Simon P. Ros

Newborn Chemical Exposure from Over-the-Counter Skin Care Products

Human exposure to potentially toxic environmental chemicals is major concern to our society. Over-the-counter (OTC) skin care products are a potential source of environmental chemical exposure to newborns. A prospective study was undertaken to define existing newborn bathing practices and quantitate environmental chemical exposure from OTC skin care products. One hundred-ninety six mothers of infants discharged from our newborn nursery were asked to respond to a questionnaire concerning newborn bathing practices and OTC skin care product usage. Complete questionnaires were returned by 23% of the mothers. The average newborn had 8 ± 3 (± SEM) skin care products applied with the resultant exposure to 48 ± 18 different environmental chemicals. Forty-seven percent of our respondents used a baby powder. The average one month old was bathed 4 times a week and was shampooed 3 times weekly. Seventy-eight percent of the respondents reported that their newborn had a rash but only 45% of those reporting a rash sought professional medical advice. Thirty-seven percent of the mothers reporting a rash made a change in bathing practice or product selection. In view of our findings, the human newborn is exposed to a large number of environmental chemicals thorough topical OTC preparations. The efficacy, transcutaneous absorption and potential toxicity of these products should be investigated.

Fractures in the Under-3-Year-Old Age Cohort

One hundred twenty-four urban children under 3 years of age admitted for fractures were retrospectively reviewed to determine the frequency of accidental and nonaccidental causes in this population. The fractures were categorized according to their mechanisms: motor-vehicle passenger or pedestrian accident, other accidents, or child abuse. There were no differences in the frequency of fractures by race, date of birth, or season in which the injury occurred. Skull fractures were most frequent (62%), followed by femur fractures (11%). There was a 26% increase in fractures between 1987 and 1989, especially in the non-motor vehicle cohort. Caretaker ignorance and/or carelessness was a common cause of fractures in the infant and toddler age group. Injuries were still occurring in spite of infant car seat use. The American public must be educated in preventive medicine and safety to decrease the senseless morbidity of our greatest resource.

Are skull radiographs useful in the evaluation of asymptomatic infants following minor head injury

Head injuries constitute a common problem in the pediatric population. Recent studies indicate that infants are at increased risk for skull fractures following head trauma. The purpose of our study is to examine the utility of skull radiographs in asymptomatic infants presenting after a minor head injury. We retrospectively reviewed the records of all head-injured infants who presented to our emergency department between March 1990 and July 1991. All symptomatic patients and all infants who did not undergo radiologic evaluation were excluded from the analysis. During the study period, 35 asymptomatic infants were evaluated in our emergency department following head trauma. The mean age of the study patients was 5.5 ± 3.8 months; 54% were male; and falls accounted for the injury in 88% of cases. The skull radiograms were normal in 30 patients, equivocal in two, and positive for a parietal skull fracture in three. The three infants who sustained skull fractures were male, were younger than three months, and had fallen from heights not exceeding three feet. Computed head tomograms revealed no intracranial pathology in these patients. We conclude that all infants who present following minor skull trauma should undergo radiologic evaluation.

Successful use of a metal detector in locating coins ingested by children

The purpose of this study was to examine the accuracy of a metal detector in locating coins ingested by children. The metal detector correctly identified the presence or absence of coins in 13 patients (93%), as confirmed by radiologic studies.

Telephone follow-up of patients discharged from the emergency department : how reliable ?

As the result of the current emphasis on health care cost containment, outpatient management of entities previously in the domain of inpatient therapy is being proposed. The advocates of this approach stress the importance of telephone follow-up in patients chosen for outpatient therapy. Our objective was to determine the reliability of phone follow-up in patients discharged from the emergency department (ED). We attempted to contact by phone 250 consecutive children evaluated and discharged from Loyola University Medical Center Emergency Department. A maximum of six attempts per patient was made starting within 72 hours of the ED visit. Calls were placed to home, work, and contact numbers provided at the time of the ED visit, and messages were left on answering machines or with persons who answered the phone. The time needed to reach the guardian was calculated from the time of the first call until successful contact of the guardian. We were successful in contacting 68.4% of our study subjects. Patients with commercial insurance were contacted more often than those with other types of insurance. A mean of 1.61 ± 1.09 calls were needed to reach the guardians who were successfully contacted, and the mean time required was 3.14 ± 7.25 hours. Medical indication for telephone follow-up, as determined by the managing physician, did not influence our ability to reach the study subjects. In view of our moderate success rate in reaching patients discharged from the ED, we advocate caution in the implementation of outpatient strategies in the management of febrile children who are at high risk for life-threatening complications.

Occult bacteremia: Is there a standard of care?

The evaluation and management of patients with occult bacteremia is controversial. The purpose of this study was to define the prevailing practices in the emergency management of occult bacteremia. Short, anonymous surveys were mailed to all 517 members of the Section on Emergency Medicine at the American Academy of Pediatrics. Three hundred six (59%) of those surveyed returned completed questionnaires. Eleven different temperature cutoff points are used, and 105 (34%) consider occult bacteremia in patients with temperature above 39°C. Seventeen different age intervals are used to define the patients at risk for occult bacteremia, and the age range three to 24 months is used by 173 (57%) of those surveyed. Complete blood cell count is the most commonly used screening test; it is routinely ordered by 225 respondents (74%). One hundred thirty-seven participants (45%) routinely obtain blood cultures in all patients at risk for occult bacteremia, whereas 111 (36%) use the clinical appearance (toxicity) of the patient to determine whether a blood culture should be drawn. One hundred sixty-one (53%) of those surveyed routinely administer antibiotics to toxic-appearing patients pending the results of the blood culture. Laboratory criteria are used by 135 (44%) in the decision whether to administer empiric antibiotics. Ceftriaxone is the most commonly used antibiotic; it is routinely administered by 230 respondents (75%). Twenty participants (7%) routinely admit all patients with Streptococcus pneumoniae, whereas 217 (71%) admit all patients with Haemophilus influenzae bacteremia and 234 (76%) admit all patients with Neisseria meningitidis bacteremia. We conclude that diversity exists in the evaluation and management of occult bacteremia.

Metal detectors: an alternative approach to the evaluation of coin ingestions in children?

Foreign body ingestions constitute a common problem in pediatric emergency medicine. Recent data indicate that, despite current recommendations, most children who ingest coins do not undergo radiologic evaluation. The purpose of this study was to determine the accuracy of a metal detector in locating coins in a model simulating coin ingestions in children. Initially, the distance between the anterior chest wall (ACW) and the esophagus was measured on 17 chest computed tomograms obtained on children between the ages of three months and six years. Subsequently, a distance equal to the mean ACW-to-gastroesophageal junction measurement was marked across the investigators forearm. A second investigator then attempted to detect the presence of the coin through the forearm by using a Super Scanner (Garrett Security Systems, Inc, Garland, TX) metal detector. The study was conducted in a blinded manner and consisted of SO attempts equally divided among pennies, nickels, dimes, quarters, and controls (no coin). The accuracy of the metal detector in identifying the presence or absence of coins in our model was 100%. We conclude that the metal detector evaluated by us is highly accurate in identifying coins through human tissues and that it should become a valuable and practical tool in the evaluation of children following a coin ingestion.

Adenosine in the emergency management of supraventricular tachycardia

In summary, adenosine is highly effective in terminating paroxysmal supraventricular tachycardia, and its very short half-life and benign side effects make it a promising alternative to other modes of therapy presently used. Further controlled prospective studies are needed before adenosine can become the drug of choice in the management of paroxysmal supraventricular tachycardia in children.

Effect of intraosseous saline infusion on hematologic parameters

STUDY OBJECTIVE To examine the effects of intraosseous saline infusion on hematologic parameters. DESIGN AND SETTING Eight New Zealand White rabbits were anesthetized with intramuscular ketamine. An initial blood sample was withdrawn from a earlobe vein on induction of anesthesia. An 18-gauge intraosseous needle was then inserted into the rabbits proximal tibia, and 10 mL/kg of normal saline was infused over one minute. Two additional blood samples were obtained 15 and 30 minutes after the intraosseous infusion. MEASUREMENTS Complete blood counts were performed on the blood samples. RESULTS Significant differences were found in monocytes, basophils, and nucleated RBCs from samples drawn before and after intraosseous infusion. The microscopic examination of the peripheral blood smear revealed an increase in the number of burr cells, schistocytes, and polychromasia in the postinfusion samples. CONCLUSION We advocate caution in the interpretation of hematologic studies performed on blood samples obtained shortly after an intraosseous infusion.

Analysis of infant lumbar puncture success rates: sitting flexed versus lateral flexed positions.

Objectives The primary objective was to determine whether the sitting flexed position yields higher success rates of obtaining cerebrospinal fluid (CSF) for culture. The secondary objectives were to determine whether the sitting flexed position yields higher success rates of obtaining the following: CSF for cell count, non–traumatic CSF, and CSF on the first attempt. Methods The study investigator performed a retrospective chart review of infants 0 to 365 days of age who had a lumbar puncture (LP) performed from January 1 to December 31 of 2010. Data on the LP position and the number of attempts were abstracted from procedure notes. Twenty-one LPs were excluded because of incomplete data on LP position and/or number of attempts. Spinal fluid count results were obtained from electronic medical records. Non–traumatic LPs were defined in 2 categories: CSF red blood cell counts of 500 cells per cubic millimeter or less and 10,000 cells per cubic millimeter or less. Results One hundred thirty-two LPs were included: 30 sitting flexed and 102 lateral flexed. There were no differences in success rates between positions for the primary objective of obtaining CSF for culture and the secondary study objectives of obtaining CSF for cell count and non–traumatic CSF. A significant secondary objective was that operators who performed the LP in the sitting flexed position were more likely to obtain CSF on the first attempt (odds ratio, 2.74; confidence interval, 1.17–6.45). Conclusions The sitting flexed position was as successful as the lateral flexed position in the primary objective of obtaining CSF for culture and the secondary objectives of obtaining CSF for cell count and non–traumatic CSF. For the secondary objective of obtaining CSF on the first attempt, the sitting flexed position was associated with a higher rate of obtaining CSF on the first attempt in infants younger than 12 months.