tim?”
http://www.ncbi.nlm.nih.gov/pubmed/1340779

“Children’s Nomenclatural Adventurism and Medical Evaluation study”
http://www.ncbi.nlm.nih.gov/pubmed/20415998

“No poinsettia this Christmas”
http://www.ncbi.nlm.nih.gov/pubmed/16866065

Ranitidine Kills Neonates

Specifically, 24 to 32-week premature neonates, but it’s still an interesting demonstration of the unanticipated dangers of reducing the body’s nonimmune defense mechanisms.

This is a non-randomized, controlled, prospective, observational study from Italy that simply looked at how many premature neonates in their NICU received ranitidine treatment for acid suppression.  The secondary endpoints of the study were any observed associations between ranitidine use/non-use and NEC, mortality, sepsis, length of hospitalization, etc.  This is still non-randomized observational data, so the associations may be affected by other unknown confounders – but mortality in the non-ranitidine group was 1.6% and the mortality in the ranitidine group was 9.8%.  This difference is probably all attributable to infection, considering 25.3% of the ranitidine group developed sepsis compared to 8.7% in the non-ranitidine group.

An impressive difference, even in a non-randomized cohort.  Not a lot of obviously significant differences between groups.  We’ve seen similar, smaller increases in infection in ICU adults receiving acid-suppression medication – I wonder if these effects extend to young infants on ranitidine as well?

“Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns”
http://www.ncbi.nlm.nih.gov/pubmed/22157140

Under/Overtesting in Fever Without a Source

A curious study that observes, from the NHAMCS dataset, the testing performed by Emergency Physicians on children who have fever without a source between the ages of 3 and 36 months.

The general point of the authors, while acknowledging the limitations of this sort of data-dredging, is that testing strategies by Emergency Physicians appear to be generally non-conforming with the American Academy of Pediatrics recommendations for testing in otherwise well-appearing children.  They are hesitant to critique the patients who received laboratory testing – because they have no data on how well-appearing the child may have been or other comorbidities that might indicate testing – but they do take issue with the fact that only 43% of females under age 2 with a fever received a urinalysis and culture.  The 2008 Pediatrics guidelines – not endorsed by ACEP – would recommend that all of them receive UA and culture.  Considering the prevalence of UTI in febrile females under 2 years of age ranges from 8-17%, their criticism is probably valid.
Other trivia: 20% of children with no testing performed received antibiotics.  This could be due to missing ICD-9 data about another clinical diagnosis – but more likely due to simply treating fever unnecessarily.  
And, finally, children from zip codes with higher median incomes were more likely to receive CBC and UA.  More UAs, probably good.  More CBCs, probably bad.
Just an interesting summation of observational data.

Why Aren’t You Using Nitrous Yet?

Another massive study reviewing adverse events encountered during procedural sedation – this time with nitrous oxide given in concentrations up to 70%.  It is odd that resistance is encountered regarding high concentrations of nitrous oxide – considering 30% O2 is still greater than the fraction of inspired oxygen on room air – but this, and other studies like it, should help allay any concerns.

Out of their 7,802 nitrous administrations, they recorded 9 “potentially serious” adverse events – eight desaturations and one potential aspiration event requiring oropharyngeal suctioning.  More importantly, a reasonable percentage of these administrations were in children with comorbid diseases or potentially serious illness that needed sedation for significant procedures – LP, CT scans, NG/G-tube placement, and “other” that included EMGs and botulinium toxin injections.  Their rates of serious events are similar to other published series where either zero or <1% potentially serious events occurred – except for the study that reported 30% adverse events, but included “euphoria” and “dreaming” as adverse events.

This is not, however, an ED-only study, and one of the limitations is that they don’t specifically record whether they are able to successfully complete the intended procedure with this method – however, one would imagine, if it didn’t work the first 7,000 times, they wouldn’t have kept doing it…

“Safety of High-Concentration Nitrous Oxide by Nasal Mask for Pediatric Procedural Sedation”
http://www.ncbi.nlm.nih.gov/pubmed/22134227

Skipping the LP in Infants 30-90 Days – Eh.

This is another one of those “practice-changing” types of articles, where the authors try to debunk some specific aggressive diagnostic or therapeutic modality that is over-utilized in a low-prevalence, high-risk population.  This article, which you may have already seen, is regarding the need for a lumbar puncture in infants between 30 and 90 days.

They perform a retrospective review of nonconsecutive infants between 30 and 90 days of age who presented to the Emergency Department and received the “septic workup” – urinalysis/culture, blood culture, and lumbar puncture/CSF culture.  They analyze a data set of 392 infants, the overwhelming majority of which are completely culture negative.  52 of them are culture positive on their urinalysis, 13 are culture positive in the blood, and 4 are CSF culture positive.  The authors note that only one patient who had a positive urinalysis also had a positive CSF fluid culture – and that infant did not qualify as a low-risk infant by the Rochester criteria – so a well-appearing infant with a positive urinalysis need not undergo LP.

So, essentially, this study tells us only that meningitis is rare and that UTIs are common.  The authors attempt to make the flawed logical argument against LP in their discussion by emphasizing the negative predictive value for meningitis in the setting of an abnormal UA is 98.2%.  However, they erroneously discount the negative likelihood ratio of 0.87 (95% CI, 0.5–1.5).  Therefore, statistically speaking, based on their results, repeating this study 100 times could lead to nearly half the study results showing a positive urinalysis favored concomitant meningitis.

Now, in a clinical sense, the authors are likely correct.  An infant who looks well, meets the Rochester criteria, has an identified source for fever, and will be receiving antibiotics is at low risk for meningitis – by prevalence alone, not by anything this study shows – and is probable to have a good clinical outcome since they’re receiving antibiotics (in the event that same organism is resulting in a well-appearing, subclinical systemic and cerebrospinal bacteremia).  The argument should not be that you can generate a zero-risk population with their combination of +UA and Rochester, but that the risk of bad outcome may be similar to the risk of harms associated with the lumbar puncture, false positives, and follow-on treatment/testing.

“Is a Lumbar Puncture Necessary When Evaluating Febrile Infants (30 to 90 Days of Age) With an Abnormal Urinalysis?”

When Parents Refuse a Septic Workup

This is a brief commentary and discussion regarding the implications of parental refusal of hospitalization and evaluation of a potentially septic neonate.  It is absolutely an issue we all hope to never face, but probably will at some point in our careers.

Two pediatricians offer differing opinions on the extent to which social work and child protective services need be involved, raising such issues as the threshold percentage for likelihood of serious bacterial infection/bacteremia should be for “imminent harm” to the child, and the perceived benefits of therapy.  No specific answers are gleaned from the article, but it is worth reading and thinking through the discussions you would have in a similar situation.

“When Parents Refuse a Septic Workup for a Newborn”
www.ncbi.nlm.nih.gov/pubmed/22025599