Factors Associated with Unscheduled Emergency Department Revisits in Children with Acute Lower Respiratory Tract Diseases.

Purpose: To identify factors associated with unscheduled emergency department (ED) revisits within 72 hours in children with acute dyspnea from lower respiratory tract diseases. Patients and Methods: This retrospective cohort study included pediatric patients (age group: one month to 15 years old) who visited the ED with acute lower respiratory tract diseases between January 1st, 2017 and February 28th, 2019. The medical records were reviewed and discharged patients were dichotomized into revisit and non-revisit groups, based on whether the patients needed a revisit or not. Baseline characteristics, vital signs, diagnosis, treatment, pediatrician consultation, ED length of stay, and primary doctor of both groups were compared. Univariate and multivariate analyses by logistic regression were used to determine the significant factors associated with the revisits. Results: Medical records of 918 eligible pediatric patients (1417 visits) were reviewed. Factors significantly associated with the revisits were history of asthma or current controller use (odds ratio [OR]: 3.08: 95% confidence interval [CI]: 1.86-5.1). Not prescribing systemic corticosteroids (P < 0.001), or prescribing them upon discharge without first dose in the ED (P = 0.022) were significantly associated with revisits. Conclusion: No prescription of systemic corticosteroids or prescription upon discharge, without an immediate dose at the ED, in children with history of asthma or current controller use were associated with revisits.

Utilization of Point-of-Care Ultrasound to Detect Splenic Microabscesses in Pediatric Melioidosis.

Melioidosis is an infectious disease most commonly found in places with tropical climates. Definitive diagnosis can be confirmed by culture or pathological results of blood or infected organ. However, imaging study is helpful in providing early provisional diagnosis and guiding therapy. Point-of-care ultrasound can be currently performed bedside by non-radiological staff such as emergency physicians or intensivists. We present the case of a pediatric patient who got diagnosed with melioidosis after detection of multiple splenic and hepatic abscesses by point-of-care ultrasound, leading to early diagnosis and appropriate empirical antibiotic selection, resulting in good treatment outcome.

Evaluation of Digital Face Recognition Technology for Pain Assessment in Young Children.

OBJECTIVES: Accurate assessment of pain in young children is challenging. An Emotion Application Programing Interface (API) can analyze and report 8 emotions from facial images. Each emotion ranges between 0 (no correlation) to 1 (greatest correlation). We evaluated correlation between the Emotion API with the FLACC scale (face, lets, activity, cry, and consolability) among children younger than 6 years old during blood sampling. METHODS: Prospective pilot exploratory study in children during blood sampling. Pictures with facial expressions were uploaded to Emotion API program. Primary outcome was the correlation coefficient between FLACC scale and emotions. Secondary outcomes included maximal correlation of each emotion for 3 pictures-before, during and after needle penetration; and the average of each emotion for 9 pictures-4 before, 1 during and 4 after needle penetration to the skin. RESULTS: A total of 77 children were included. During needle penetration, SADNESS was significantly correlated (0.887, P<0.05), and NEUTRAL was negative correlated with the FLACC scale (-0.841; P<0.05). The maximal correlation of each emotion showed increase in SADNESS and decrease in NEUTRAL emotions during, compared to before, needle penetration. Similar findings were observed when the average of each emotion was compared during to before needle penetration. DISCUSSION: During a blood test procedure, young children show higher SADNESS and lower NEUTRAL emotions as reported by the Emotion API. This software program may be useful in reporting emotions related to pain in young children, and more research is needed to compare its validity, reliability and real-time application compared to the FLACC scale.

Zinc supplementation for pediatric pneumonia.

Question Among young children suffering from pneumonia, zinc deficiency has been documented in many countries. Is supplementation with zinc effective in the treatment and prevention of childhood pneumonia? Answer Several studies reported that zinc supplementation for more than 3 months was effective for preventing pneumonia in children younger than 5 years of age; however, the evidence is not sufficient to confirm its prophylactic properties if it is given for shorter periods of time. Adjunctive zinc supplementation for treatment of pneumonia has failed to show a benefit.

Antibiotic therapy for children with acute otitis media.

Question Acute otitis media is one of the most common infections in childhood. Routine prescription of antibiotics has led to adverse events and bacterial resistance to antibiotics. I have heard that "watchful waiting" is a good strategy to reduce this potential problem in children older than 6 months of age. Should I apply this strategy in my clinical practice? Answer Watchful waiting can be applied in selected children with nonsevere acute otitis media by withholding antibiotics and observing the child for clinical improvement. Antibiotics should be promptly provided if the child's infection worsens or fails to improve within 24 to 48 hours. Guidelines and most ongoing studies support these recommendations. Correct choice of regimen, dose, frequency, and length of treatment are all important.

L'antibiothérapie pour une otite moyenne aiguë chez l'enfant.

Question L'otite moyenne aiguë compte parmi les infections les plus communes durant l'enfance. La prescription systématique d'antibiotiques a entraîné des effets indésirables et une résistance bactérienne aux antibiotiques. J'ai entendu dire qu'une « attente vigilante ¼ est une bonne stratégie pour réduire ce problème potentiel chez les enfants de plus de 6 mois. Me faudrait-il l'adopter dans ma pratique clinique? Réponse Une attente vigilante est une stratégie appropriée chez certains enfants souffrant d'une otite moyenne aiguë bénigne; elle consiste à s'abstenir de donner des antibiotiques et à observer l'enfant pour savoir s'il y a une amélioration clinique. Il faut fournir sans délai des antibiotiques si l'infection de l'enfant s'aggrave ou s'il ne se produit pas d'amélioration dans les 24 à 48 heures. Les lignes directrices et la plupart des études en cours corroborent ces recommandations. Il importe de choisir de façon appropriée le schéma thérapeutique, la dose, la fréquence et la durée du traitement.

Acetylsalicylic acid for children with Kawasaki disease.

Question A 7-year-old child in my office was recently discharged from the hospital after receiving intravenous immunoglobulin for Kawasaki disease. Should I continue treatment with acetylsalicylic acid (ASA), and if so, what is the appropriate dose? Answer The role of ASA for Kawasaki disease during the acute febrile phase has recently been called into question. According to several studies, ASA might reduce the duration of fever but it does not appear to directly reduce the incidence of coronary artery complications. However, with no high-quality randomized controlled trials, the evidence is scarce and more studies with good methodology are needed to determine the value of ASA in the treatment of Kawasaki disease. Currently, guidelines recommending the use of ASA should be followed.

L'acide acétylsalicylique pour les enfants atteints de la maladie de Kawasaki.

Question Un enfant de 7 ans qui fréquente ma clinique a récemment reçu son congé de l'hôpital après une administration d'immunoglobuline par voie intraveineuse pour la maladie de Kawasaki. Faut-il poursuivre son traitement à l'acide acétylsalicylique (AAS) et, dans l'affirmative, quelle est la dose appropriée? Réponse Le rôle de l'AAS pour la maladie de Kawasaki durant la phase fébrile aiguë a récemment été remis en question. Selon diverses études, l'AAS pourrait réduire la durée de la fièvre, mais il ne semble pas réduire directement l'incidence de complications aux artères coronaires. Par ailleurs, en l'absence d'études randomisées contrôlées, les données probantes sont limitées et il faudrait de plus nombreuses études utilisant une bonne méthodologie pour déterminer l'utilité de l'AAS dans le traitement de la maladie de Kawasaki. À l'heure actuelle, il y a lieu de suivre les lignes directrices qui recommandent le recours à l'AAS.

Topiramate for pediatric migraine prevention.

Question I have several teenagers in my clinic with migraine headache and some of them have frequent episodes that cause considerable interference with daily activity. I would like to offer them prophylactic therapy to reduce the frequency of their migraine episodes. Is topiramate an effective and safe option for adolescents? Answer Both Health Canada and the US Food and Drug Administration have approved the use of topiramate for migraine prevention in adults; however, only the US Food and Drug Administration has approved topiramate for migraine prophylaxis in adolescents 12 to 17 years of age. Although several studies support its effectiveness in preventing migraine, most of these studies are small; and a recent large multicentre, randomized placebo-controlled trial was stopped early when no benefit was shown over placebo. Adverse effects of topiramate are mild and typically resolve over time. The recommended dosage is 2 mg/kg per day, up to an adult dose of 100 mg/d.

Hyperbaric oxygen therapy for children with autism spectrum disorder.

Question As autism spectrum disorder (ASD) is a multifactorial condition, with genetic and environmental risk factors contributing to children's unique presentation and symptom severity, a range of treatments have been suggested. Parents of children with ASD in my clinic are asking me about alternative therapies to improve their children's condition. One of those therapies is hyperbaric oxygen therapy (HBOT); commercial advertisement in the past has suggested good results with this approach. Should I recommend the use of HBOT for children with ASD? Answer Hyperbaric oxygen therapy provides a higher concentration of oxygen delivered in a chamber or tube containing higher than sea level atmospheric pressure. Case series and randomized controlled trials show no evidence to support the benefit of HBOT for children with ASD. Only 1 randomized controlled trial reported effectiveness of this treatment, and those results have yet to be repeated.

Corticosteroids for renal scar prevention in children with acute pyelonephritis.

Question Acute pyelonephritis in children is of great concern and I usually refer these patients to a pediatrician or send them to the emergency department owing to the risk of renal scarring. Are steroids an acceptable treatment to reduce risk of scarring? Answer Several agents have been studied in an effort to prevent renal scar formation following acute pyelonephritis in children. Use of corticosteroids, in conjunction with standard therapy for acute pyelonephritis, shows promising findings. However, evidence is very limited and steroids should not be offered on a regular basis as part of treatment.

Acetaminophen use and asthma in children.

Question A child with a history of asthma came to my clinic with acute fever. I have heard that acetaminophen might be associated with exacerbation of asthma. Is it safe if I recommend acetaminophen for this child? Answer Most studies suggest an association between acetaminophen use in children and development of asthma later in childhood. However, several confounding factors in study design might contribute to this positive correlation, and without a prospective controlled trial, confirming this finding is challenging. If children have a known history of asthma, it is likely safe to administer a single dose of acetaminophen without concern of precipitating adverse respiratory symptoms. Regular use of acetaminophen to relieve fever or pain does not seem to exacerbate asthma in children more than ibuprofen does.

L'acétaminophène et l'asthme chez l'enfant.

Question Un enfant ayant des antécédents d'asthme se présente à ma clinique avec une fièvre aiguë. J'ai entendu dire que l'acétaminophène pouvait être associé à des exacerbations de l'asthme. Est-il sécuritaire de recommander de l'acétaminophène pour cet enfant? Réponse La plupart des études laissent entendre une association entre le recours à l'acétaminophène et le développement de l'asthme plus tard durant l'enfance. Toutefois, divers facteurs de confusion dans la conception des études pourraient avoir contribué à cette corrélation positive et, en l'absence d'une étude prospective contrôlée, il est difficile de confirmer cette constatation. Si l'enfant a des antécédents d'asthme connus, il est probablement sécuritaire d'administrer une unique dose d'acétaminophène sans s'inquiéter de précipiter des symptômes respiratoires indésirables. L'utilisation régulière d'acétaminophène pour soulager la fièvre ou la douleur ne semble pas exacerber davantage l'asthme chez les enfants que l'ibuprofène.

Nebulized epinephrine for young children with bronchiolitis.

QUESTION: Every winter I see infants with flulike symptoms and wheezing. I frequently diagnose them with bronchiolitis based on their presenting symptoms. Would it be prudent to send those infants to the nearest emergency department for treatment with nebulized epinephrine? ANSWER: Nebulized epinephrine should not be routinely used in infants with bronchiolitis. It is an option to consider in those with severe symptoms. If it is given and there are no signs of improvement, further doses are discouraged. Ongoing studies of epinephrine combined with other agents (eg, hypertonic saline, oral dexamethasone) are needed to confirm their benefit.