James F. Wiley

Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children

STUDY OBJECTIVE To compare nebulized dexamethasone with oral prednisone in the treatment of children with asthma. DESIGN A randomized, double-blind, double-placebo study. SETTING An urban pediatric emergency department. PARTICIPANTS Patients aged 1 to 17 years with acute asthma. INTERVENTIONS Patients with moderate asthma exacerbation received frequent aerosolized albuterol and either 1.5 mg/kg of nebulized dexamethasone or 2 mg/kg of oral prednisone. RESULTS A total of 111 children was evaluated; 21% of those treated with dexamethasone required hospitalization, compared with 31% of those treated with prednisone (P = .26). A significantly greater proportion of dexamethasone-treated children were discharged home within 2 hours (23% versus 7%, P = .02). In the dexamethasone group, 8% who received the drug by mouthpiece were hospitalized compared with 33% who received it by face mask (P = .06). Fewer children treated with dexamethasone vomited (0% versus 15%, P = .001) and fewer relapsed within 48 hours of ED discharge (0% versus 16%, P = .008). CONCLUSION Nebulized dexamethasone was as effective as oral prednisone in the ED treatment of moderately ill children with acute asthma and was associated with more rapid clinical improvement, more reliable drug delivery, and fewer relapses.

Cardiotoxic effects of astemizole overdose in children

Astemizole, a nonsedating antihistamine, caused a prolonged corrected QT interval, ventricular dysrhythmias, and atrioventricular heart block after overdose in five children. Cardiotoxic effects lasted an average of 2 1/2 days. Children poisoned with astemizole need emergent medical evaluation, a 12-lead electrocardiogram with calculation of the corrected QT interval, and continuous cardiac monitoring for 24 hours.

Use of an observation unit by a pediatric emergency department for common pediatric illnesses.

Objective To describe the use of a pediatric observation unit (OU), including relapse rates for common pediatric illnesses, and to assess effectiveness of OU utilization. Design Retrospective, cohort of all emergency department (ED) visits, OU and inpatient unit (IU) admissions. Setting Tertiary care children’s hospital. Participants All children evaluated in the ED and subsequently admitted to either the OU or IU over a 2-year period. Main Outcome Measure Rates with 95% confidence intervals (CI) for OU use and need for subsequent IU admission from OU, and odds ratios (OR) with 95% CI for use of the OU for specific pediatric disorders. Results During 10/1/96–9/30/98, there were 44,459 ED visits, 1798 (4.0%) OU admissions, and 3241 (7.3%) inpatient admissions (IA) from the ED. OU mean length of stay was 15.6 ± 6.1 hours; mean age was 6 ± 5.3 years with 31% under 2 years of age. Of the total admissions (IU and OU), diagnoses with high OU utilization were: asthma 274/575, 48%; croup 76/125, 61%; enteritis/dehydration 284/470, 60%; poisonings 82/118, 70%; and seizures 80/204, 39%. The likelihood of an OU admission for these illnesses versus IU (adjusted for subsequent need for IU admission) was: asthma OR 1.3 (1.1, 1.5), P < 0.005; croup OR 2.3 (1.6, 3.3), <0.001; enteritis/ dehydration OR 2.8 (2.1, 3.0), P < 0.001; poisonings OR 3.8 (2.5, 5.7), P < 0.001; and seizures OR 0.8 (0.6, 1.2), P = 0.28. For these diagnoses, OU admissions resulting in IU admission occurred for asthma 45/274, 16.4%; croup 7/76, 9.2%; enteritis/ dehydration 13/284, 4.6%; poisonings 3/82, 3.7%; and seizures 15/80, 18.8%, resulting in an overall need for further hospitalization to the IU for these diagnoses of 83/796, 10.4%, (95% CI 8.3, 12.6). Conclusion Admissions to the observation unit comprised over one third of all admissions from a pediatric ED. Certain pediatric illnesses appear to be well suited for admission to the observation unit, with low likelihood of the need for subsequent admission to the inpatient unit. Given the current trends in third-party payer reimbursements for short (<24 hours) admissions, observation unit use provides a more attractive alternative to inpatient admission for many pediatric patients.

Observation units : The role of an outpatient extended treatment site in pediatric care

This article explores the role of extended outpatient treatment in pediatric care, presents important considerations when planning and implementing an outpatient extended treatment site (OETS), discusses operations of a recently opened unit, and examines the research and teaching potential of an OETS.

Mammalian Bites Review of Evaluation and Management

Mammalian bites account for a large number of emergency department and doctors visits. Children are the victims in more than half of reported cases. Dogs account for the majority of wounds, and almost all fatalities in these cases are due to dog bites. Human bites and cat bites account for the majority of infected wounds. Basic wound care, combined with appropriate antibiotic coverage in high risk wounds, is the most important principle of management.

Severe intoxication from xylazine inhalation

We present the first documented case of overdose from xylazine inhalation. The patient developed findings consistent with alpha 2 adrenergic agonist toxicity, eg coma, miosis, apnea, bradycardia, hypothermia, and dry mouth 2 hours after exposure. Standard dose naloxone did not reverse these effects. The patient fully recovered after appropriate supportive measures. A review of prior reports of xylazine exposure is provided.

A comparison of pediatric emergency medicine and general emergency medicine physicians' practice patterns: results from the Future of Pediatric Education II Survey of Sections Project.

Background This survey was conducted to obtain information about career and practice issues facing pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians. We hypothesized that PEM physicians work fewer clinical hours and perform more teaching and research in their positions than GEM physicians. Methods Two surveys sponsored by the Future of Pediatric Education II Project were sent to 1545 emergency physicians identified by the American Board of Pediatrics, the American Academy of Pediatrics, and the American College of Emergency Physicians between October 1997 and February 1998. Data on demographics, job description, recent job changes, and career expectations were obtained and analyzed using Student t test or Welch analysis of variance for continuous variables and χ2 for categorical data. P values less than 0.05 were considered significant. Comparisons between PEM and GEM physicians were adjusted using analysis of covariance to control for the effect of medical school affiliation. Results Effective response rate was 934 (64%) of 1451. A total of 705 (75%) respondents identified themselves as a PEM physician, and 229 (25%) identified as a GEM physician. PEM physicians were younger (41.0 y vs 45.1 y) and more likely to be women (44% vs 15%, P < 0.0001 for both). Children younger than 18 years made up 80.9% and 28.6% of patients seen by PEM and GEM physicians, respectively (P < 0.001). Seventy-nine percent of PEM physicians and 42% of GEM physicians held an academic appointment (P < 0.0001). No differences were found for full-time equivalents per physician group (9.7 vs 9.1) or clinical hours spent in the emergency department (ED) (31.5 vs 32.7) when means were adjusted for academic appointment. During ED clinical activities, PEM physicians reported more time spent supervising trainees (34% vs 16%, P < 0.0001), and GEM physicians reported more time spent in direct patient care (77% vs 57%, P < 0.0001). Total clinical hours worked per week were greater for GEM physicians (37.9 vs 35.3, P < 0.05). PEM physicians spent more time than GEM physicians teaching (12% vs 8%, P < 0.005) and conducting clinical research (5% vs 2%, P < 0.0003). Of PEM and GEM physicians combined, 26% reported a job change in the past 3 years. Extended reduction of ED clinical duties occurred most commonly because of child care issues and was reported more commonly by women than men (53% vs 6%, P < 0.0001) irrespective of PEM or GEM practice. The likelihood of leaving emergency medicine practice within 5 years increased with age for both groups: 10% of PEM and GEM physicians under 40 years old anticipated leaving practice versus 30% of those older than 50 years (P < 0.0001). PEM physicians were more likely than GEM physicians to predict an increased need for additional pediatric subspecialists in general (60% vs 26%, P < 0.001) and for pediatric subspecialists in their discipline (54% vs 17%, P < 0.001). PEM subspecialists were twice as likely as GEM specialists to perceive competition in their subspecialty (60% vs 31%, P < 0.001). Conclusions According to our sample, GEM and PEM physicians worked the same number of clinical hours in the ED but reported significant differences in how those hours are spent. Job changes and extended leaves were common in both groups. These results suggest that PEM and GEM physicians face similar vocational challenges, especially in the areas of balancing of family time, clinical hours, and academic productivity. These data also have important implications for workforce projection for the PEM physician supply, given the current estimated attrition rate, frequency of leave from clinical duties, and projection for increased need for PEM physicians in the future.

Acculturation Determines BMI Percentile and Noncore Food Intake in Hispanic Children

Hispanic children in the United States are disproportionately affected by obesity. The role of acculturation in obesity is unclear. This study examined the relation between child obesity, dietary intake, and maternal acculturation in Hispanic children. We hypothesized that children of more acculturated mothers would consume more unhealthy foods and would have higher body mass index (BMI) percentiles. A total of 209 Hispanic mothers of children aged 2-4 y (50% female, 35.3 ± 8.7 mo, BMI percentile: 73.1 ± 27.8, 30% obese, 19% overweight) were recruited for an obesity prevention/reversal study. The associations between baseline maternal acculturation [Brief Acculturation Rating Scale for Mexican Americans-II (Brief ARSMA-II)], child BMI percentile, and child diet were examined. Factor analysis of the Brief ARSMA-II in Puerto Rican mothers resulted in 2 new factors, which were named the Hispanic Orientation Score (4 items, loadings: 0.64-0.81) and U.S. Mainland Orientation Score (6 items, loadings: -0.61-0.92). In the total sample, children who consumed more noncore foods were more likely to be overweight or obese (P < 0.01). Additionally, children of mothers with greater acculturation to the United States consumed more noncore foods (P < 0.0001) and had higher BMI percentiles (P < 0.04). However, mothers with greater Hispanic acculturation served fewer noncore foods (P < 0.0001). In the Puerto Rican subgroup of mothers, Puerto Rican mothers with greater acculturation to the United States served more noncore foods (P < 0.0001), but there was no association between acculturation and child BMI percentile in this subgroup. These mothers, however, served fewer sugar-sweetened beverages (P < 0.01) compared with non-Puerto Rican mothers, and this may have negated the effect of noncore food consumption on BMI percentile. These data suggest a complex relation between acculturation, noncore food consumption, and child BMI percentile in Puerto Rican and non-Puerto Rican Hispanic children.

The Relationship between Dietary Patterns, Body Mass Index Percentile, and Household Food Security in Young Urban Children

BACKGROUND The relationship between food insecurity and child obesity is unclear. Few studies have examined dietary patterns in children with regard to household food security and weight status. The aim of this study was to examine the association between household food security, dietary intake, and BMI percentile in low-income, preschool children. METHODS Low-income caregivers (n=222) with children ages 2-4 years were enrolled in a primary-care-based obesity prevention/reversal study (Steps to Growing Up Healthy) between October 2010 and December 2011. At baseline, demographic data, household food security status (US Household Food Security Instrument) and dietary intake (Childrens Dietary Questionnaire; CDQ) were collected. BMI percentile was calculated from anthropometric data. RESULTS Participating children were primarily Hispanic (90%), Medicaid insured (95%), 50% female, 35±8.7 months of age (mean±standard deviation), 19% overweight (BMI 85th-94th percentile), and 29% obese (≥95th percentile). Thirty-eight percent of interviews were conducted in Spanish. Twenty-five percent of households reported food insecurity. There was no association between household food insecurity and child BMI percentile. Dietary patterns of the children based on the CDQ did not differ by household food security status. Food group subscale scores (fruit and vegetable, fat from dairy, sweetened beverages, and noncore foods) on the CDQ did not differ between normal weight and overweight/obese children. Maternal depression and stress did not mediate the relationship between household food insecurity and child weight status. Hispanic children were more likely to be overweight or obese in both food-secure and food-insecure households. CONCLUSIONS Household food insecurity was not associated with child BMI percentile in this study. Dietary intake patterns of children from food-insecure households were not different compared to those from food-secure households.

Unintentional albuterol ingestion in children

This study was designed to determine the threshold dose for toxicity, the potential for serious medical complications, and the medical care required after unintentional albuterol ingestion in children. This study was prospective and descriptive. Data were obtained on pediatric albuterol ingestions evaluated emergently as reported to three regional poison control centers. Data elements included dose ingested, physical findings, medical treatment, and outcome. During 18 months, 78 patients who ingested albuterol and who received urgent medical evaluation were identified. Mean age was 2.8 years. The amount ingested ranged from 0.2 to 8.8 mg/kg. The most commonly reported signs of toxicity were tachycardia (57%, 44/78), widened pulse pressure (50%, 27/ 54), hyperglycemia (50%, 12/24), agitation (45%, 35/78), low serum carbon dioxide (42%, 10/24), vomiting (26%, 20/78), and hypokalemia (26%, 9/35). We found a threshold dose of 1 mg/kg for three or more signs of toxicity (P <.01). No patient required any specific treatment for toxicity. Seventy two percent of patients were discharged from medical care within six hours of ingestion. Albuterol overdose in children causes a variety of cardiovascular, neuromuscular, and metabolic effects that are usually benign. The threshold dose for the development of three or more signs of toxicity is 1 mg/kg or three to 10 times the recommended daily dose. Toxicity is short-lived and does not require specific therapy or hospital admission in most cases.