Multidisciplinary education and management program for children with asthma.

A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.

Unilateral leptospiral pneumonia and cold agglutinin disease.

Pneumonia that is unresponsive to appropriate antibiotic therapy suggests an infection due to more unusual or resistant organisms. In this report, a child with unilateral pneumonia, pleural effusion, and anti-I cold hemagglutinin antibodies is presented. The usual causes of this clinical picture were suspected and treated, but the child did not improve. Features of her history suggested a more unusual etiology, and a diagnosis of leptospirosis was made. A brief discussion of leptospiral disease in children is provided.

Primary tracheomalacia and gastroesophageal reflux in infants with cough.

Cough is an uncommon sign in infants. Cough may result from the presence of abnormal secretions in the airway or abnormalities of the central airways that affect the infant's ability to clear normal secretions. Tracheomalacia (TM) and gastroesophageal reflux (GER) can both cause cough in infants. Four infants whose cough began in the newborn period were diagnosed with TM and GER. Symptoms of central airway obstruction (homophonous wheeze or tracheal cough) suggested the diagnoses. In three patients, the diagnosis was made by barium esophagraphy and airway fluoroscopy. The infants responded to conservative and medical therapy for GER and to nebulized bronchodilators. Tracheomalacia and GER cause cough in infants that begins in the newborn period. The diagnosis can often be made with studies available to the primary care provider, and the conditions are often responsive to medical management.

The diagnosis of gastroesophageal reflux in hospitalized infants: 1971-1995.

Gastroesophageal reflux (GER) is being increasingly diagnosed and implicated for a range of pediatric problems. This study examines the diagnostic rate for GER in US Army hospitals between 1971 and 1995. During this 25-year period, 2059 diagnoses of GER were identified, for a 20-fold increase. Both the rate and total number of cases rose significantly in medical centers and community hospitals alike. The increase in GER diagnoses does not necessarily imply an increase in prevalence. It may be the result of an increased awareness of the problem or over diagnosis. However, it may also reflect an increased prevalence of pathologic GER, which is potentially the result of changes in the practice of infant care.

Increased gastroesophageal reflux in infants: can history provide an explanation?

Gastroesophageal reflux (GER), a problem rarely mentioned half a century ago, has now become a major source of blame for a number of pediatric maladies. Over the past few decades, the rate of GER diagnosis in hospitalized infants less than 1 y old rose more than 10-fold. An increased rate of diagnosis does not mean that GER disease is more common. The increase in diagnosis may be the result of overdiagnosis, inappropriate diagnosis or an increased ability to detect GER. However, it is also possible that increased GER diagnosis may reflect a real increase in the prevalence of pathological GER and GER disease. Three aspects of infant rearing have changed dramatically during the past 50 y: what infants are fed, how much they are fed and where they are placed between feedings. This essay examines these aspects of infant rearing and their possible relationship with increased GER.

Use of seating devices in infants too young to sit.

OBJECTIVES: To determine how frequently seating devices are available in homes with small infants and how often they are used for infants who are too young to sit erect and unsupported. DESIGN: Observational study using a questionnaire administered to a cohort of parents of well infants younger than 5 months. SETTING: Well-Baby Clinic, Department of Pediatrics, Tripler Army Medical Center, a tertiary care center serving the population of military dependents on the island of Oahu, Hawaii. RESULTS: Infant seating devices were available in the homes of all of the infants whose parents completed the questionnaire during the study. Of 187 infants, 176 (94%) spent 30 minutes or longer in seating devices each day. The mean (tSD) time spent each day in seating devices was 5.7 +/- 3.5 hours and ranged from 0 to 16 hours. CONCLUSIONS: Seating devices were widely available for use in the care of the infants. Car seats that double as infant carriers and infant seats likely are being used extensively outside of automobiles. Prolonged use of infant seating devices with infants who are too young to sit unsupported may have several potential adverse consequences.

Etiology of chronic cough in a population of children referred to a pediatric pulmonologist.

BACKGROUND: Chronic cough is a common complaint encountered by physicians who care for children. It is also a common reason for referral to a pulmonologist. Determining the cause of chronic cough, however, rarely requires specialized diagnostic procedures that are unavailable to the primary care physician. METHODS: A computerized listing of new patients referred to a pediatric pulmonologist between July 1993 and June 1995 was reviewed. Of 299 patients examined as outpatients during this period, 95 were referred for chronic cough. The diagnosis and diagnostic procedures were examined to determine how frequently procedures available exclusively to subspecialists were necessary to determine the cause of chronic cough. RESULTS: Of the 95 patients who were examined for cough during the period studied, the diagnosis was made by history in 5, pulmonary function testing in 11, radiographic tests in 15, and a therapeutic trial in 58. In only 6 cases was the diagnosis made using tests unavailable to the primary care physician (5 bronchoscopy, 1 allergy skin testing). CONCLUSIONS: In 89 cases the cause of chronic cough was determined by procedures available to the referring physician. In most cases chronic cough in children can be diagnosed and managed by physicians who are aware of the spectrum of common disorders that lead to cough.