Carolyn E. Beck

Hypotonic Versus Isotonic Maintenance Intravenous Fluid Therapy in Hospitalized Children: A Systematic Review

A systematic review of studies comparing hypotonic versus isotonic intravenous maintenance fluids in hospitalized children was conducted to determine whether hypotonic solutions increase the risk of acute hyponatremia. Studies were identified from electronic databases and hand-searched reference lists. A total of 283 abstracts were reviewed, 55 full-text articles were retrieved, and 3 studies were included. All studies were observational and were overall inconclusive. All authors cautioned against the routine use of hypotonic maintenance fluids, but hypotonic fluid administration did not always explain the development of acute hyponatremia. Further evidence is required as to the appropriate maintenance solution for hospitalized children.

Comparison of Isotonic and Hypotonic Intravenous Maintenance Fluids: A Randomized Clinical Trial

IMPORTANCE Use of hypotonic intravenous fluids for maintenance requirements is associated with increased risk of hyponatremia that results in morbidity and mortality in children. Clinical trial data comparing isotonic and hypotonic maintenance fluids in nonsurgical hospitalized pediatric patients outside intensive care units are lacking. OBJECTIVE To compare isotonic (sodium chloride, 0.9%, and dextrose, 5%) with hypotonic (sodium chloride, 0.45%, and dextrose, 5%) intravenous maintenance fluids in a hospitalized general pediatric population. DESIGN, SETTING, AND PARTICIPANTS In this double-blind randomized clinical trial,we recruited 110 children admitted to a general pediatric unit of a tertiary care childrens hospital from March 1, 2008, through August 31, 2012 (age range, 1 month to 18 years), with normal baseline serum sodium levels who were anticipated to require intravenous maintenance fluids for 48 hours or longer (intent-to-treat analyses). Children with diagnoses that required specific fluid tonicity and volumes were excluded. INTERVENTIONS Patients were randomized to receive isotonic or hypotonic intravenous fluid at maintenance rates for 48 hours. MAIN OUTCOMES AND MEASURES The primary outcome was mean serum sodium level at 48 hours. The secondary outcomes were mean sodium level at 24 hours, hyponatremia and hypernatremia, weight gain, hypertension, and edema. Confounding variables were included in multiple regression models. Post hoc analyses included change from baseline sodium level at 24 and 48 hours and subgroup analysis of children with primary respiratory diagnosis. RESULTS Of 110 enrolled patients, 54 received isotonic fluids and 56 received hypotonic fluids. The mean (SD) sodium level at 48 hours was 139.9 (2.7) mEq/L in the isotonic group and 139.6 (2.6) mEq/L in the hypotonic group (95% CI of the difference, -0.94 to 1.74 mEq/L; P = .60). Two patients in the hypotonic group developed hyponatremia, 1 in each group developed hypernatremia, 2 in each group developed hypertension, and 2 in the isotonic group developed edema. Mean (SD) change from baseline to 48-hour sodium level was +1.3 (2.9) vs -0.12 (2.8) mEq/L, respectively (absolute difference, 1.4 mEq/L; 95% CI of the difference, -0.01 to 2.8 mEq/L; P = .05). CONCLUSIONS AND RELEVANCE Our study results support the notion that isotonic maintenance fluid administration is safe in general pediatric patients and may result in fewer cases of hyponatremia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00632775.

Mercury Intoxication: It Still Exists

Abstract:  A 3‐year‐old boy presented to the Hospital for Sick Children with systemic symptoms and oropharyngeal and peripheral extremity changes suggestive of Kawasaki disease. He was found to have severe hypertension. Investigation for a catecholamine‐secreting tumor was negative. Toxins were considered when the patients 20‐month‐old brother presented with similar symptoms, and the boys were subsequently diagnosed with elemental mercury poisoning. We review the literature on mercury intoxication and discuss the historical context, clinical syndrome (acrodynia), treatment, and radiologic findings of this unusual diagnosis.

Office-Based Randomized Controlled Trial to Reduce Screen Time in Preschool Children

OBJECTIVE: To determine if an intervention for preschool-aged children in primary care is effective in reducing screen time, meals in front of the television, and BMI. METHODS: A randomized controlled trial was conducted at a primary care pediatric group practice in Toronto, Canada. Three-year-old children and their parents were randomly assigned to receive a short behavioral counseling intervention on strategies to decrease screen time. The primary outcome 1 year later was parent reported screen time. Secondary outcomes included television in the child’s bedroom, number of meals in front of the television, and BMI. RESULTS: In the intention-to-treat analysis at 1 year, there were no significant differences in mean total weekday minutes of screen time (60, interquartile range [IQR]: 35–120 vs 65, IQR: 35–120; P = .68) or mean total weekend day minutes of screen time (80, IQR: 45–130 vs 90, IQR: 60–120; P = .33) between the intervention and control group. Adjusting for baseline BMI, there was a reduction in the number of weekday meals in front of the television (1.6 ± 1.0 vs 1.9 ± 1.2; P = .03) but no differences in BMI or number of televisions in the bedroom. CONCLUSIONS: This pragmatic trial was not effective in reducing screen time or BMI but was effective in reducing meals in front of the screen. Short interventions focused solely on reducing screen time implemented in the primary care practice setting may not be effective in this age group.

Parental factors associated with screen time in pre-school children in primary-care practice: a TARGet Kids! study.

OBJECTIVE To identify child and parental factors associated with screen time in 3-year-old children. DESIGN Observational study. SETTING Participants were recruited from a large primary-care paediatric group practice in Toronto, Canada. SUBJECTS Healthy 3-year-old children were included. A questionnaire was completed by their parents on screen time. Descriptive statistics and linear regression models were used to assess associations between child screen time and selected factors. Multivariable models included factors from the univariate analysis with P < 0·1. Estimated effects and 95% CI are reported. RESULTS A total of 157 children were enrolled (91% recruitment). The mean screen time per weekday was 104 min (similar for weekend day). In all, 10% of children had a television (TV) in their bedroom; 59% consumed at least one meal while watching TV; and 81% of parents had household rules about screen time. Controlling for maternal education and age, eating lunch and dinner in front of the screen and mother being employed were associated with an increase in child weekday screen time of 96 (95% CI 30, 192), 42 (95% CI 12, 90) and 36 (95% CI 6, 72) min/d, respectively. Eating lunch in front of the screen and an increase of 1 h of parental screen time were associated with an increase of 78 (95% CI 36, 132) and 12 (95% CI 6, 18) min/d in child weekend screen time. Family rules decreased child weekend screen time by 30 (95% CI 6, 54) min/d. CONCLUSIONS Interventions that include these important parental factors should be evaluated for their effectiveness in reducing screen time.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; &kgr;, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures Error and AE rates. Results Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Predictors of bacteremia among children with sickle cell disease presenting with fever.

Introduction: Bacterial sepsis is more common and potentially life threatening in children with sickle cell disease (SCD). Identification of variables that predict bacteremia may aid clinicians in recognizing patients with SCD at higher risk for sepsis. Objective: To determine whether absolute neutrophil count (ANC) >20×109/L is an independent risk factor for bacteremia in children with SCD and to identify other predictors of bacteremia in this population. Methods: A case-control study was conducted. Subjects were 0 to 18 years of age admitted to a tertiary care pediatric hospital over a 17-year period with SCD and fever at presentation. Cases had bacteremia, whereas controls had negative blood cultures. Results: Data were analyzed for 40 cases and 120 controls. ANC>20×109/L was significantly more prevalent among cases (odds ratio [OR], 7.0; 95% confidence interval [CI], 2.6-18.9). Cases were more likely to have emesis (OR, 2.9; 95% CI, 1.0-8.4) and a higher proportion of band cells (OR, 1.3; 95% CI, 1.1-1.4) at presentation. Conclusions: In a febrile child with SCD, an ANC>20×109/L, a higher proportion of band cells, and the presence of vomiting were associated with an increased likelihood of bacteremia.

Shared decision making in the management of children with newly diagnosed immune thrombocytopenia.

This study aimed to examine the treatment decision-making process for children hospitalized with newly diagnosed immune thrombocytopenia (ITP). Using focus groups, we studied children with ITP, parents of children with ITP, and health care professionals, inquiring about participants’ experience with decision support and decision making in newly diagnosed ITP. Data were examined using thematic analysis. Themes that emerged from children were feelings of “anxiety, fear, and confusion”; the need to “understand information”; and “treatment choice,” the experience of which was age dependent. For parents, “anxiety, fear, and confusion” was a dominant theme; “treatment choice” revealed that participants felt directed toward intravenous immune globulin (IVIG) for initial treatment. For health care professionals, “comfort level” highlighted factors contributing to professionals’ comfort with offering options; “assumptions” were made about parental desire for participation in shared decision making (SDM) and parental acceptance of treatment options; “providing information” was informative regarding modes of facilitating SDM; and “treatment choice” revealed a discrepancy between current practice (directed toward IVIG) and the ideal of SDM. At our center, families of children with newly diagnosed ITP are not experiencing SDM. Our findings support the implementation of SDM to facilitate patient-centered care for the management of pediatric ITP.