Comparing nasal suction devices in children with bronchiolitis: A pilot randomized control trial.

BACKGROUND/OBJECTIVES: Bronchiolitis is the most common cause of lower respiratory tract infections that lead to hospitalizations in infants and young children. METHODS: In this randomized controlled pilot study, we compared two separate nasal suction devices, namely the over counter device by the brand name of NoseFrida and the standard hospital device NeoSucker, in hospitalized children with bronchiolitis to assess equivalence of length of stay within a ± 5-h equivalence margin and to compare readmission rates and associated complications. Additionally, parental satisfaction for the NoseFrida device was measured with a six question (5-point Likert scale) survey. RESULTS: There were 20 patients randomized to the NeoSucker group and 24 randomized to the NoseFrida group. The mean length of stay for the NoseFrida group was 33.5 ± 25.4 h compared to 31.0 ± 15.6 h in the NeoSucker group, which did not establish equivalence within the ±5-h equivalence margin (p = 0.352). Parents were generally satisfied with the NoseFrida. Patients treated with the two devices had similar frequencies of deep suctioning and readmission within 48 h. CONCLUSIONS: Although the mean length of stay was comparable for bronchiolitis patients treated with the NoseFrida and NeoSucker, the relatively small sample size and large amount of variability precluded demonstrating equivalence. Since this was a pilot, further studies are needed to evaluate the recommendation for the use of such devices in both the hospital setting and in the outpatient management of bronchiolitis.

Drowning prevention counselling by paediatricians to educate caregivers on water safety.

AIM: Drowning is the leading cause of unintentional injury death for children 1-4 years of age in the USA. Texas, a southeastern state, is disproportionately burdened by paediatric drowning. The aim of this project was to increase drowning prevention counselling provided during well-child visits to families with children aged 0-10 years. METHODS: We developed and implemented a water safety counselling programme for paediatricians to impart to families during well child, urgent care and ED visits for 0-10 year age group. Physicians completed and self-reported demographic, pre- and post-intervention, counselling rate and project evaluation surveys, while caregivers completed post-intervention surveys only. Both physicians and caregivers were surveyed on evidence-based drowning prevention strategies (four-sided fencing of pools, touch supervision, life jackets and swim/cardio-pulmonary resuscitation classes). RESULTS: Thirty-three physicians and 1934 caregivers participated in the project. Physicians demonstrated statistically significant improvement in discussing drowning prevention with patients (3.5 vs. 4 on Likert scale; P = 0.002) in 2018 versus 2019. The counselling frequency in primary care settings increased from 54% to 70% from year 1 to 2. 100% of physicians correctly identified the best drowning prevention strategy and 80.6% of caregivers reported learning new water safety information in 2019 versus 68.8% in 2018 (P value < 0.001). CONCLUSIONS: This water safety education programme demonstrated increased drowning prevention counselling during well-child visits. The counselling was effective as demonstrated by increased caregiver acquisition of new water safety information. Paediatricians had adequate drowning prevention knowledge; an efficient counselling strategy helped them impart this knowledge to their patients.

Teenage boy with bullous rash.

-A 14-year-old boy with recent antibiotic treatment for tonsillitis, presented to the emergency department with 1-week history of worsening rash and haemorrhagic bullae involving the bilateral legs, trunk and hands (figures 1 and 2). Laboratory results were significant for proteinuria (2+protein) and haematuria (1+, 5-10 red blood cells/high power field); 24 hours urinary protein and renal function were within normal limits. The patient had an inconclusive skin biopsy.

Correlation of clinical and chest radiograph findings in pediatric submersion cases.

BACKGROUND: Submersion injuries are a leading cause of injury death in children in the United States. The clinical course of a submersion patient varies depending on the presence of anoxic brain injury and acute respiratory failure. OBJECTIVE: We studied changes in clinical findings and chest radiograph findings and determined the sensitivity/specificity of the presenting chest radiograph in predicting clinical improvement within the first 24 h in pediatric submersion cases. MATERIALS AND METHODS: We conducted a cross-sectional study of pediatric submersion patients through age 18 years treated at a children's hospital from 2010 to 2013. We reviewed demographics, comorbidities, prehospital/hospital course and chest radiographic findings. Clinical improvement occurred when a child demonstrated normal vital signs and mentation. We compared radiographic findings among children based on clinical improvement up to 24 h post submersion. Using odds ratios, we calculated associations between radiographic findings and clinical improvement. We studied the sensitivity/specificity of the presenting chest radiograph in predicting clinical improvement within 24 h. RESULTS: One hundred forty-two of 262 (54%) patients had initial chest radiographs; 41% had follow-up radiographs. The odds of an abnormal initial chest radiograph were 4 times higher in children with respiratory distress or abnormal mentation at emergency department (ED) presentation compared to children without these findings (odds ratio [OR]=4.83; 95% confidence interval [CI]=2.1-10.85; P<0.001). Improvement in radiographic findings occurred in 85% of children within 24 h. Children with an abnormal initial chest radiograph were 87% less likely to improve clinically by 24 h (P<0.001). A presenting chest radiograph that was normal or with mild pulmonary edema/atelectasis predicted clinical improvement within 24 h (sensitivity 95%, specificity 57%). CONCLUSION: Most chest radiographic findings improve in pediatric submersion patients who recover within the first 24 h. An initial chest radiograph that is normal or with mild pulmonary edema/atelectasis satisfactorily predicts clinical improvement by 24 h post submersion.

Hyperlipidemia.

Cardiovascular disease remains the top cause of morbidity and mortality in the United States. Atherosclerotic plaques are known to start in adolescence, and, therefore, young adults can be affected by coronary artery disease. Children with known risk factors, such as genetic predisposition, including familial hyperlipidemias, diabetes, and renal diseases, are at higher risk. With childhood obesity becoming an epidemic in certain parts of the United States, this problem is further highlighted as an important issue affecting children's health. There are unclear recommendations for pediatricians regarding cholesterol screening of pediatric populations, when to initiate hyperlipidemia treatment with statin therapy, and when to refer to a specialist for further management. This article reviews the epidemiology and pathophysiology of hyperlipidemia, recommendations for screening and types of screening, management (including pharmacology), prognosis, and prevention.

An Infected Urachal Cyst in a 4-Year-Old Girl Presenting with Recurrent Abdominal Pain.

BACKGROUND: Urachal cysts are remnants of urachal ducts and usually present when they get infected or undergo malignant transformation. CASE REPORT: A 4-year-old girl presented to the Emergency Department (ED) with intermittent abdominal pain, fever, dysuria, and umbilical swelling. She was diagnosed with an abscess related to an infected urachal cyst by ultrasound. The patient was treated with antibiotics, and the abscess was drained by Interventional Radiology with ultrasound guidance. She recovered uneventfully and was discharged home. The urachal cyst was excised a month later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Though urachal cysts are rare, it is important to consider this entity in the differential diagnosis of acute abdomen and recurrent abdominal pain in the ED setting.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit.

BACKGROUND: Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics. OBJECTIVES: The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI. METHODS: A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted. RESULTS: One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study. CONCLUSIONS: The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Vomiting is not associated with poor outcomes in pediatric victims of unintentional submersions.

INTRODUCTION: The outcome of submersion victims depends on submersion duration and the availability of timely and effective resuscitation. The prognostic implication of vomiting during resuscitation of submersion victims is unclear. The study sought to determine whether vomiting during resuscitation in children treated for unintentional submersion injuries adversely impacts outcome. METHODS: This was a retrospective study of unintentional submersion victims under age 18 treated at an urban tertiary-care children's hospital from 2003-2009. Submersion and victim details were obtained from hospital, EMS, and fatality records. Outcomes studied were survival at 24 hours and condition (Favorable: good/mild impairment or Poor: death/severe disability) at hospital discharge. Descriptive comparisons between emesis groups (yes/no) and categorical covariates were analyzed. RESULTS: There were 281 victims. The median age was 3 years; 66% were males. Most incidents occurred at swimming pools (77%) and bathtubs (16%). Most were hospitalized (83%). The presence or absence of emesis was documented in 246 (88%). Victims with emesis were significantly less likely to have apnea or be intubated in the ED, have a low ED GCS or die. No patient who had emesis died at 24 hours or had a poor outcome at hospital discharge. Victims who had emesis post-resuscitation were significantly more likely to have received CPR or chest compressions than rescue breaths. CONCLUSIONS: Emesis in pediatric submersion victims is inversely associated with death at 24 hours or poor outcome at hospital discharge. The relationship between emesis and the adequacy of resuscitation of pediatric submersion victims needs to be further studied.