Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition.

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Use of alternative and complementary therapies for pediatric asthma.

This survey of 48 multicultural parents of children with asthma identifies and compares alternative and complementary treatments used for asthma, and compares any potentially effective or harmful effects. Thirty-nine (81%) of the parents used at least one form of alternative or complementary therapy to treat their child's asthma. Nontraditional therapies included prayer, over-the-counter medications, herbal teas, vitamins, and massage. African-American parents were more likely to rely on prayer, and Hispanic parents were more likely to use herbal and massage therapies. Use of over-the-counter medications and vitamins was similar among groups. Three herbal remedies were potentially toxic: lobelia, possible pennyroyal mint, and tree tea oil. Medical histories for all patients should include inquiries into the use of alternative therapies.

A guide to the pediatric patient with "difficult" asthma.

Patients whose asthma symptoms are poorly controlled with the therapies usually recommended for this disease are considered to have "difficult" asthma. Although such patients represent a small proportion of patients with asthma, children who have difficult asthma are at increased risk for morbidity and mortality. Once the diagnosis of asthma is established, caregivers must appropriately categorize and treat the asthma according to the patient's level of symptom severity. The purpose of this article is to present an approach to the management of patients with difficult asthma by (a) searching for alternative diagnoses or conditions that are often associated with asthma, (b) investigating environmental issues, (c) reviewing inhalation techniques, and (d) determining the patient's level of compliance with the prescribed treatment plan and simplifying it whenever possible.

Verapamil therapy for persistent antral spasms in a child.

Little is known about the use of calcium channel blockers in children with gastric motility disorders. We report the case of an 11-year-old child who was hospitalized after 3 weeks of persistent vomiting, abdominal pain, and a 12-lb weight loss. When his symptoms failed to improve with traditional treatment, verapamil therapy was begun. Within 24 hours, his symptoms totally resolved.

Evaluation of a lead screening program in Houston, Tex.

Universal screening for childhood lead poisoning is widely debated. Our purpose was to compare screening results at three pediatric clinics within Houston and to evaluate the effectiveness of screening according to published criteria. The clinics were chosen for their geographic and socioeconomic diversity. Children between 6 months and 6 years of age were tested, and the results were classified according to current guidelines. We screened 864 children. Results between sites were significantly different, P = 0.002. No children with blood lead levels greater than 0.45 mumol/L (9 micrograms/dL) were identified at Clinic C compared to 76 (8.8%) from Clinics A and B, but no site had children with levels greater than or equal to 2.20 mumol/L (45 micrograms/dL). The prevalence of childhood lead poisoning can vary even within the city. If regional screening is to replace universal screening, statewide as well as citywide data are needed to identify high-risk areas. This could be done by clinic site, zip code, or census track data with a minimum of 3000 children.

Use of folk remedies in a Hispanic population.

OBJECTIVES: To identify the types of home remedies used for common pediatric problems in a Hispanic population and to study traditional folk illnesses and their cures. DESIGN: Survey of 51 Hispanic caregivers, mostly mothers. SETTING: A pediatric primary care facility in an urban Hispanic neighborhood in Houston, Tex. MAIN OUTCOME MEASURES: Remedies used for common pediatric illnesses and for the traditional folk illnesses: mal ojo (evil eye), empacho (blocked intestine), mollera caida (fallen fontanelle), and susto (fright). RESULTS: A combination of herbs and pharmaceuticals was used for many illnesses. Teas were most commonly used for colic, upper respiratory tract symptoms, and abdominal pain. Pharmaceuticals were most commonly used for upper respiratory tract symptoms, fever, and diarrhea. Belief in folk illnesses was common: 36 (70%) had experience with mal ojo, 33 (64%) with empacho, 27 (52%) with mollera caida, and 19 (37%) with susto; 10 (20%) had taken their children to curanderos (traditional healers) for treatment of folk illnesses. CONCLUSIONS: Cultural health beliefs were widely maintained in this Hispanic population. Many patients integrated cultural health practices with reliance on medical practitioners. Knowledge and acknowledgement of these practices are important for physician-patient communication and may affect compliance with other medical procedures and treatments.

Diagnostic tests for occult bacteremia: temperature response to acetaminophen versus WBC count.

A cohort of 484 febrile children were examined to (1) assess the utility of temperature response to acetaminophen as a diagnostic test for occult bacteremia (OB) and (2) compare it with the white blood cell (WBC) count. For a period of 18 months, the records of all febrile children seen in the emergency department were reviewed. Testing a response to acetaminophen of a < or = 0.8 degrees C decrease in temperature, the sensitivity, specificity, and positive and negative predictive values were 47%, 74%, 12%, and 95%, respectively. When compared with a WBC count > or = 15,000/microL, the corresponding values were 76%, 65%, 15%, and 97%. Receiveroperator characteristic curves were constructed to compare temperature responses with WBC values. The difference was not significant (P > 0.05). The conclusion reached was that temperature response to acetaminophen has predictive values that are similar to the WBC count, and it may provide useful information. However, neither test is impressive, and the clinician cannot reliably predict which febrile children are at risk.

Weight-training injuries. Common injuries and preventative methods.

The use of weights is an increasingly popular conditioning technique, competitive sport and recreational activity among children, adolescents and young adults. Weight-training can cause significant musculoskeletal injuries such as fractures, dislocations, spondylolysis, spondylolisthesis, intervertebral disk herniation, and meniscal injuries of the knee. Although injuries can occur during the use of weight machines, most apparently happen during the aggressive use of free weights. Prepubescent and older athletes who are well trained and supervised appear to have low injury rates in strength training programmes. Good coaching and proper weightlifting techniques and other injury prevention methods are likely to minimise the number of musculoskeletal problems caused by weight-training.

Extreme leukocytosis in patients presenting to a pediatric emergency department.

We determined the frequency and clinical significance of white blood cell (WBC) counts greater than or equal to 25,000/microliters in children presenting to an emergency department (ED) and defined a degree of leukocytosis which might be considered extreme in this setting. Records of all patients seen in the ED between February 1985 and December 1986 with WBC counts greater than or equal to 25,000/microliters were identified. Each patient was paired with the chronologically nearest patient with a WBC count between 15,000 and 25,000/microliters. Of the total WBCs obtained, 5.8% were greater than or equal to 25,000/microliters; only 1% were greater than or equal to 35,000/microliters. Eighteen percent of patients with counts greater than or equal to 25,000/microliters had a serious disease, and 6% had bacteremia. Twenty-six percent of patients with counts greater than or equal to 35,000/microliters had a serious disease, and 10% had bacteremia. On the basis of infrequency and severity of illness, we suggest that, in children presenting to a pediatric emergency department, WBC counts greater than or equal to 35,000/microliters be considered extreme leukocytosis.

Temperature response to acetaminophen and risk of occult bacteremia: a case-control study.

A case-control study of 34 children with occult bacteremia was conducted to test the hypothesis that nonresponse to acetaminophen (decrease less than or equal to 0.8 degrees C) is a risk factor for occult bacteremia. Febrile children visiting the emergency center from May 1986 to October 1987 were monitored for occult bacteremia. Inclusion criteria were age 2 months to 6 years, temperature greater than or equal to 38.9 degrees C, and having a blood culture. Exclusion criteria were serious acute or chronic illness, sponging for fever reduction, current therapy with antibiotics or steroids, and admission to the hospital. Records of 3892 febrile children were reviewed. Of these, 2101 (54%) had a blood culture and 1028 (26%) were eligible. All patients (positive blood culture) were matched with two control subjects (negative blood culture). Patients and control subjects had similar age, gender, ethnicity, height of initial temperature, time to second temperature, and dose of acetaminophen. The estimated risk of occult bacteremia for nonresponders was 9.2 (95% confidence interval 2.7, 32.0). We conclude that children who do not respond to acetaminophen by at least a 0.8 degrees C decrease in temperature have an increased risk of occult bacteremia. However, achieving a response to acetaminophen does not eliminate the possibility that the child has occult bacteremia.