Evaluation of the utility of radiography in acute bronchiolitis.

OBJECTIVES: To determine the proportion of radiographs inconsistent with bronchiolitis in children with typical presentation of bronchiolitis and to compare rates of intended antibiotic therapy before radiography versus those given antibiotics after radiography. STUDY DESIGN: We conducted a prospective cohort study in a pediatric emergency department of 265 infants aged 2 to 23 months with radiographs showing either airway disease only (simple bronchiolitis), airway and airspace disease (complex bronchiolitis), and inconsistent diagnoses (eg, lobar consolidation). RESULTS: The rate of inconsistent radiographs was 2 of 265 cases (0.75%; 95% CI 0-1.8). A total of 246 children (92.8%) had simple radiographs, and 17 radiographs (6.9%) were complex. To identify 1 inconsistent and 1 complex radiograph requires imaging 133 and 15 children, respectively. Of 148 infants with oxygen saturation >92% and a respiratory disease assessment score <10 of 17 points, 143 (96.6%) had a simple radiograph, compared with 102 of 117 infants (87.2%) with higher scores or lower saturation (odds ratio, 3.9; 95% CI, 1.3-14.3). Seven infants (2.6%) were identified for antibiotics pre-radiography; 39 infants (14.7%) received antibiotics post-radiography (95% CI, 8-16). CONCLUSIONS: Infants with typical bronchiolitis do not need imaging because it is almost always consistent with bronchiolitis. Risk of airspace disease appears particularly low in children with saturation higher than 92% and mild to moderate distress.

Wrist buckle fractures: a survey of current practice patterns and attitudes toward immobilization.

OBJECTIVES: Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons. METHODS: A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children's hospitals. RESULTS: Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combination (splint and cast) and 12% prefer backslabs. Sixty percent of ED physicians "usually or always" use casts and 31% "usually or always" use backslabs. Although there was variation among the orthopedic surgeons regarding the recommended length of immobilization, most (70%) recommended 2 to 4 weeks, although some (12%) treated only until pain free. ED physicians showed greater diversity regarding length of immobilization. CONCLUSIONS: Although many physicians believe that wrist buckle fractures need to be immobilized, a significant number do not. There is substantial variability in the type and length of immobilization used. This variability suggests that the optimal management strategy for wrist buckle fractures is unclear and should be determined in future prospective studies.

Predictors of major intervention in infants with bronchiolitis.

OBJECTIVE: We sought to identify predictors of the major medical intervention (MMI) in infants with bronchiolitis in the Emergency Department (ED) to recognize those in need of hospitalization versus the candidates for discharge. PATIENTS AND METHODS: We conducted an analysis of data from a prospective cohort study of previously healthy infants 2-23 months presenting to our ED with first episode of wheeze and respiratory distress. Infants were divided into those with at least one MMI defined as oxygen administration for saturation of <90%, intravenous (IV) fluids of 20 ml/kg, apnea management, or critical care unit (CCU) admission (MMI group) versus those without (no-MMI group). The primary outcome was the association between the MMI versus no-MMI groups and potential risk factors for these outcomes. RESULTS: Of 312 study infants, 52 experienced MMI--all received oxygen for saturation <90%, four also received IV fluids and none required apnea management or CCU care. The following four risk factors were associated with MMI: baseline accessory muscle score >or=6/9 [OR 2.44, 95% CI 1.29; 4.62], oxygen saturation or=60 [OR 1.85, 95% CI 0.97; 3.54], and poor fluid intake [OR 2.65, 95% CI 1.12; 6.26]. Of the 148 infants without predictors 11 (7.4%) received MMI, 145 required either no MMI or oxygen for

A single versus multiple doses of dexamethasone in infants wheezing for the first time.

RATIONALE: Corticosteroid therapy is not routinely recommended in true bronchiolitis. However, since bronchiolitis and the first asthma attack are impossible to distinguish, some infants with the first wheezing episode receive corticosteroids. Optimal duration of corticosteroid therapy in this scenario is unknown. This study compared efficacy of multiple administrations and a single dose of dexamethasone in bronchiolitis. METHODS: In this randomized double blind trial, previously healthy outpatients 2-23 months of age with bronchiolitis and Respiratory Disease Assessment Instrument (RDAI) score 6 or more received 1 mg/kg of oral dexamethasone in the Emergency Department. Prior to discharge at 4 hr they were randomized to either 4 daily doses of dexamethasone 0.15 mg/kg or placebo equivalent. Primary outcome was the proportion of subsequent hospitalizations or prescribed trials of bronchodilator/corticosteroid therapy for dyspnea by day 6 in the groups. Secondary outcomes were changes in the RDAI to day 6, and proportions with unscheduled visits by days 6 and 28. RESULTS: The rate of primary outcome in the single dose group (SDG, N = 64) was 9/64 or 14.1% versus 7/61 or 11.5% in the multiple dose group (MDG, N = 61) [95% CI 0.09; 0.14]. Twelve (18.8%) children in the SDG had unscheduled medical visits by day 6 versus 11 (18.0%) children in the MDG [95% CI 0.13; 0.14]. On day 6 the RDAI decreased from 9.5 +/- 2.1 to 2.1 +/- 2.4 in the SDG and from 9.8 +/- 2.2 to 1.6 +/- 2.3 in the MDG [95% CI 0.36; 2.06]. Between days 7-28, 24/64 (37.5%) SDG infants returned for care versus 20/61 (32.8%) of the MDG [95% CI 0.12; 0.21]. CONCLUSIONS: Our study suggests that, in outpatients with bronchiolitis who receive dexamethasone, continuation of this agent beyond the initial dose does not provide significant benefit.

Injury admissions to pediatric intensive care are predictable and preventable: a call to action.

Injuries are often preventable yet remain the most common cause of death in children ages 1 to 19 years in Canada. In this retrospective case series, the authors sought to determine the proportion of injury admissions to a tertiary multidisciplinary university hospital Pediatric intensive care unit (PICU) that were preventable by known measures. Patients were a consecutive sample of 104 children, aged 99 (mean [SD] 70; range, 1-215) months, who were admitted to PICU due to injury from July 1997 to June 1998. Charts were reviewed to determine morbidity (PICU days, ventilation days, and discharge to a rehabilitation hospital), mortality, and whether the injury occurred by a preventable mechanism (as recommended by the American Academy of Pediatrics). Out of 790 admissions, 104 (13.2%) were for injury-81% unintentional and 19% intentional. Unintentional injuries occurred by diverse mechanisms, and 65/84 (77%; 95% confidence interval, 67%-86%) were potentially preventable. Unintentional injuries were especially preventable in the younger age groups (P = .009): 71% (5/7) in those<1 year; 89% (31/35) in those 1 to 4 years; 89% (16/18) in those 5 to 9 years; and 54% (13/24) in those> or =10 years. Most intentional injuries were suicide attempts in adolescents, and 88% had multiple risk factors for suicide. Patients were in PICU for 2.9 (SD 4.5) days, ventilated in 73% for 2.8 (SD 4.4) days, had a mortality of 12.5% (95% confidence interval, 6.8%- 20.4%), and demonstrated common need for rehabilitation. Thus, injuries in children resulting in admission to the PICU are common and highly preventable events with significant morbidity and mortality. Novel strategies to improve the public's perception of the cost of childhood injury are needed.