Enteric Fever in a Multicultural Canadian Tertiary Care Pediatric Setting: A 28-Year Review.

We undertook a 28-year review of enteric fever at a large tertiary care pediatric center. Most cases occurred in children who visited friends and relatives in the Indian subcontinent, and there was significant antibiotic resistance. Documented vaccination rates were low, and many cases also had evidence of delays in diagnosis and treatment.

From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice.

Previous research has highlighted the importance of addressing the social determinants of health to improve child health outcomes. However, significant barriers exist that limit the paediatrician's ability to properly address these issues. Barriers include a lack of clinical time, resources, training and education with regard to the social determinants of health; awareness of community resources; and case-management capacity. General practice recommendations to help the health care provider link patients to the community are insufficient. The objective of the current article was to present options for improving the link between the office and the community, using screening questions incorporating physician-based tools that link community resources. Simple interventions, such as routine referral to early-year centres and selected referral to public health home-visiting programs, may help to address populations with the greatest needs.

Des recherches antérieures ont fait ressortir l'importance de tenir compte des déterminants sociaux de la santé pour améliorer la santé des enfants. Cependant, des obstacles importants empêchent les pédiatres de bien se pencher sur la question, incluant le manque de temps clinique, de ressources, de formation et d'enseignement sur les déterminants de la santé, la connaissance des ressources communautaires et la capacité de gestion des cas. Les recommandations faites en pratique générale pour aider le dispensateur de soins à orienter les patients vers des ressources communautaires ne suffisent pas. Le présent article vise à présenter des moyens de faire de meilleurs liens entre le cabinet et la communauté, à l'aide de questions de dépistage intégrant des outils médicaux qui dirigent les patients vers des ressources communautaires. Des interventions simples, telles que l'orientation systématique vers des centres de la petite enfance et l'orientation sélective vers des programmes de visite à domicile par la santé publique, peuvent contribuer à servir les populations qui ont les besoins les plus criants.

Speech and language support: How physicians can identify and treat speech and language delays in the office setting.

Failure to recognize and intervene early in speech and language delays can lead to multifaceted and potentially severe consequences for early child development and later literacy skills. While routine evaluations of speech and language during well-child visits are recommended, there is no standardized (office) approach to facilitate this. Furthermore, extensive wait times for speech and language pathology consultation represent valuable lost time for the child and family. Using speech and language expertise, and paediatric collaboration, key content for an office-based tool was developed. THE TOOL AIMED TO HELP PHYSICIANS ACHIEVE THREE MAIN GOALS: early and accurate identification of speech and language delays as well as children at risk for literacy challenges; appropriate referral to speech and language services when required; and teaching and, thus, empowering parents to create rich and responsive language environments at home. Using this tool, in combination with the Canadian Paediatric Society's Read, Speak, Sing and Grow Literacy Initiative, physicians will be better positioned to offer practical strategies to caregivers to enhance children's speech and language capabilities. The tool represents a strategy to evaluate speech and language delays. It depicts age-specific linguistic/phonetic milestones and suggests interventions. The tool represents a practical interim treatment while the family is waiting for formal speech and language therapy consultation.

Le défaut de dépister et d'intervenir rapidement en cas de retards de la parole et du langage peut avoir des conséquences multiples au potentiel grave en matière de développement de la petite enfance et d'aptitudes à la littératie plus tard. Il est recommandé de procéder à l'évaluation systématique de la parole et du langage pendant les bilans de santé des enfants, mais il n'existe pas d'approche normalisée (en cabinet) pour la faciliter. De plus, les temps d'attente prolongés avant d'obtenir une consultation en orthophonie constituent une perte de temps précieux pour l'enfant et sa famille. Faisant appel à des compétences en orthophonie et à la collaboration de pédiatres, les chercheurs ont préparé le contenu essentiel d'un outil à utiliser en cabinet.L'outil visait à aider les médecins à réaliser trois grands objectifs : le dépistage rapide et précis des retards de la parole et du langage et des enfants vulnérables à des problèmes de littératie, l'aiguillage convenable vers des services d'orthophonie, au besoin, et l'enseignement aux parents, afin de les habiliter à créer des environnements de langage riches et réceptifs à la maison. À l'aide de cet outil, en collaboration avec le programme Lisez, parlez, chantez de la Société canadienne de pédiatrie et l'initiative Grow Literacy, les médecins seront mieux placés pour offrir des stratégies pratiques aux personnes qui s'occupent d'enfants afin de renforcer les capacités des enfants sur le plan de la parole et du langage.L'outil représente une stratégie pour évaluer les retards de la parole et du langage. Il dépeint les étapes linguistiques et phonétiques propres à l'âge et propose des interventions. L'outil représente un traitement provisoire pratique tandis que la famille attend une consultation officielle en orthophonie.

Spotlight on middle childhood: Rejuvenating the 'forgotten years'.

Middle childhood, from six to 12 years of age, is often known as the 'forgotten years' of development because most research is focused on early childhood development or adolescent growth. However, middle childhood is rich in potential for cognitive, social, emotional and physical advancements. During this period, the brain is actively undergoing synaptic pruning and, as such, is constantly becoming more refined, a process that is heavily dependent on a child's environment. This discovery opens the door to optimizing the experiences a child needs to provide themselves with a strong foundation for adulthood. The present article reviews the neurological changes that occur in middle childhood, their impact on overall development and how to implement this knowledge to augment a child's capabilities.

La période intermédiaire de l'enfance, de six à 12 ans, est souvent connue comme « les années oubliées ¼ du développement, car une bonne partie de la recherche est axée sur le développement de la petite enfance ou la croissance à l'adolescence. Cependant, cette période est riche en potentiel sur le plan du progrès cognitif, social, affectif et physique. Le cerveau subit activement un élagage synaptique et devient donc de plus en plus raffiné, un processus qui dépend lourdement de l'environnement de l'enfant. Cette découverte ouvre la porte à l'optimisation des expériences que vit l'enfant afin d'établir des assises solides pour l'âge adulte. Le présent article aborde les changements neurologiques qui se produisent pendant la période intermédiaire de l'enfance, leurs répercussions sur le développement global et la mise en œuvre de ces connaissances pour accroître les capacités de l'enfant.

Increasing fluoroquinolone resistance in Salmonella typhi in Ontario, 2002-2007.

We reviewed the antibiotic susceptibility patterns of all isolates of Salmonella typhi in Ontario, Canada from January 2002 to December 2007. We identified a total of 381 unique cases over the 5-year period (50-73 cases per year). Of the 381 cases, 171 were female, 164 were male, and no gender was identified for 33 cases. Age of the patients ranged from less than 1 to 102 years of age (median age of 20 years). Although resistance patterns for ampicillin, trimethoprim-sulfamethoxazole, third generation cephalosporins (cefotaxime until May 2005 and ceftriaxone from June 2005 to present), and chloramphenicol remained stable, nalidixic acid resistance rose sharply between 2003 and 2005 and has remained at approximately 80% of isolates since 2005. The significant and sustained increase in nalidixic acid-resistant S. typhi suggests that ciprofloxacin should no longer be used as the drug of choice for the empiric treatment of typhoid fever in Ontario.

Acute neurological events associated with influenza vaccination: are the WHO criteria for assessing causality adequate?

We identified neurological admissions temporally associated with influenza vaccine to determine the likelihood of causality using World Health Organization (WHO) criteria. Although all cases were categorized as possibly related to the vaccine, most had a compelling alternative explanation. This observation suggests that the current WHO criteria may not be sufficient in determining if an adverse event is truly vaccine related.

The prevention and management of infections in children with asplenia or hyposplenia.

Overwhelming sepsis remains a significant complication of asplenia and hyposplenia. The mainstays of prevention are education, immunization, and prophylactic antibiotics. Evidence to base recommendation and guidelines is lacking. Such decisions as the specific immunizations required, the timing of immunizations, the duration of antibiotic prophylaxis, and the prevention of overwhelming postsplenectomy sepsis in children undergoing splenectomy are often empiric. This article reviews the current literature on the prevention and management of severe infections in children with underlying asplenia or hyposplenia.

Blastomycosis in Ontario, 1994-2003.

We describe a case of blastomycosis in an 8-year-old boy with Blastomyces-associated osteomyelitis and possible pulmonary involvement. We also identify 309 cases of blastomycosis in Ontario that were seen during a 10-year period, 57% of which occurred from 2001 to 2003. The overall incidence during the study period was 0.30 cases per 100,000 population. Most patients were from north Ontario (n = 188), where the incidence was 2.44 cases per 100,000. The incidence in the Toronto region was 0.29 per 100,000. Thirteen percent of cases occurred in children <19 years of age. These findings substantially increase the number of known cases in Ontario and Canada. Clinicians may encounter persons infected with Blastomyces dermatitidis and must be familiar with its signs and symptoms and be aware of locations, such as northwestern Ontario, where disease is endemic or hyperendemic. We advocate resuming blastomycosis as a reportable disease in Ontario to facilitate tracking cases.

The prevention and treatment of bacterial infections in children with asplenia or hyposplenia: practice considerations at the Hospital for Sick Children, Toronto.

Children born without a spleen or who have impaired splenic function, due to disease or splenectomy, are at significantly increased risk of life-threatening bacterial sepsis. The mainstays of prevention are education, immunization, and prophylactic antibiotics. The availability of conjugate 7-valent pneumococcal vaccines for use in children to age 9 years at least, as well as conjugate meningococcal C vaccine in some countries, for use beginning in infancy, appear to represent beneficial additions, but not substitutions, to previous recommendations for the use of polysaccharide 23-valent pneumococcal and quadrivalent A, C, Y, W-135 vaccines. Routine immunization against H. influenzae type b should continue with non-immunized children older than age 5 years receiving two doses 2 months apart, similar to children who have not previously received conjugate pneumococcal vaccine in infancy. Annual influenza immunization, which reduces the risk of secondary bacterial infection, is also recommended for asplenic children and their household contacts. Many experts continue prophylaxis indefinitely although prophylaxis of the penicillin allergic child remains suboptimal.

A pharmacoeconomic evaluation of 7-valent pneumococcal conjugate vaccine in Canada.

The objective of this study was to evaluate the projected health benefits, costs, and cost-effectiveness of pneumococcal conjugate vaccination for infants and children aged <5 years in Canada. A health state model incorporating incidence, vaccine efficacy, costs, and transitional probabilities for the health states (well, meningitis, bacteremia, otitis media, pneumonia, and death) was constructed for a 10-year time horizon. Implementation of a pneumococcal conjugate vaccine program in Canada for each annual birth cohort of 340,000 persons observed over 10 years would be expected to save approximately 12 lives and 100,000 cases of pneumococcal disease over 10 years, resulting in total savings of $67 million (Canadian dollars [Can$]). Vaccination of healthy infants would result in net savings for society if the vaccine costs less than Can$50 per dose. Moreover, for a vaccine purchase price of Can$67.50, infant vaccination would cost society Can$79,000 per life-year gained. Pneumococcal conjugate vaccination is a potentially cost-effective means of pneumococcal disease prevention.

Microbiologic findings and risk factors for antimicrobial resistance at myringotomy for tympanostomy tube placement--a prospective study of 601 children in Toronto.

CONTEXT: There is limited information on the identity and antibiotic susceptibility of bacterial pathogens in children with chronic otitis media whose repeated antibiotic use may place them at increased risk of antibiotic-resistant bacteria. OBJECTIVE: To determine, at myringotomy for tympanostomy tube placement, (1) the prevalence of bacteria, (2) the extent and patterns of antibiotic resistance, and (3) the risk factors associated with the presence and resistant status of pathogens. DESIGN: Prospective, multi-site, cohort study. SETTING AND PATIENTS: Children undergoing myringotomy for tympanostomy tube placement between November 1, 1999 and March 31, 2000 in seven hospitals in Toronto, Ontario, were identified. If fluid was present, aspirates were submitted for bacteriologic testing. A follow-up telephone questionnaire was administered to patient caregivers in order to identify risk factors for the presence of (1) culturable pathogens and (2) resistant pathogens. MAIN OUTCOME MEASURES: The identification and prevalence of bacteria cultured from the middle ears of subjects, and the degree of nonsusceptibility to commonly prescribed antibiotics. RESULTS: Among 601 patients (mean age 3.9 years, 60.7% male), both a telephone interview (n=544) and an ear specimen (n=527) were obtained for 478. Pathogens were found in middle ear effusions of 37% of the children in the study; including at least one 'definite' pathogen in 189 children (31.4%), and a further 32 children (5.3%) with at least one 'possible' pathogen. Definite pathogens included Haemophilus influenzae in 17% of the children, followed by Moraxella catarrhalis (9%) and Streptococcus pneumoniae (6%); ampicillin nonsusceptibility was found in 40, 100 and 24%, respectively. Overall, 123 children (20.5%) were found to have definite pathogens with resistance to ampicillin/penicillin, trimethoprim-sulfamethoxazole, or clarithromycin/erythromycin. Patient characteristics included premature birth and/or long length of stay in the nursery (23%), first infection before the age of 6 months (26%), put to bed with a bottle (28%), household smoker (34%), in out-of-home child care (38%), history of eczema, bronchiolitis and/or asthma (39%), and use of pacifiers (40%). Household characteristics were smoking (34%), married/common law parents (85%), and 60% had completed college or university; in 26% both parents were born outside of Canada; 73% of children were Caucasian. Of the 75% who responded to the question regarding income, 42% had household income over $60,000 (CAN). Risk factors for the presence of a pathogen and for a resistant pathogen in multivariate analysis included younger age, lower maternal education, day care centre attendance, no previous adenoidectomy and bilateral, primarily winter infections as well as amoxicillin use in the previous 6 months. CONCLUSION: Modifiable risk factors for otitis media including household smoking and pacifier use are present in many children undergoing tympanostomy tube placement; child care centre attendees are over-represented. Multiple antibiotic courses were commonly prescribed prior to surgery. H. influenzae and M. catarrhalis are important pathogens and therapy in clinical failures should be directed against them. The 7-valent protein conjugate polysaccharide vaccine (Prevnar) would have covered 73% of the serotypes of S. pneumoniae isolated in this study.

Outcome of penicillin-nonsusceptible Streptococcus pneumoniae meningitis: a nested case-control study.

BACKGROUND: There are few data comparing the clinical features, management and outcome of penicillin-nonsusceptible (PNSP) meningitis patients with penicillin-susceptible (PSSP) meningitis patients. METHODS: We performed a retrospective, nested case-control study comparing cases with PNSP meningitis with controls with PSSP meningitis obtained from the Immunization Monitoring Program, Active (IMPACT) cross-Canada surveillance study of invasive infections. RESULTS: There were 30 PNSP meningitis cases (10.1% of total) and 45 PSSP meningitis controls from 6 centers obtained from 297 meningitis cases in the IMPACT database from 1991 through 1999. Vancomycin was used for empiric therapy in no cases and controls in 1991 to 1993 and in all cases in 1999. A third generation cephalosporin was used in 93.3% of confirmed PNSP cases, and 70.0% also received vancomycin and/or rifampin. Penicillin was used in 66.7% of confirmed PSSP cases. PNSP cases were more likely than PSSP controls to have a second lumbar puncture (odds ratio, 4.1; P= 0.01). PNSP cases were treated with intravenous antibiotics for an average of 15.6 days compared with 12.3 days for controls ( P= 0.04). Among PNSP cases, those patients who did not receive empiric vancomycin were treated with intravenous antibiotics for an average of 18.5 days compared with 12.0 days for those who did receive empiric vancomycin ( P= 0.04). The overall mortality was 5.3%, and 36.6% of survivors had >or=1 neurologic sequelae, including 19.7% with hearing loss. In multivariate statistical models, PNSP was not a risk factor for intensive care unit admission or neurologic sequelae. CONCLUSIONS: Management of suspected bacterial meningitis and confirmed meningitis in Canadian children changed in the past decade. Treatment of PNSP meningitis is significantly different from that for PSSP meningitis. These changes have occurred in response to the emergence of PNSP in Canada. Neurologic sequelae remain common after meningitis, but there are no differences between PNSP cases and PSSP cases.

Human surveillance for West Nile virus infection in Ontario in 2000.

BACKGROUND: The first reports of West Nile virus (WNV) infection in the United States in 1999 prompted Ontario to establish a surveillance protocol to monitor for the possible spread of the virus into the province. Surveillance components included evaluation of dead birds, sentinel chickens, mosquito pools and human disease. We report the results of human surveillance in 2000. METHODS: Between July 1 and Oct. 31, 2000, an active surveillance program was undertaken in which designated site coordinators in sentinel hospitals identified patients who met the suspect case definition (fever and fluctuating level of consciousness [encephalopathy], with or without muscle weakness). During the same period, following province-wide distribution of educational material, all other patients tested for WNV antibodies were identified through review of provincial laboratory reports (laboratory-based enhanced passive surveillance). RESULTS: Of the 60 hospitals contacted, 59 agreed to participate in the active surveillance program; 52 provided information on a regular (weekly) basis, and 7 submitted fewer than 8 reports. Thirty-six (61%) of the sentinel sites reported suspect cases. In total, 188 patients were tested (130 identified through active surveillance and 58 through enhanced passive surveillance). Patients identified through active surveillance were more likely than those identified through passive surveillance to meet the suspect case definition (43% [n = 56] v. 7% [n = 4]), to be admitted to hospital (75% [n = 99] v. 16% [n = 9]), to have a longer hospital stay (mean 25 v. 3 days), to have had a second (convalescent) serum sample collected (37% [n = 48] v. 31% [n = 18]), to have had a cerebrospinal fluid (CSF) sample banked (56% [n = 73] v. 14% [n = 8]) and to have had a discharge diagnosis reported (79% [n = 103] v. 28% [n = 16]). Of the 60 patients (32%) who met the suspect case definition, 34 (57% [31 active, 3 passive]) had a discharge diagnosis of encephalitis. Of these, 17 (50% [15 active, 2 passive]) had paired serum samples collected, and 18 (51% [all active]) had a CSF sample banked. The reported causal agents were herpes simplex virus (n = 8), varicelia virus (n = 2), Powassan virus (n = 1), echovirus 30 (n = 1) and group B Streptococcus (n = 1); the cause was unknown in 18 cases. One patient died of encephalitis. The remaining 26 patients who met the suspect case definition were ultimately found to have nonencephalitic infections, vascular events or alcohol- or drug-related illness. The 128 (68%) tested for WNV who did not meet the suspect case definition included 9 patients ultimately discharged with a diagnosis of encephalitis. No cases of WNV infection were identified. INTERPRETATION: Only one-third of the tested patients met the suspect case definition of encephalopathy on admission, and nearly half of them were later found to have another diagnosis; others did not meet the case definition but were later discharged with a diagnosis of encephalitis. This affirms that identification of acute encephalitis on the basis of symptoms at the time of admission is often impossible.

Esophagatis and perinatal cytomegalovirus infection.

A 6-week-old male infant presented to hospital with a large upper gastrointestinal hemorrhage. Endoscopic biopsies of his esophagus and duodenum showed cytomegalovirus (CMV) inclusions and CMV early antigen was detected by immunohistochemistry. There were no other signs of congenital CMV infection. This case adds to the clinical spectrum of perinatal CMV infection and may be more common than is currently recognized.

Acute childhood encephalitis and Mycoplasma pneumoniae.

In a prospective 5-year study of children with acute encephalitis, evidence of Mycoplasma pneumoniae infection was demonstrated in 50 (31%) of 159 children. In 11 (6.9%) of these patients, M. pneumoniae was determined to be the probable cause of encephalitis on the basis of its detection in cerebrospinal fluid (CSF) by polymerase chain reaction (PCR) or by positive results of serologic tests for M. pneumoniae and detection of the organism in the throat by PCR. CSF PCR positivity correlated with a shorter prodromal illness (P=.015) and lack of respiratory symptoms (P=.06). Long-term neurologic sequelae occurred in 64% of probable cases. Thirty children (18.9%) who were seropositive for M. pneumoniae but did not have the organism detected by culture or PCR had convincing evidence implicating other organisms as the cause of encephalitis, suggesting that current serologic assays for M. pneumoniae are not sufficiently specific to establish a diagnosis of M. pneumoniae encephalitis.

Practical vaccination guidelines for children with cancer.

The paediatrician or family physician usually provides primary care for children diagnosed with cancer. Immunizations are an important facet of this care, but guidelines for the immunization of these immunocom-promised children are difficult to locate and cumbersome to follow. The authors have developed immunization guidelines for children receiving chemotherapy for cancer that will hopefully facilitate the care of this group of children. Before initiating any immunizations in this group of children, communication with a cancer specialist is recommended. There is little evidence-based literature to support immunization guidelines in immunocompromised hosts; thus, the recommendations presented are derived from the available literature, existing guidelines and expert opinion.