Management of problems related to the new morbidity by community-based paediatricians in Israel.

OBJECTIVES: To assess community-based paediatricians' management of clinical situations, particularly those related to the new morbidity (NM), such as chronic disease, developmental, behavioural, and psychosocial problems, and to identify the main associated factors. METHODS: The study population included all community-based paediatricians employed by Israel's two largest health maintenance organizations in the central and southern regions of the country (n= 574; 74% response rate). Using a self-administered questionnaire including 20 vignettes describing common clinical situations (14 related to NM; 6 related to classic paediatrics (CP)), physicians reported how they would manage each situation and how they perceived their role in managing such problems. RESULTS: Paediatricians were less likely to take an active role in managing NM-related problems than CP-related problems (68.3% vs. 93.2%; P < 0.001). In most NM situations, when paediatricians regarded the problem as part of their role, they were more likely to either manage the problem by themselves or with the help of other professionals. A multivariable linear regression model, adjusting for demographic, practice and training characteristics indicated the following predictive factors for taking an active role in managing NM (P < 0.001): practicing in the periphery, consulting with non-medical community-based professionals and combining community and hospital practice. CONCLUSIONS: To assure comprehensive paediatric care, simultaneous modification of paediatricians' residency training, practice environment and role perception are required.

Successful withdrawal from analgesic abuse in a group of youngsters with chronic daily headache.

Abuse of ergotamine and analgesics is common in adults. It coexists with headache and can also induce headaches. Ten to 15% of patients attending headache clinics and 1% of the general population suffer from chronic daily headache due to medication misuse. Indeed, this phenomenon was recently regarded as an epidemic. Nonetheless, analgesic-induced headache in children and adolescents was first reported in 1998. We report on our experience with children and adolescents with daily or almost-daily headache concomitant with daily or almost-daily analgesic intake. Over a period of 3 years, we evaluated 26 children (19 girls and 7 boys) with chronic daily or near-daily headache related to daily analgesic intake. The mean age of the group was 14.2 years (range, 12-18), and the mean headache history duration was 1.6 years (range, 3 months to 4 1/2 years). The mean number of headache days per month was 28.1 (range, 19-31). All patients had no history of migraine prior to the chronic headache phase according to the International Headache Society criteria. They were using at least one dose of analgesic drug for each headache, whereas 16 were using analgesic drugs daily. The weekly analgesic intake averaged 28.1 tablets (range, 19-41). The majority abused simple analgesics. Twenty-one took acetaminophen alone. Five took a combination; four took a compound containing acetaminophen, caffeine, and codeine; and the fifth patient took a compound containing aspirin, caffeine, and codeine. All patients were informed about the phenomenon of medication-induced headache and were encouraged to achieve drug withdrawal. Withdrawal led to complete cessation of all headaches in 20 patients. In 5 patients, the daily headache resolved; however, they suffered from intermittent episodic migraine attacks, which were frequent enough in 3 to initiate prophylactic medication. One adolescent continued to have daily headache. Analgesic-induced headache does occur in adolescents. Successful withdrawal from the offending analgesics was achieved without hospitalization or significant interference with daily life and with complete disappearance of the induced chronic daily headache in 25 of 26 patients.

Intramuscular ceftriaxone compared with oral amoxicillin-clavulanate for treatment of acute otitis media in children.

UNLABELLED: Two hundred and fifteen children aged 4 months 6 years with acute otitis media (AOM) were randomized to be treated either by a single i.m. injection of ceftriaxone, 50 mg/kg, with a second dose in the event of unsatisfactory response after 48 h or a history of recurrent AOM (109 patients) or amoxicillin clavulanate 12.5 mg tid (106 patients). The failure rate was similar in children treated by ceftriaxone and amoxicillin clavulanate, 4.6% and 4.7%, respectively (standard error for intergroup difference -2.87%, 95% confidence interval -5.62% to 5.87%). No significant differences between the groups were found in the dynamics of the resolution of the acute symptomatology, otoscopy findings, relapse rate at 30 days or tympanographic evidence of middle ear effusion at the scheduled visits on days 30, 60 and 90. Recurrence of AOM between days 31 and 90 was observed significantly in more children treated with amoxicillin clavulanate than with ceftriaxone--25 out of 84 (29.4%) versus 11 out of 81 (13.6%) (P = 0.012). CONCLUSION: Ceftriaxone injection(s) is as efficient at least as 10-day oral amoxicillin clavulanate for treatment of acute otitis media in children. Although not recommended as routine, ceftriaxone can be considered in the management of acute otitis media under special circumstances, particularly in cases when the ability to tolerate or absorb oral drugs is compromised, in children refusing or unable to take oral therapy or when the compliance is questionable.

Continuous avoidance measures with or without acaricide in dust mite-allergic asthmatic children.

BACKGROUND: Improvement in the quality of life in the Western world and increased time spent indoors by children have enhanced the spread of house dust mites and increased the exposure time for sensitive children. Also, exposure to house dust mites in infancy and subsequent development of childhood asthma have been clinically linked. Recently, new acaricides have been developed. OBJECTIVE: To test the efficacy of the new acaricide (esdepallethin and piperonyl butoxide--"Acardust") combined with environmental control compared with continuous house dust mite avoidance measures. METHOD: Forty-six house dust mite-allergic, asthmatic children were evaluated for 6 months in a prospective, randomized, double-blind, and placebo-controlled study. Patients were randomly allocated to active and placebo acaricide treatment combined with avoidance measures, whereas only continuous avoidance measures were taken in the third group. Symptom score, medication usage, and peak flow measurements were recorded daily. The amount of house dust mite allergen in the dust vacuumed from the bedrooms was also measured. RESULTS: Morning and evening peak expiratory flow rates and forced expiratory volume in one second remained unchanged throughout the study period. In all groups, the symptom scores improved significantly, whereas the amount of house dust mite allergen decreased significantly at the end of the trial. CONCLUSIONS: Continuous house dust mite avoidance measures have a significant positive effect on the symptomology of children with mild or moderate asthma. "Acardust" combined with continuous house dust mite avoidance measures is not more effective than continuous house dust mite avoidance measures alone in the treatment of house dust mite-allergic, asthmatic children.

Compulsive water drinking in infants and young children.

The management and follow-up of five patients with asymptomatic compulsive water drinking is described. Three out of the five patients were female and two were male. The age range was 6 to 20 months. All the patients presented with polyuria or polydipsia and urine osmolalities of 39 to 112 mOsm/L. The daily fluid intake ranged from 3.5 to 5 L, and the urine output was 11 to 14 mL/kg/hr. Significant improvement was noticed after a gradual weaning process. As fluid intake returned to normal, urine osmolalities reached values between 210 and 500 mOsm/L after 4 weeks, and between 630 and 800 mOsm/L after 8 weeks. No relapse was noted during the 6- to 24-month follow-up period. Pediatricians should be aware of this potentially dangerous--yet not uncommon--habit.

Swimming and grommets.

BACKGROUND: Traditionally, children with tympanostomy ventilating tubes, or grommets, were advised that water should not enter their ears in order to prevent ear infections. This group of children has been considered somewhat handicapped regarding swimming. We conducted a prospective study to determine if there is a relation between suppurative otitis media and surface swimming in children with grommets. METHODS: Forty-two children with tympanostomy ventilating tubes were included in this study. Of the 42 children, 22 were swimmers and 20 were nonswimmers, who served as the control group. The age range was 3 to 12 years, and there was no difference in the age distribution between the groups. Surface swimming was allowed without earplugs or a bathing cap, although it was mandatory to use polymyxin B-neomycin-hydrocortisone eardrops at bedtime on the day of swimming. No diving was allowed. RESULTS: Three of 22 swimmers and 2 of 20 nonswimmers developed otorrhea. In 4 of the 5 children, the otorrhea was followed by an upper respiratory tract infection. In all cases, a bacterial culture revealed Pseudomonas. The ear drainage was easily controlled with local otic treatment in all the patients. CONCLUSIONS: Taking into consideration the possible risks of infection and bearing in mind the value and joy of swimming to children and parents, families should be reassured that surface swimming does not increase the risk of infection in children with tympanostomy tubes.

Removal of nasal foreign bodies in children.

Among the foreign bodies most often found in children's nostrils are hair, beads, toy parts, paper wads, and food. Sometimes extraction of nasal foreign bodies can be difficult, especially if they are spherical. The classical presentation is a unilateral, persistent, foul-smelling, purulent, or bloody nasal discharge. Ulceration, dislodgement of the foreign body into the nasopharynx, and aspiration of the foreign body can complicate the problem.

Prevalence of asthma in Israeli schoolchildren. A comparative study of Jewish and Arab populations.

The prevalence of asthma in 2,160 schoolchildren from Arab and Jewish rural and urban communities in central Israel, was determined by means of questionnaire. For the purposes of the study, asthmatic children were defined as those suffering from two or more asthmatic episodes which had been diagnosed by their physicians and had necessitated anti-asthmatic therapy. Doubtful cases were classified after personal interviewing and physical examination. The overall prevalence of asthma was 6.38%. In the Arab rural sample, it was 2.86%, significantly lower than the other groups studied: Arab urban 6.63% (P < 0.001), Jewish urban 9.2% and Jewish rural 8.66% (P < 0.001). The relatively low prevalence in the Arab rural sample is in accordance with the rarity of asthma reported from less advanced societies in other countries. The reasoning for the low asthmatic morbidity found in this group is not clear.

Familial hyperinsulinism: successful conservative management.

A large family in whom 4 of 13 children were affected with hyperinsulinism of variable severity is described. The oldest affected child required subtotal pancreatectomy to control the hypoglycemia, but the three younger children were managed successfully with prolonged conservative therapy with maintenance oral doses of diazoxide. The three affected school-age children in the family have deficits in the areas of visuomotor integration and short-term memory. The three youngest children have normal intelligence compared with four unaffected siblings; only the oldest child, who has undergone pancreatectomy, has low-average intelligence (IQ80). We conclude that in infants with persistent but asymptomatic hyperinsulinemic hypoglycemia every effort should be made to treat conservatively with antihypoglycemic agents such as diazoxide for as long as possible to allow for spontaneous remission and thereby avoid pancreatectomy.