Rapid painless diagnosis of viral respiratory infection.

The concordance of nasal compared with nasopharyngeal swabs was assessed for the diagnosis of respiratory viral infections, and the degree of discomfort associated with each procedure was compared. The use of nasal swabs was shown to be as accurate but significantly less painful than nasopharyngeal swabs for virus diagnosis.

Hospitalization of children with acute immune thrombocytopenic purpura - is it necessary?

OBJECTIVE: To identify a target group of children with acute immune thrombocytopenic purpura (ITP) that may not require hospitalization for management. METHODS: A retrospective chart review was conducted of all children admitted over a two-year period to a tertiary care paediatric hospital with the diagnosis of acute ITP. Patients were classified according to typical and atypical presentations. Typical patients were defined as those aged between one and 10 years, with no hepatomegaly or significant splenomegaly and who had typical laboratory features for ITP. Patients who did not meet these criteria were categorized as atypical. Outcome measures included length of stay (LOS) in hospital; frequency of bone marrow aspiration (BMA); type of treatment; incidence of intracranial hemorrhage (ICH) or severe bleeding; and admission and discharge platelet counts. RESULTS: There were 74 patients hospitalized for a mean of 3.6 days. No patients suffered an ICH or bleeding requiring transfusion. Patients with typical presentations (42) were compared with patients with atypical presentations (32) and were not significantly different for clinically important outcomes such as admission and discharge platelet counts, serious complications or type of therapy. Typical patients had significantly fewer BMAs than did atypical patients - 22 of 42 (52%) versus 25 of 32 (78%) (P=0.02), and a shorter LOS - 3.1 (+/-0.9) days versus 4.2 (+/-1.8) days (P=0.01). CONCLUSIONS: Children presenting with ITP have a low incidence of bleeding complications and many of these patients can be managed as outpatients. A multicentre study is needed to properly delineate a low risk group suited for outpatient medical management.

Screening for celiac disease in children with recurrent abdominal pain.

BACKGROUND: The clinical presentation of celiac disease--a life-long gluten intolerance--may be characterized by chronic abdominal pain. The objective of this study was to determine if children with recurrent abdominal pain had a higher prevalence of antiendomysial antibodies (a serologic marker of celiac disease) compared with healthy children. METHODS: Children with recurrent abdominal pain and healthy control participants were recruited from the offices of community pediatricians. Serum samples were drawn and antiendomysial antibodies were measured in both groups. Demographic data included age, gender, height, and weight. RESULTS: A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for antiendomysial antibody. The frequency of antiendomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants. CONCLUSIONS: This community-based case-control study found no association between recurrent abdominal pain and the prevalence of antiendomysial antibody. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.

Canadian Acute Respiratory Illness and Flu Scale (CARIFS): development of a valid measure for childhood respiratory infections.

Although acute respiratory infection (ARI) is the most frequent clinical syndrome in childhood, there is no validated measure of its severity. Therefore a parental questionnaire was developed: the Canadian Acute Respiratory Illness Flu Scale (CARIFS). A process of item generation, item reduction, and scale construction resulted in a scale composed of 18 items covering three domains; symptoms (e.g., cough); function (e.g., play), and parental impact (e.g., clinginess). The validity of the scale was evaluated in a study of 220 children with ARI. Construct validity was assessed by comparing the CARIFS score with physician, nurse, and parental assessment of the child's health. Data were available from 206 children (94%). The CARIFS correlated well with measures of the construct (Spearman's correlations between 0.36 and 0.52). Responsiveness was shown, with 90% of children having a CARIFS score less than a quarter of its initial value, by the tenth day.

Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians.

AIM: To determine the diagnostic accuracy of physical examination by office based (general practice) paediatricians in the evaluation of heart murmurs. DESIGN: Each of 30 office based paediatricians blindly examined a random sample of children with murmurs (43% of which were pathological). Sensitivity and specificity were calculated and were related to paediatricians' characteristics. RESULTS: Mean (SD) sensitivity was 82 (24)% with a mean specificity of 72 (24)% in differentiating pathological from innocent murmurs, with further investigations requested for 54% of assessments. The addition of a referral strategy would have increased mean sensitivity to 87 (20)% and specificity to 98 (8)%. Diagnostic accuracy was not significantly related to the paediatricians' age, education or practice characteristics, but was related to referral practices and confidence in assessment. CONCLUSIONS: Diagnostic accuracy of clinical assessment of heart murmurs by office based paediatricians is suboptimal, and educational strategies are needed to improve accuracy and reduce unnecessary referrals and misdiagnosis.

Influenza vaccination of high-risk children: a survey of three physician groups.

OBJECTIVE: To determine the variability in physician knowledge, attitudes, and behaviours in relation to influenza vaccination of children. METHOD: A 17-item cross-sectional questionnaire, with follow-up mailings to non-responders, was mailed to a random sample of 100 family physicians and 100 community pediatricians within Metropolitan Toronto and all 130 subspecialists at The Hospital for Sick Children, Toronto. RESULTS: Of 315 eligible physicians, 243 (77%) responded. Of the three groups, community pediatricians were more likely than either family physicians or subspecialists, to recommend vaccination for all but one of the high-risk conditions. Pediatricians (54%) were also the most likely to use active strategies to contact families of high-risk children compared with family physicians and subspecialists (both 23%). Only 44% of all physicians were themselves vaccinated against influenza. CONCLUSIONS: Influenza vaccination is recommended by most physicians; however, the responsibility for vaccination appears to fall to those in the community. Physician education plus further research and a review of provincial strategies for improving vaccination are needed.

Evaluation of short-course therapy with cefixime or rifampin for eradication of pharyngeally carried group A streptococci. The Ontario GAS Study Group.

Therapy to eradicate pharyngeally carried group A streptococci (GAS) has increasingly been used in the management of institutional outbreaks and is now recommended for household contacts of patients with streptococcal toxic shock syndrome. In this randomized, controlled trial, contacts of patients with GAS infections were screened for pharyngeal GAS colonization. Those whose cultures were positive were randomized to receive either cefixime (8 mg/[kg.d]; maximum 400 mg) or rifampin (20 mg/kg; maximum, 600 mg) once a day for 4 days. Two to five days following completion of therapy, repeated cultures were negative for 13 (38%) of 34 rifampin recipients and 71 (77%; 95% CI, 69%-85%) of 97 cefixime recipients. At 10-14 days after treatment, only 53% of cefixime recipients remained culture-negative. Rates of successful clearance improved with increasing age (P < .01); among 17 adults who received cefixime, the success rate was 94%. Four days of therapy with rifampin is not effective for eradication of pharyngeally carried GAS. Four days of therapy with cefixime may be effective for adults, but further studies are needed.

Effect of neonatal circumcision on pain responses during vaccination in boys.

Using data from one of our randomised trials, we investigated post-hoc whether male neonatal circumcision is associated with a greater pain response to routine vaccination at 4 or 6 months. Pain response during routine vaccination with diphtheria-pertussis-tetanus (DPT) alone or DPT followed by Haemophilus influenzae type b conjugate (HIB) was scored blind. 42 boys received DPT and 18 also received HIB. After DPT, median visual analogue scores by an observer were higher in the circumcised group (40 vs 26 mm, p = 0.03). After HIB, circumcised infants had higher behavioural pain scores (8 vs 6, p = 0.01) and cried longer (53 vs 19 s, p = 0.02). Thus neonatal circumcision may affect pain response several months after the event.

Use of lidocaine-prilocaine cream for vaccination pain in infants.

PURPOSE: To determine whether use of lidocaine-prilocaine 5% cream (EMLA) decreases pain associated with diphtheria-pertussis-tetanus (DPT) vaccination in infants. METHODS: Randomize, double-blind, controlled trial in outpatient pediatric practice, Toronto, Ontario, Canada. Before vaccination, parents applied 2.5 gm of EMLA or placebo to the infant's leg and covered it with an occlusive dressing for at least 60 minutes. The infant received a 0.5 ml intramuscular injection of DPT at 2 degree to 8 degree C with a 1.6 cm 25-gauge needle; the infant was videotaped. The Modified Behavioral Pain Scale (MBPS) was used to assess baseline and postvaccination pain scores. Latency and duration of infant cry were also measured. RESULTS: A total of 49 evaluable infants received EMLA, and 47 infants received placebo. There were no significant differences in demographic data; mean age was 5 months; and 50% of the subjects were male. The median difference in pre-vaccination and postvaccination MBPS scores was lower for EMLA than for placebo (p = 0.001). The latency to the first cry was longer for subjects who were treated with EMLA (p = 0.0004)), but the total crying time was shorter (10.3 seconds vs 25.2 seconds; p = 0.027). Of the study group, 90% (45/50) of subjects treated with EMLA and 12% (6/49) of subjects treated with placebo had local skin reactions (p < 0.0001), mainly skin blanching. CONCLUSIONS: Pretreatment with EMLA decreases infant pain from DPT vaccinations. Application of these data is limited to healthy infants receiving DPT vaccinations.

Physicians' attitudes toward the diagnosis and management of fever in children 3 months to 2 years of age.

Ninety-seven primary-care physicians, including 73 family physicians and 24 pediatricians, were surveyed in order to ascertain their knowledge and attitudes regarding fever in children 3 months to 2 years of age. A rectal temperature between 37.0 degrees C and 37.9 degrees C was considered to indicate fever by 35% of physicians. Only 17% believed there was no danger from fever, while 12% believed that fever could cause brain damage. Seizures were considered a principal danger of fever by 49% of physicians, and 22% believed that brain damage could result from typical febrile seizures. While 70% chose relief of discomfort as the main purpose of antipyretic treatment, 30% would use temperature alone as an indication for antipyretics. It is concluded that although many physicians have an acceptable attitude toward the diagnosis and management of fever, a significant number still have exaggerated concerns.

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.

Evaluation of Fever in a child aged three months to 24 months.

Fever in the young infant may be especially challenging to the attending physician, particularly when no focus for the infection can be found on physical examination. Can the physician's clinical judgement be trusted? What constitutes a fever? How was the temperature measured? Can the fever harm the child? Does the child have a benign viremia or does the fever indicate a more serious underlying bacterial illness? Does a blood culture, a spinal tap, or a complete blood count need to be done? Should antibiotics or just antipyretics be prescribed? Should antipyretics be used in all febrile children; if so, in what dose? These questions have been considered at one time or another by all physicians taking care of children. Only with a comprehensive, scientific, and practical approach can the febrile infant be optimally managed.

Adverse reactions to diphtheria, tetanus, pertussis-polio vaccination at 18 months of age: effect of injection site and needle length.

Adverse reactions after diphtheria, pertussis, tetanus, polio vaccination at 18 months of age were investigated in three groups: 74 children injected in the deltoid muscle with a 16-mm (5/8-in) needle, 64 in the anterolateral thigh with a 16-mm needle, and 67 in the anterolateral thigh with a 25-mm (1-in) needle. No significant differences in systemic reactions were observed. Severe pain occurred in 30.5% of the groups injected in the thigh compared with only 8.1% of the group injected in the arm (P less than .001). Children vaccinated in the thigh had decreased movement of the extremity significantly more often than those injected in the arm (49.9% v 25.6%, P less than .0005), and two thirds of the former limped for 24 to 48 hours. Redness and swelling were observed more often after injection in the arm than in the thigh (58.1% v 26.7%, P less than .0005). The only effect of changing needle length in the groups injected in the thigh was the occurrence of more redness and swelling in children vaccinated with the 16-mm needle compared with the 25-mm needle. Overall, parents rated more reactions as moderate to severe among children injected in the thigh than among children injected in the arm (64.2% v 37.9%, P less than .001). The deltoid muscle appears to be the preferred site for administration of diphtheria, pertussis, tetanus, polio vaccine at 18 months of age.