Unilateral leptospiral pneumonia and cold agglutinin disease.

Pneumonia that is unresponsive to appropriate antibiotic therapy suggests an infection due to more unusual or resistant organisms. In this report, a child with unilateral pneumonia, pleural effusion, and anti-I cold hemagglutinin antibodies is presented. The usual causes of this clinical picture were suspected and treated, but the child did not improve. Features of her history suggested a more unusual etiology, and a diagnosis of leptospirosis was made. A brief discussion of leptospiral disease in children is provided.

Cost effectiveness of antibiotic therapy for otitis media in a military pediatric clinic.

Amoxicillin continues to be the drug of first choice in the treatment of acute otitis media in children, because it is generally considered to be the safest and least expensive of the available choices. However, amoxicillin may not be the most cost-effective therapy in some settings because of its decreasing efficacy and moderately high rate of minor adverse effects. In this review, the cost effectiveness of antibiotics used to treat otitis media in a large military pediatric clinic are compared, using the decision analysis method. With this model, trimethoprim-sulfamethoxyazole is more cost-effective than amoxicillin, and cefaclor, given twice a day for 5 days, is the next most cost-effective regimen. In addition, the major and minor adverse effects of each of the agents are compared and the additional impact on cost effectiveness is considered.

Use of seating devices in infants too young to sit.

OBJECTIVES: To determine how frequently seating devices are available in homes with small infants and how often they are used for infants who are too young to sit erect and unsupported. DESIGN: Observational study using a questionnaire administered to a cohort of parents of well infants younger than 5 months. SETTING: Well-Baby Clinic, Department of Pediatrics, Tripler Army Medical Center, a tertiary care center serving the population of military dependents on the island of Oahu, Hawaii. RESULTS: Infant seating devices were available in the homes of all of the infants whose parents completed the questionnaire during the study. Of 187 infants, 176 (94%) spent 30 minutes or longer in seating devices each day. The mean (tSD) time spent each day in seating devices was 5.7 +/- 3.5 hours and ranged from 0 to 16 hours. CONCLUSIONS: Seating devices were widely available for use in the care of the infants. Car seats that double as infant carriers and infant seats likely are being used extensively outside of automobiles. Prolonged use of infant seating devices with infants who are too young to sit unsupported may have several potential adverse consequences.

Bronchiolitis in children.

Bronchiolitis is an acute inflammation of the airways. In infancy, it usually results from viral infection, with RSV the most common agent. The clinical syndrome is characterized by symptoms of lower respiratory tract infection and obstruction. In most patients, the duration of illness is 1 week, but bronchiolitis can cause serious morbidity in patients with pre-existing cardiopulmonary disease. In addition, patients may be left with serious sequelae, including PBAR and OB. RSV causes direct damage to airways, but an exaggerated host immune response may contribute to the pathogenesis of airway obstruction in bronchiolitis. The mainstays of therapy include oxygen supplementation and fluid resuscitation, and other modalities remain controversial. There are no studies to support the use of corticosteroids alone in the treatment of bronchiolitis, but several recent reports demonstrate the value of bronchodilator therapy in some patients. Antiviral agents such as ribavirin show great promise in a therapy for bronchiolitis. In addition, ribavirin may modify some aspects of the immune response during acute infection with RSV, and therefore may play a role in the prevention of long-term sequelae.

Multidisciplinary education and management program for children with asthma.

A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.

Primary tracheomalacia and gastroesophageal reflux in infants with cough.

Cough is an uncommon sign in infants. Cough may result from the presence of abnormal secretions in the airway or abnormalities of the central airways that affect the infant's ability to clear normal secretions. Tracheomalacia (TM) and gastroesophageal reflux (GER) can both cause cough in infants. Four infants whose cough began in the newborn period were diagnosed with TM and GER. Symptoms of central airway obstruction (homophonous wheeze or tracheal cough) suggested the diagnoses. In three patients, the diagnosis was made by barium esophagraphy and airway fluoroscopy. The infants responded to conservative and medical therapy for GER and to nebulized bronchodilators. Tracheomalacia and GER cause cough in infants that begins in the newborn period. The diagnosis can often be made with studies available to the primary care provider, and the conditions are often responsive to medical management.

Health care for the children of Army service members: cost of alternatives.

The United States Army is committed to providing quality health care for active-duty service members, their dependents, and retired service members. Historically, the Army has never had enough active-duty physicians to provide care for all its beneficiaries. Alternatives utilizing civilian health care providers have been established to provide the balance of the medical services. In this review, the cost of each of the civilian health care providers in the Ft. Hood, Texas area is compared to that of the Army pediatrician. The Army pediatrician proves to be the least expensive of the health care providers.

Source of health care for military dependents with cystic fibrosis.

Health care to military dependents with cystic fibrosis (CF) may be compromised by lack of consistency. Civilian centers provide an alternative for care. A reliable count of dependents with CF is unknown. We surveyed 196 military treatment facilities (MTFs) to obtain data on dependents with CF and compared it with data from the National CF Registry. Seventy-seven percent of the MTFs responded and 143 patients were identified. Registry data identified 373 CHAMPUS patients at 82 civilian centers. There were 284 patients in the Registry only and 54 patients in the MTF survey only. Eighty-nine patients were identified through both data sources. A total of 427 patients were identified. Under current CHAMPUS reorganization plans, MTFs will serve as "gateways" for funding of specialized civilian care. Thus, the influx of these and other chronically ill children into the MTF may tax the resources and capabilities of these facilities.

The diagnosis of gastroesophageal reflux in hospitalized infants: 1971-1995.

Gastroesophageal reflux (GER) is being increasingly diagnosed and implicated for a range of pediatric problems. This study examines the diagnostic rate for GER in US Army hospitals between 1971 and 1995. During this 25-year period, 2059 diagnoses of GER were identified, for a 20-fold increase. Both the rate and total number of cases rose significantly in medical centers and community hospitals alike. The increase in GER diagnoses does not necessarily imply an increase in prevalence. It may be the result of an increased awareness of the problem or over diagnosis. However, it may also reflect an increased prevalence of pathologic GER, which is potentially the result of changes in the practice of infant care.

Conservative therapy for gastroesophageal reflux in infants with obstructive pulmonary disease.

Gastroesophageal reflux (GER) is a commonly recognized problem in infants. However, it is difficult to demonstrate a causal relationship between GER and recurrent obstructive pulmonary disease (ROPD) in infants. In this review, 3 infants with GER and severe ROPD experienced dramatic improvement with conservative GER therapy.