Alternating antipyretics: is this an alternative?

OBJECTIVES: To identify current fever management strategies and their basis, and to assess the frequency of alternating acetaminophen and ibuprofen. BACKGROUND: Practicing pediatricians confront the dilemma of elevated temperature and the anxiety this creates for parents. An informal survey of pediatricians revealed a variety of management strategies, including alternating acetaminophen and ibuprofen. There are no scientific data regarding alternating these 2 products. Design. During professional meetings, pediatricians voluntarily filled out a 15-item questionnaire. RESULTS: One hundred sixty-one completed surveys were reviewed. Respondents were mostly general pediatricians (67.7%), with >/=20 years in practice (55.9%). Most respondents chose a temperature of 101(o)F to start antipyretic treatment (61.9%). A small percentage used discomfort alone as the indication (13%). The antipyretic of choice was temperature-dependent in 50% of respondents; 57% used ibuprofen for temperature >/=102 degrees F. Fifty percent of respondents advised parents to alternate acetaminophen and ibuprofen. The method of alternation varied. The most common answers given for choosing a particular antipyretic regime were recommendations of the American Academy of Pediatrics (29%) and opinions of colleagues and mentors (25%). Physicians with <5 years of practice were significantly more likely to alternate antipyretics (69.7%). CONCLUSION: Acetaminophen and ibuprofen are commonly being used in an alternating manner for management of fever. There is presently no scientific evidence that this combination is safe or achieves faster antipyresis than either agent alone. There is evidence that the improper use of these agents may cause harm. Despite 29% of participants citing American Academy of Pediatrics recommendations as the basis for fever management, no such policy or recommendations exist. The observation that this practice is more common in younger practitioners may reflect their continued anxiety about fever (fever phobia). Until properly controlled studies have assessed the risk of combining these 2 products, practitioners should proceed with caution.

Premature infants in car seats: effect of sleep state on breathing.

Previous studies have shown that premature infants may be at risk for hypoxemia and bradycardia when placed in standard car seats. However, the relationship of such breathing abnormalities to sleep state have not been studied. The purpose of the present study was to investigate the effect of car seat positioning on respiratory patterns in preterm infants during sleep and to evaluate their relationship to sleep state. Complete polysomnography, including sleep and breathing parameters, was performed on twenty-eight premature infants. Each infant was randomly assigned to the car seat or prone (crib) position for the first recording period. Following the recording of at least two sleep cycles, the position was reversed. The percentage of active and quiet sleep was calculated and breathing parameters were measured. In the car seat, the infants spent significantly more time in active sleep and less time in quiet sleep than in the prone position, of the respiratory parameters, periodic breathing (PB) was significantly higher in the car seat. The presence of at least one abnormal breathing events (bradycardia, desaturation, PB apnoea) was also significantly higher in the car seat. An analysis of variance (ANOVA) of PB revealed significant sleep-state effect (active vs. quiet sleep), but no significant condition or interaction effects, indicating that PB was more frequent in active sleep regardless of the sleeping condition. It is concluded that increased active sleep in the car seat condition, rather than the positioning of the infant in the seat per se, may account for the increase in periodic breathing and possibly other breathing abnormalities reported in car seats.

Non-automotive vehicle injuries in adolescents.

After reviewing the data associated with injuries and deaths to adolescents participating in the activities described above, the question repeatedly arises: Why does our society continue to accept and promote this toll of injuries and deaths? While waiting for answers from researchers, physicians must continue an advocacy role for measures of protection known to reduce the morbidity and years of life lost among the adolescent age group.

Use of a soft catheter for acute peritoneal dialysis in infants and children.

Acute peritoneal dialysis in 49 infants and children is described comparing the use of the conventional hard Trocath catheter and the soft catheter. The mean age of the patients was 3.6 years (range 1 day--17 years). Sixteen were treated using the hard Trocath catheter and 33 were treated using a soft catheter. Overall mortality for the total patient population was 43%. Twenty-three neonates were included in the series with an overall mortality of 61%. Significantly less mortality was observed in the 26 patients older than two months of age (31%). Major complications of the dialysis procedure included viscus perforation in three neonatal patients and subcutaneous extravasation of dialysate in two older patients. These major complications occurred only with the use of the Trocath. Two episodes of peritonitis occurred in two adolescent patients and were associated with an interruption of the sterile system. Peritonitis was not specifically related to the type of catheter used. We conclude that major complications associated with the use of the hard catheter for peritoneal dialysis in neonates precludes its continued use in this population. The alternative use of a soft catheter is recommended in neonates. Elective use of a soft catheter for acute peritoneal dialysis in older patients would also seem to be indicated.

Gastrointestinal dialysis with activated charcoal and cathartic in the treatment of adolescent intoxications.

This article reports five patients who had taken a substantial medication overdose and presented in coma. Two had taken a salicylate overdose and three a phenobarbital overdose (one of these ingested a combination of phenobarbital and phenytoin). The cases were treated by our standard protocol of supportive therapy and alkaline diuresis plus repetitive oral doses of activated charcoal (gastrointestinal dialysis). All patients were alert and oriented within 24 hours. Toxicokinetic analysis of the blood levels is discussed. Gastrointestinal dialysis represents a relatively noninvasive method that may benefit certain intoxicated patients even after systemic absorption has occurred. The technique and recommendations for its use are discussed and described in detail.

Injuries at play.

The problem of toy-related injuries is a complicated one. The authors detail specific hazards related to toys, playgrounds, skateboards, and baby walkers. Guidelines are provided for toy suitability for children of all ages.

Management of the choking child.

There is controversy regarding the best maneuver to expel a completely obstructing foreign body from the upper airway of a patient. Further study and research are needed. However, we recommend that no change in the present recommendations be made until these studies are accomplished. We have attempted to outline the major aspects of the controversy and give the rationale for the present recommendations.

Prevention of childhood injuries.

Accidents account for more deaths among children aged 1 to 14 years than the next five most common causes. Thinking about accidents as injuries that happen in a context comprising a host, an agent, and an environment may help prevent them. Until a profile of the family and child at risk of injuries is developed, causal factors must be identified and removed, and parents and children educated about injury prevention. Different problems occur at different stages of a child's development. The agents most commonly associated with injuries are automobiles, bicycles, swimming, and animals. The special vulnerability of infants was addressed by the American Academy of Pediatrics' "First Ride/A Safe Ride" program, which encouraged the use of safety seats. Design changes have reduced the number of bicycle injuries, but human factors continue to contribute significantly. Most drownings occur in fresh water, with many children within a few feet of safety; continuing education is essential. Inculcating respect for animals, learning safety rules for interaction, and advice on pet ownership help to reduce animal bite injuries.

Ingestions considered nontoxic.

The authors have compiled a list of common household products and drugs that are frequently ingested by children and may be considered nontoxic unless taken deliberately or in large amounts. An understanding of the nontoxic ingestion should prevent overtreatment and decrease emergency room visits.

PIP: In 1980, the National Clearinghouse for Poison Control Centers (NCPCC) received 126,000 reports from Poison Control Centers, but the true incidence of ingestions was actually much higher. Only 1 in 50 ingestions may be reported, indicating that the majority of ingestions are innocuous. 70% of reported episodes occurred in children under 5 years of age. Nontoxic ingestions occur when a victim consumes a nonedible product that usually does not produce symptoms. No product is entirely safe and all can produce symptoms if a large enough concentration is consumed. Knowledge of nontoxic ingestions helps avoid overtreatment and its risks and serves as a warning of inadequate supervision or an improper and unsafe environment. The designation of nontoxic ingestion has 6 criteria: 1) absolute identification of the product 2) absolute assurance that only 1 product was ingested 3) no signal word (danger, poison, warning, caution) on the container 4) a good approximation of the amount ingested 5) assurance that the victim is free of symptoms and 6) the ability to call back at intervals to determine that no symptoms have developed. A good rule of thumb for the average drug that 5 times the therapeutic dose may be a toxic dose; opiate narcotics are the exception and require medical observation because of their narrow margin of safety. There are several points to consider in deciding wheter to decontaminate the gastrointestinal tract, including the toxicity of the ingested agent, the amount ingested, the elapsed time since ingestion, and the presence of symptoms. Emergency room referral is mandatory in case of exposure to highly toxic agents, of a dose sufficient to lead to anticipation of servere symptoms, of manifestations of toxic exposure such as alterations in vital signs already present, or of a history of intentional ingestion. A detailed discussion of frequently ingested nontoxic household items and related items that may be toxic includes writing and art materials, toiletries and laundry agents, deordorizers and disinfectants, tobacco and matches, medicinals, pesticides and insecticides, miscellaneous substances, petroleum distillate hydrocarbons, and plants. Hormonal contraceptives have been reported to produce almost no toxicity. A 1962-65 report from the NCPCC of 962 ingestions listed only 40 producing nausea nd vomiting even after consumption of 21 pills. An iron additive could make the ingestion toxic for iron.

Ingestions considered nontoxic.

We have compiled a list of common household products and drugs that are frequently ingested by children and may be considered nontoxic unless taken deliberately or in large amounts. An understanding of the nontoxic ingestion should prevent overtreatment, decrease emergency room visits, and allow physicians and poison control centers the opportunity to practice poison prevention. The reporting of all ingestions is encouraged to obtain information on the human experiment that occurs when a non-edible material is ingested. Only as we accumulate this knowledge will we be able to advise with a degree of certainty what treatment is needed.