Probiotics for infantile colic: a randomized, double-blind, placebo-controlled trial investigating Lactobacillus reuteri DSM 17938.

OBJECTIVE: To investigate the effectiveness of Lactobacillus reuteri DSM 17938 for the treatment of infantile colic in breastfed Canadian infants, compared with placebo. STUDY DESIGN: A randomized, double-blind, placebo-controlled trial was conducted involving 52 infants with colic, according to modified Wessel criteria, who were assigned at random to receive L reuteri DSM 17938 (10(8) colony-forming units) (n = 24) or placebo (n = 28) for 21 days. Daily crying and fussing times were recorded in a structured diary, and maternal questionnaires were completed to monitor changes in infant colic symptoms and adverse events. RESULTS: Total average crying and fussing times throughout the study (from baseline to day 21) were significantly shorter among infants with colic in the probiotic group compared with infants in the placebo group (1719 ± 750 minutes [29 ± 13 hours] vs 2195 ± 764 minutes [37 ± 13 hours]; P = .028) (relative risk, 0.78; 95% CI, 0.58-0.98). Infants given L reuteri DSM 17938 showed a significant reduction in daily crying and fussing times at the end of treatment period compared with those receiving placebo (median, 60 minutes/day [IQR, 64 minutes/day] vs 102 minutes/day [IQR, 87 minutes/day]; P = .045). On day 21, a significantly higher proportion of infants in the L reuteri DSM 17938 group responded to treatment with a ≥50% crying time reduction compared with infants given placebo (17 vs 6, P = .035; relative risk, 3.3; 95% CI, 1.55-7.03). CONCLUSION: Administration of L reuteri DSM 17938 significantly improved colic symptoms by reducing crying and fussing times in breastfed Canadian infants with colic.

Office-based randomized controlled trial to reduce screen time in preschool children.

OBJECTIVE: To determine if an intervention for preschool-aged children in primary care is effective in reducing screen time, meals in front of the television, and BMI. METHODS: A randomized controlled trial was conducted at a primary care pediatric group practice in Toronto, Canada. Three-year-old children and their parents were randomly assigned to receive a short behavioral counseling intervention on strategies to decrease screen time. The primary outcome 1 year later was parent reported screen time. Secondary outcomes included television in the child's bedroom, number of meals in front of the television, and BMI. RESULTS: In the intention-to-treat analysis at 1 year, there were no significant differences in mean total weekday minutes of screen time (60, interquartile range [IQR]: 35-120 vs 65, IQR: 35-120; P = .68) or mean total weekend day minutes of screen time (80, IQR: 45-130 vs 90, IQR: 60-120; P = .33) between the intervention and control group. Adjusting for baseline BMI, there was a reduction in the number of weekday meals in front of the television (1.6 ± 1.0 vs 1.9 ± 1.2; P = .03) but no differences in BMI or number of televisions in the bedroom. CONCLUSIONS: This pragmatic trial was not effective in reducing screen time or BMI but was effective in reducing meals in front of the screen. Short interventions focused solely on reducing screen time implemented in the primary care practice setting may not be effective in this age group.

Parental factors associated with screen time in pre-school children in primary-care practice: a TARGet Kids! study.

OBJECTIVE: To identify child and parental factors associated with screen time in 3-year-old children. DESIGN: Observational study. SETTING: Participants were recruited from a large primary-care paediatric group practice in Toronto, Canada. SUBJECTS: Healthy 3-year-old children were included. A questionnaire was completed by their parents on screen time. Descriptive statistics and linear regression models were used to assess associations between child screen time and selected factors. Multivariable models included factors from the univariate analysis with P < 0·1. Estimated effects and 95% CI are reported. RESULTS: A total of 157 children were enrolled (91% recruitment). The mean screen time per weekday was 104 min (similar for weekend day). In all, 10% of children had a television (TV) in their bedroom; 59% consumed at least one meal while watching TV; and 81% of parents had household rules about screen time. Controlling for maternal education and age, eating lunch and dinner in front of the screen and mother being employed were associated with an increase in child weekday screen time of 96 (95% CI 30, 192), 42 (95% CI 12, 90) and 36 (95% CI 6, 72) min/d, respectively. Eating lunch in front of the screen and an increase of 1 h of parental screen time were associated with an increase of 78 (95% CI 36, 132) and 12 (95% CI 6, 18) min/d in child weekend screen time. Family rules decreased child weekend screen time by 30 (95% CI 6, 54) min/d. CONCLUSIONS: Interventions that include these important parental factors should be evaluated for their effectiveness in reducing screen time.

Office-based intervention to reduce bottle use among toddlers: TARGet Kids! Pragmatic, randomized trial.

OBJECTIVE: The goal was to determine whether an office-based, educational intervention for parents of 9-month-old children could reduce bottle use and iron depletion at 2 years of age. METHODS: Between January 2006 and 2007, 251 healthy, 9-month-old infants attending a routine health maintenance visit were assigned randomly to intervention or control groups. Parents in the intervention group were introduced to a 1-week protocol to wean their children from the bottle. Iron depletion (ferritin levels of <10 microg/L) and bottle use at 2 years were assessed. RESULTS: A total of 201 children were monitored to 2 years of age (follow-up rate: 81%). Rates of iron depletion (10 [10%] of 102 children vs 13 [13%] of 99 children; P = .42) and milk consumption of >16 oz (16 [16%] of 102 children vs 17 [17%] of 99 children; P = .7) were not significantly different between the 2 groups at 2 years of age. However, children in the intervention group started using a cup 3 months earlier (9 vs 12 months; P = .001), were weaned from the bottle 4 months earlier (12 vs 16 months; P = .004), and were more than one-half as likely to be using a bottle at 2 years of age (15 [15%] of 102 children vs 39 [40%] of 99 children; P = .0004). CONCLUSIONS: This simple intervention administered during a health maintenance visit did not result in a decrease in iron depletion at 2 years of age but did result in a 60% reduction in prolonged bottle use.

Idiopathic suppurative pylephlebitis: interventional radiological diagnosis and management.

We report the imaging findings and management of a case of suppurative pylephlebitis of unknown cause in a 10-year-old girl. Percutaneous aspiration of frank pus from the portal vein confirmed the diagnosis and contributed to therapy. Percutaneous transhepatic thrombolysis was attempted but was unsuccessful. Because of the nonspecific presentation of this condition and the lack of familiarity of physicians with this entity, the diagnosis is often delayed. Our aim is to increase the awareness of this entity and stress the importance of early diagnosis and appropriate therapy.

Common medical pains.

Pain in infancy and childhood is extremely common. Sources of pain include illness, injury, and medical and dental procedures. Over the past two decades, tremendous progress has been made in the assessment, prevention and treatment of pain. It is important for the paediatric health care provider to be aware of the implications and consequences of pain in childhood. A multitude of interventions are available to reduce or alleviate pain in children of all ages, including neonates. These include behavioural and psychological methods, as well as a host of pharmacological preparations, which are safe and effective when used as indicated. Many complementary and alternative treatments appear to be promising in treating and relieving pain, although further research is required. The present article reviews the most common sources of pain in childhood and infancy, as well as current treatment strategies and options.

Iron depletion is associated with daytime bottle-feeding in the second and third years of life.

OBJECTIVE: To measure the association between daytime bottle-feeding and iron depletion in young children. DESIGN: Cross-sectional design with concurrent measurement of exposure and outcome. The exposure was the current container (bottle or cup) used for daytime milk consumption. Child, maternal, and dietary variables were collected. SETTING: Community-based pediatric practice serving a diverse population in an urban Canadian city. PARTICIPANTS: One hundred fifty healthy children, aged 12 to 38 months, attending a well-child care visit. MAIN OUTCOME MEASURE: Iron depletion (serum ferritin level, <10 microg/L]). RESULTS: Of the 150 children, 82 (55%) were bottle-fed and 68 (45%) were cup fed. Iron depletion occurred in 29 (37%) of 78 bottle-fed and in 12 (18%) of 67 cup-fed children. The crude relative risk for iron depletion was 1.81 (95% confidence interval, 1.09-3.01). In the final logistic regression model, a significant association between bottle use and iron depletion was identified, beginning after the age of 16 months. At 18 months, the relative risk, adjusted for several child, maternal, and dietary variables, for the association between bottle use and iron depletion was 1.31 (95% confidence interval,1.24-1.47); at 24 months, the adjusted relative risk was 2.50 (95% confidence interval, 2.46-2.53). Milk consumption of more than 16 oz/d occurred in 55 (67%) of the 82 bottle-fed and in 22 (32%) of the 68 cup-fed children (P<.001). CONCLUSIONS: In the second and third years of life, there is an almost 2-fold association between iron depletion and daytime bottle-feeding compared with cup feeding. The child's age may be a modifier, and milk volume consumed may be a mediator, of this association. Duration of bottle use is a potentially modifiable practice.

Mercury intoxication: it still exists.

A3-year-old boy presented to the Hospital for Sick Children with systemic symptoms and oropharyngeal and peripheral extremity changes suggestive of Kawasaki disease. He was found to have severe hypertension. Investigation for a catecholamine-secreting tumor was negative. Toxins were considered when the patient's 20-month-old brother presented with similar symptoms, and the boys were subsequently diagnosed with elemental mercury poisoning. We review the literature on mercury intoxication and discuss the historical context, clinical syndrome (acrodynia), treatment, and radiologic findings of this unusual diagnosis.

Systemic exposure to morphine and the risk of acute chest syndrome in sickle cell disease.

BACKGROUND: The etiology of acute chest syndrome, the most severe complication of the sickle cell crisis, is unknown. OBJECTIVE: Our objective was to assess exposure to morphine as an etiologic factor for acute chest syndrome in sickle cell disease. METHODS: A post hoc analysis of a randomized controlled trial comparing oral with continuous infusion of morphine was performed. Children (aged 5-17 years) with sickle cell crisis were randomized to receive oral sustained-release morphine, 1.9 mg. kg(-1). 12 h(-1), or a continuous intravenous infusion of morphine at 0.04 mg. kg(-1). h(-1) by use of a double-blind, placebo-controlled design. In a subgroup of 15 patients, the pharmacokinetics of morphine and its active metabolite morphine-6-glucuronide were also studied. RESULTS: At baseline, demographic and physiologic characteristics were similar between groups. There were no differences in the number of previous rescue doses per day, painful sites per episode, physician contacts per year, and hospitalizations per year between treatment arms. There was a 2-fold higher morphine area under the concentration-time curve at steady state (AUC(ss)) and a 3-fold higher morphine-6-glucuronide AUC(ss) with oral morphine than with a continuous intravenous infusion of morphine (P <.001 and P <.006, respectively). New onset of acute chest syndrome was 3-fold more prevalent in the oral group (57%) versus the continuous intravenous infusion group (17%) (P <.001). CONCLUSIONS: The risk of acute chest syndrome is significantly associated with high systemic exposure to morphine and its active metabolite morphine-6-glucuronide after oral administration of slow-release morphine. Morphine may facilitate respiratory deterioration by eliciting a decrease in oxygen saturation, by inducing histamine release, or through an as-yet-unidentified mechanism. The safe systemic exposure to morphine in terms of area under the concentration-time curve should be further studied in children with sickle cell disease.

Is it all right to drink a little during pregnancy?

QUESTION: When I told a female patient who just transferred from another city to abstain from alcohol during pregnancy, she was surprised. She mentioned that, in the past, several doctors had told her it was all right to drink moderately. I am confused. Have I missed something? ANSWER: No, you have not. Women should be advised to abstain from alcohol during pregnancy. There are insufficient data to suggest a safe threshold for fetal alcohol exposure.

Parents' responses to symptoms of respiratory tract infection in their children.

BACKGROUND: Little is known about the determinants of parental response when children appear to have a respiratory tract infection (RTI). Our objective was to identify what factors predict that parents will seek medical consultation. METHODS: In a prospective cohort study we consecutively recruited 400 children aged 2 months to 12 years from the urban, largely middle-class, primary-care practices of 7 pediatricians in Toronto. Baseline demographic data were collected and the children followed by telephone inquiry until an RTI developed or 6 months elapsed. Data about any medical consultation for the RTI were collected. The parents completed a questionnaire on clinical features and parental interpretations and concerns. Potential predictors of consultation were organized into 4 domains: family factors, principal complaints, functional burden of illness (determined with a validated measure, the Canadian Acute Respiratory Illness and Flu Scale [CARIFS]) and parental interpretation of the illness. Key variables for each domain were derived by endorsement, correlation and combination, and univariate association with the outcome (medical consultation). A model was created to identify independent predictors of consultation. RESULTS: Of the 383 children (96%) for whom the study was completed, 275 (72%) had symptoms of an RTI within 6 months after recruitment. Medical consultation was sought for 140 (56%) of the 251 for whom further data were available. The questionnaire data and follow up were complete for 197 (78%) of the 251. Children with earaches compared to children without were more likely to be taken to a physician (odds ratio [OR] 10.2; 95% confidence interval [CI] 2.8-37.4), as were children with high fever (temperature > 40 degrees C) compared to children with no fever or fever < or = 40 degrees C (OR 3.2; 95% CI 1.2-8.6). Parents who rated their children as having a complaint that was severe or persisting for more than 24 hours were more likely to see a physician than parents who rated their children as having no complaints (OR 8.5; 95% CI 2.3-32.0). Parental concern that the illness had an unusual course, with prolonged duration or deterioration (OR 5.7; 95% CI 1.3-24.8), that the child had a specific illness (OR 2.9; 95% CI 1.1-7.7) or that specific treatment was needed (OR 5.0; 95% CI 1.1-23.1), compared to children with no illnesses or need for treatment, also predicted consultation with a physician. Parents' postsecondary education (OR 4.0; 95% CI 1.1-14.6), compared to parents with less than postsecondary education, was the only parental factor that independently predicted taking a child to see a physician. Child's age 48 months or less was the only child factor that independently predicted physician consultation (0-6 months, OR 9.2, 95% CI 1.4-58.1; 7-12 months, OR 17.3, 95% CI 2.0-147.2; 13-24 months, OR 9.2, 95% CI 1.3-63.6; 25-48 months, OR 5.2, 95% CI 0.8-34.4). Neither family demographics nor functional burden of illness predicted consultation. INTERPRETATION: Generally, parents choose reasonable criteria for seeking physician advice. However, their perceptions and interpretations may be based in part on limited understanding of some factors. Further research is necessary to determine how these findings can be used to improve anticipatory guidance to parents and better address parental concerns.

Comparison of oral versus normal and high-dose rectal acetaminophen in the treatment of febrile children.

OBJECTIVES: To compare the defervescent effect of high-dose rectal suppository acetaminophen with the recommended oral and rectal dosages and to evaluate acceptability of rectal acetaminophen. METHODS: A randomized, controlled trial was performed in 70 patients aged 6 months to 6 years with fever > or =39 degrees C. Group A received rectal acetaminophen 15 mg/kg, group B received rectal acetaminophen 30 mg/kg, and group C received oral acetaminophen 15 mg/kg. Primary outcome was maximal change in temperature during the 3-hour study period after initial treatment. RESULTS: There were 24 patients in group A, 23 in group B, and 23 in group C. There was no significant difference in temperature change between the groups during the 3 hours or in the maximum drop in temperature or final temperature. Visual analog scores for satisfaction of parents did not reveal any significant differences between the oral and rectal routes. CONCLUSIONS: There was no difference between the temperature decrement in patients treated with 15 mg/kg oral acetaminophen and the same or double dose rectally. Thus, there seems to be no evidence to support the use of higher doses of rectal acetaminophen for the treatment of fever in children. The rectal route proved to be as acceptable as the oral among parents.