Samina Ali

A Randomized Trial of Nebulized 3% Hypertonic Saline With Epinephrine in the Treatment of Acute Bronchiolitis in the Emergency Department

OBJECTIVE To determine whether nebulized 3% hypertonic saline with epinephrine is more effective than nebulized 0.9% saline with epinephrine in the treatment of bronchiolitis in the emergency department. DESIGN Randomized, double-blind, controlled trial. SETTING Single-center urban pediatric emergency department. PARTICIPANTS Infants younger than 12 months with mild to moderate bronchiolitis. INTERVENTIONS Patients were randomized to receive nebulized racemic epinephrine in either hypertonic or normal saline. OUTCOME MEASURES The primary outcome measure was the change in respiratory distress, as measured by the Respiratory Assessment Change Score (RACS) from baseline to 120 minutes. The change in oxygen saturation was also determined. Secondary outcome measures included the rates of hospital admission and return to the emergency department. RESULTS Forty-six patients were enrolled and evaluated. The 2 study groups had similar baseline characteristics. The RACS from baseline to 120 minutes demonstrated no improvement in respiratory distress in the hypertonic saline group compared with the normal saline control group. The change in oxygen saturation in the hypertonic saline group was not significant when compared with the control group. Rates of admission and return to the emergency department were not different between the 2 groups. CONCLUSIONS In the treatment of acute bronchiolitis, hypertonic saline and epinephrine did not improve clinical outcome any more than normal saline and epinephrine in the emergency setting. This differs from previously published results of outpatient and inpatient populations and merits further evaluation. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN66632312.

A randomized controlled trial of sucrose and/or pacifier as analgesia for infants receiving venipuncture in a pediatric emergency department

BackgroundAlthough sucrose has been accepted as an effective analgesic agent for procedural pain in neonates, previous studies are largely in the NICU population using the procedure of heel lance. This is the first report of the effect of sucrose, pacifier or the combination thereof for the procedural pain of venipuncture in infants in the pediatric emergency department population.MethodsThe study design was a double (sucrose) and single blind (pacifier), placebo-controlled randomized trial – factorial design carried out in a pediatric emergency department. The study population was infants, aged 0 – 6 months. Eighty-four patients were randomly assigned to one of four groups: a) sucrose b) sucrose & pacifier c) control d) control & pacifier. Each child received 2 ml of either 44% sucrose or sterile water, by mouth. The primary outcome measure: FLACC pain scale score change from baseline. Secondary outcome measures: crying time and heart rate change from baseline.ResultsSucrose did not significantly reduce the FLACC score, crying time or heart rate. However sub-group analysis revealed that sucrose had a much greater effect in the younger groups. Pacifier use reduced FLACC score (not statistically significant), crying times (statistically significant) but not heart rate. Subgroup analysis revealed a mean crying time difference of 76.52 seconds (p < 0.0171) (0–1 month) and 123.9 seconds (p < 0.0029) (1–3 month). For subgroup age > 3 months pacifier did not have any significant effect on crying time. Age adjusted regression analysis revealed that both sucrose and pacifier had significant effects on crying time. Crying time increased with both increasing age and increasing gestational age.ConclusionPacifiers are inexpensive, effective analgesics and are easy to use in the PED for venipuncture in infants aged 0–3 months. The benefits of sucrose alone as an analgesic require further investigation in the older infant, but sucrose does appear to provide additional benefit when used with a pacifier in this age group.Trial registrationCurrent Controlled Trials ISRCTN15819627

Practice Variations in the Treatment of Febrile Infants Among Pediatric Emergency Physicians

OBJECTIVES: The objectives of this study were to characterize variations in treatment decisions for young febrile infants in pediatric emergency departments across Canada and to document the extent of practice variations among pediatric emergency department practitioners. METHODS: This was a prospective, concurrent, cohort study of consecutive infants up to 90 days of age who presented to 6 pediatric emergency departments in Canada with fever (rectal temperature of ≥38.0°C). We recorded information in the emergency department and contacted the families by telephone to confirm the final disposition. RESULTS: A total of 257 infants were recruited over 2 to 4 months. Patients were similar across centers in terms of gestational age and weight, chronologic age at arrival, weight, and gender. Temperatures measured at home and during triage and durations of fever also were similar among centers. In one center, significantly more children arrived with cough; in another center, fewer parents reported sick contacts at home. Rates of blood and urine testing were not significantly different across sites, but rates of lumbar puncture, respiratory virus testing, and chest radiography were different. A total of 55% of infants received antibiotics, and significant practice variations in the numbers and types of antibiotics used were documented. CONCLUSIONS: Practices in the evaluation of young infants with fever in tertiary pediatric emergency departments varied substantially. Blood and urine tests were ordered in the majority of centers, but rates of cerebrospinal fluid testing and antibiotic treatment differed across centers.

Pain assessment for children: overcoming challenges and optimizing care.

There is growing evidence that children have short- and long-term physical, physiological, and psychological effects due to untreated acute pain. Because the majority of children who seek care in an emergency department present with pain or experience pain during the evaluation and treatment in the emergency department, optimal assessment and treatment of pain are paramount for this population. This review will highlight the many complexities of the assessment of pain for the pediatric patient. In addition, a variety of factors that affect the self-report of pain in children will be identified. Optimizing the utility of a pain assessment remains a challenge for the health care provider in the emergency setting. The common goal of a decreased experience of pain for children through improved analgesic administration remains.

Pain management of musculoskeletal injuries in children: current state and future directions.

Background: Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated. Objectives: Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy. Results: Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain. Conclusions: There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.

Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries

BACKGROUND Acute gastroenteritis (AGE) is an extremely common paediatric condition, which results in significant morbidity in children and is a financial burden to the society. OBJECTIVE The purpose of this overview is to critically evaluate the evidence currently available in the Cochrane Database of Systematic Reviews (CDSR) regarding the efficacy and safety of commonly considered treatment options in children with AGE. METHODS All Cochrane reviews evaluating the following treatments in children with AGE were eligible for inclusion: oral rehydration therapy, anti-emetics and probiotics. We excluded those focusing on the treatment of antibiotic associated or nosocomial diarrhoea, persistent (chronic) diarrhoea and the prevention of gastroenteritis. We focused on the following outcomes that were selected a priori as clinically important: rate of admission to the hospital; length of stay in hospital; rate of return visits; administration of intravenous (IV) therapy owing to failure of oral rehydration therapy; adverse events and dysnatremia. MAIN RESULTS Children who received oral rehydration therapy had a shorter length of stay in hospital compared with children who received IV therapy [mean difference, MD = -1.20 days (-2.38, -0.02)]; however, the result was no longer significant when an outlying study was removed. Children who received IV therapy were at increased risk of developing phlebitis [risk difference, RD= - 0.02 (-0.04, -0.01)], while paralytic ileus was more common in children receiving ORT [RD = 0.03 (confidence interval, CI 0.01-0.05)]. Children who received oral ondansetron had lower hospital admission rates to the emergency department (ED) and lower rates of IV rehydration during their ED stay compared with children receiving placebo [risk ration, RR = 0.40 (CI 0.19-0.83) and RR = 0.41 (CI 0.29-0.59), respectively]. Children receiving IV ondansetron had lower hospital admission rates to the ED than patients receiving placebo [RR = 0.21 (0.05, 0.93)]. Probiotic use amongst children hospitalized following AGE reduced the mean duration of hospitalization by 1.12 days (CI -1.16, -0.38). CONCLUSIONS Given that oral rehydration is less invasive than IV rehydration with no evidence of important clinical differences, it is the first choice for rehydration in children with AGE and mild-to-moderate dehydration. As the vast majority of children with AGE do not require IV rehydration, oral ondansetron administration to children with significant vomiting should be performed to reduce the use of IV rehydration and the need for hospital admission. In children deemed too unwell to receive oral rehydration therapy, IV ondansetron administration is an option, as its use is associated with lower hospital admission rates. Although probiotics appear to be an effective option for the treatment of AGE amongst hospitalized children, outpatient data is lacking and more studies are urgently needed to determine the optimal organism, dosing and duration of treatment.

Who Comes Back? Characteristics and Predictors of Return to Emergency Department Services for Pediatric Mental Health Care

OBJECTIVES The objective of this study was to investigate predictors of emergency department (ED) return visits for pediatric mental health care. The authors hypothesized that through the identification of clinical and health system variables that predict return ED visits, which children and adolescents would benefit from targeted interventions for persistent mental health needs could be determined. METHODS Data on 16,154 presentations by 12,589 pediatric patients (<or=17 years old) were examined from 2002 to 2006, using the Ambulatory Care Classification System (ACCS), a provincewide database for Alberta, Canada. Multivariable logistic regressions identified predictors, while survival analyses estimated time to ED return. RESULTS In the multivariable analysis, there were four patient factors significantly associated with ED return. Male sex (odds ratio [OR] = 0.78; 99% confidence interval [CI] = 0.69 to 0.89) was associated with a lower rate of return, as was child age. The likelihood of ED return increased with age. Children <or=5 years (OR = 0.26; 99% CI = 0.14 to 0.46) and between ages 6 and 12 (OR = 0.64; 99% CI = 0.51 to 0.79) were less likely to return, compared to 13- to 17-year-olds. Patients with families receiving full assistance for covering government health care premiums were more likely to return compared to those with no assistance (OR = 1.59; 99% CI = 1.33 to 1.91). Patients were more likely to return if their initial presentation was for a mood disorder (OR = 1.72; 99% CI = 1.46 to 2.01) or psychotic-related illness (OR = 2.53; 99% CI = 1.80 to 3.56). There were two modest health care system predictors in the model. The likelihood of return decreased for patients triaged as nonurgent (OR = 0.62; 99% CI = 0.45 to 0.87) versus those triaged as urgent (level 3 acuity) and increased for patients with visits to general (vs. pediatric) EDs (OR = 1.25; 99% CI = 1.03 to 1.52). ED region (urban vs. rural) did not predict return. Within 72 hours of discharge, 6.1 and 8.7% of patients diagnosed with a mood disorder and psychotic-related illness, respectively, returned to the ED. Throughout the study period, 28.5 and 36.6% of these diagnostic populations, respectively, returned to the ED. CONCLUSIONS Among children and adolescents who accessed the ED for mental health concerns, being female, older in age, in receipt of social assistance, and having an initial visit for a mood disorder or psychotic-related illness were associated with return for further care. How patient presentations were triaged and whether visits were made to a pediatric or general ED also affected the likelihood of return.

Pediatric Suicide-Related Presentations: A Systematic Review of Mental Health Care in the Emergency Department

STUDY OBJECTIVE We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits. METHODS We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each studys primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome. RESULTS We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67). CONCLUSION Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area.

Beliefs and Expectations of Canadian Parents Who Bring Febrile Children for Medical Care

OBJECTIVES: The purpose of this survey was to study the beliefs, expectations, and satisfaction of Canadian parents regarding fever and the treatment of their febrile children. METHODS: A survey was developed exploring caregiver beliefs and treatment strategies, as well as expectations and satisfaction with medical care. Some items were modeled after previous studies to allow comparison. Caregivers with febrile children were recruited from 2005 to 2007 at 3 urgent care centers and emergency departments in Edmonton, Canada: a pediatric emergency department (n = 376), an urban urgent care center (n = 227), and a suburban urgent care clinic (n = 173). RESULTS: High and rapidly rising temperature, as well as physical symptoms associated with fever, caused concern in most parents surveyed. Seventy-four percent of parents felt that the elevated temperature from fever was dangerous and 90.3% always try to treat it. Forty degrees Celsius was the most commonly sited threshold for danger. Identifying the cause (80.6%) and seriousness (87.4%) of fever were the most com-mon stressors identified. Caregivers expected to receive information about the child’s illness and appropriate treatment. The parents most often wanted information about febrile seizures and the potential dangers of febrile illness. Only 16.7% of caregivers expected anti-biotics. Nearly 92% of subjects were usually satisfied with medical care. CONCLUSIONS: Fever phobia continues to be a significant issue for Canadian parents. As a result, they treat fever aggressively and often seek medical attention. Good communication is important for medical staff caring for febrile children and typically leads to satisfied parents.

Brief emergency department interventions for youth who use alcohol and other drugs: a systematic review

Objective Brief intervention (BI) is recommended for use with youth who use alcohol and other drugs. Emergency departments (EDs) can provide BIs at a time directly linked to harmful and hazardous use. The objective of this systematic review was to determine the effectiveness of ED-based BIs. Methods We searched 14 electronic databases, a clinical trial registry, conference proceedings, and study references. We included randomized controlled trials with youth 21 years or younger. Two reviewers independently selected studies and assessed methodological quality. One reviewer extracted and a second verified data. We summarized findings qualitatively. Results Two trials with low risk of bias, 2 trials with unclear risk of bias, and 5 trials with high risk of bias were included. Trials evaluated targeted BIs for alcohol-positive (n = 3) and alcohol/other drug–positive youth (n = 1) and universal BIs for youth reporting recent alcohol (n = 4) or cannabis use (n = 1). Few differences were found in favor of ED-based BIs, and variation in outcome measurement and poor study quality precluded firm conclusions for many comparisons. Universal and targeted BIs did not significantly reduce alcohol use more than other care. In one targeted BI trial with high risk of bias, motivational interviewing (MI) that involved parents reduced drinking quantity per occasion and high-volume alcohol use compared with MI that was delivered to youth only. Another trial with high risk of bias reported an increase in abstinence and reduction in physical altercations when youth received peer-delivered universal MI for cannabis use. In 2 trials with unclear risk of bias, MI reduced drinking and driving and alcohol-related injuries after the ED visit. Computer-based MI delivered universally in 1 trial with low risk of bias reduced alcohol-related consequences 6 months after the ED visit. Conclusions Clear benefits of using ED-based BI to reduce alcohol and other drug use and associated injuries or high-risk behaviours remain inconclusive because of variation in assessing outcomes and poor study quality.