Jack Newman

Rapid intravenous rehydration in the pediatric emergency department.

Children suffering from mild to moderate (3 to 6%) dehydration likely caused by viral gastroenteritis are often hospitalized because they are unable to tolerate oral fluids. We studied 17 such children, aged one to six years, who were otherwise healthy. All had isonatremic dehydration and were treated with 30 ml/kg of 3.3% dextrose and 0.3% saline over a period of three hours in the emergency department before being discharged. No patient required admission to the hospital. Only one patient required another course of rapid intravenous rehydration and subsequently improved without hospitalization. Although all our patients experienced vomiting before treatment, 65% had no vomiting after treatment. Rapid intravenous rehydration is an effective treatment, for children with mild to moderate dehydration secondary to presumed viral gastroenteritis, that obviates the need for hospitalization.

Malaria in children

Fifty-four cases of malaria in children seen during an 11-year period are described. There have been more cases seen in recent years, and the proportion of Plasmodium falciparum malaria has increased. Compliance with chemoprophylaxis is poor, but compliance does not guarantee protection. Malaria is the primary diagnostic consideration in any child recently returning from an endemic area who presents with fever. Two cases are described.

Breastfeeding problems presenting to the emergency department: diagnosis and management

With more mothers breastfeeding their babies and postpartnm stays in hospital becoming shorter, more mothers are presenting to the emergency department with problems that formerly were managed in the newborn nursery. This article deals with an approach to the breastfeeding baby who presents hi the emergency department because of Jaundice, poor feeding, “colic,” gastrointestinal bleeding, and failure to thrive. Although many of these problems also occur hi the bottlefeeding baby, only the special considerations which apply to the breastfeeding baby will be considered.

Response to Commentary The Galactogogue Bandwagon

Decelerate Proliferation of New Programs Hinman et al focus on the shortage of qualified program leaders (a problem of supply), but we also could approach this problem from the demand side. One of the principal reasons that we face this problem is the proliferation of new programs, a phenomenon that appears to be accelerating. Since May of 2012, 6 new PT programs have been granted initial accreditation, and an additional 26 institutions are in some stage of development.2 For PTA programs, the pace is even more rapid. Since May 2012, 28 new PTA programs have been accredited and an additional 66 are in some stage of development.2 I have argued elsewhere that the increased demand for admission to physical therapy programs would be better addressed by growth in the size of existing programs than by growth in the number of programs.3 Growing existing programs larger does not merely involve increasing class size, it also means increasing the number of faculty. A larger program with more faculty can do a better job of preparing graduates for practice because it exposes students to a broader range of faculty expertise. Furthermore, and more relevant to the present discussion, increasing total capacity by growing the size of programs makes much more efficient use of the relatively small pool of academic leadership, and it allows the development of new leadership in a controlled manner. Finding a way to shift capacity-building from a “more” strategy to a “bigger” strategy is a complex problem, beyond the scope of this commentary. What is relevant, however, is that it behooves CAPTE to look very carefully at the qualifications and experience of the proposed program leaders of new and developing programs. One of the clearest implications from the findings of Hinman et al is that program leaders in new programs are often the least prepared and yet they face the most difficult challenges. If anything, those program leaders hired to develop a new program need to be more experienced and more prepared than their counterparts in established programs. And yet the evidence points to the reverse, especially for PTA programs. In the Hinman et al data, only 9% of PTA directors in developing programs had more than 1 year of prior academic experience! The data for PT program leaders in developing programs is not given, but the authors stated that “. . . of the respondents who indicated that they were hired to develop a new PT or PTA program, the greatest percentage (44%) reported having no prior academic experience at all. This finding was more common among PTA program directors.” Thus, the best way to improve the quality of developing programs and to decelerate the pace of proliferation is to insist on highly qualified and experienced program leaders. To conclude, Hinman, Peel, and Price have collected valuable data about the reasons why program leaders leave their positions, provided a cogent analysis of the data, and made well-reasoned recommendations based on their findings. Furthermore, they have opened up an important topic for discussion: What is the quality of leadership in academic physical therapy and how can it be improved? Their article is a challenge to the academic community. We ignore this challenge at the risk of the long-term health of the academic enterprise of physical therapy.

Patterns of Walker Use and Walker Injury

Infant walkers have been described as a cause of unexpected trauma in the first year of life. We conducted a prospective study to determine the mechanism and pattern of walker injuries presenting to an urban pediatric teaching hospital. We also studied the patterns of walker use. All injuries sustained by infants in baby walkers during a 1-year period were reviewed. The 139 injuries included 29 fractures. The most severe injuries were caused by falls down stairs; these falls accounted for 123 of the injuries. Stair gates were present in one third of all falls. At follow-up 2 months later, two thirds of the children had been in the walker subsequent to the injury. One third were still in the walker at 2 months after their initial injury. Less than half of the homes that had not had stair gates in place had acquired them at the time of follow-up. Baby walkers represent a cause of significant injury in the infant population; studies of warning labels and anticipatory guidance are needed.