Use of Unsafe Teething Remedies: A Survey.

OBJECTIVE: Various teething remedies have been widely marketed to caregivers. Unsafe remedies, including teething necklaces and topical anesthetics, have been implicated in adverse events, such as suffocation injuries and death. However, little is known about the extent of their use. Our primary objective was to assess the prevalence of teething remedy use among caregivers. A secondary objective was to determine whether the use of unsafe teething remedies is related to socioeconomic status (SES) or maternal education. METHODS: Children aged 12-18 months visiting primary care providers for routine checkups were included. Children outside that age group and those with chronic medical conditions were excluded. Caregivers completed a questionnaire about their children's teething symptoms and remedies used to relieve them. Unsafe remedies were defined on the basis of American Academy of Pediatrics and Canadian Paediatric Society recommendations and included topical anesthetics, teething necklaces and liquid-filled teething rings. RESULTS: Of the 130 questionnaires, 123 were complete and included in statistical analysis: 98% of families used teething remedies and 67% were unsafe. Of these families, 27% used amber teething necklaces; 28% used more than 1 unsafe remedy. Apart from topical anesthetic use, no significant correlations were found between overall unsafe remedy use and SES or maternal education. CONCLUSION: Unsafe teething remedies are commonly used despite recommendations against them. Use of unsafe teething remedies transcends SES and education level.

An unusual case of pericardial effusion.

We report a case of a 13-year-old male with trisomy 21 in Southwestern Ontario, Canada, who presented with bilateral pneumonia, pericardial effusion, and peripheral oedema. The pericardial effusion did not respond to standard treatment options. Evaluation revealed severe dietary restriction, consistent with kwashiorkor. Hospital course was complicated by severe hypoalbuminaemia, hypocalcaemia, hypomagnesaemia, and hypophosphataemia. The pericardial effusion and other findings resolved gradually upon slow introduction of a well-balanced diet and adequate caloric and protein intake. Kwashiorkor is an unusual cause of pericardial effusion and can be overlooked especially in developed countries. It is a type of protein-calorie malnutrition often seen in children of impoverished countries and famine. It is a result of insufficient protein intake in the context of adequate caloric intake. Pericardial effusion not responding to usual treatment is a challenge, and other aetiologies must be considered. Malnutrition is often underdiagnosed or misdiagnosed in developed countries with devastating outcomes if unrecognised. This makes it imperative to consider this diagnosis, recognise potential risk factors, and be prepared to accurately assess overall nutritional status.

Effect of exclusion of frequently consumed dietary triggers in a cohort of children with chronic primary headache.

BACKGROUND: Although dietary factors are known to trigger headaches, the relationship between food and headache in children remains unclear. This prospective, observational case series aimed to evaluate the effect of exclusion of frequently-consumed foods in a cohort of children with headache. METHODS: One hundred and fifteen children aged 3-15 (mean 10.5) years with primary headache were followed in a paediatric outpatient clinic. Patients who frequently consumed foods or food additives known to trigger headaches were advised to exclude them for six weeks and to return for follow-up with headache and food diary. RESULTS: One hundred patients attended follow-up. Of these 13 (13%) did not respond to dietary exclusion; 87 (87%) achieved complete resolution of headaches by exclusion of 1-3 of the identified food(s). Caffeine was the most common implicated trigger (28), followed by monosodium glutamate (25), cocoa (22), aspartame (13), cheese (13), citrus (10) and nitrites (six). One patient was sensitive to tomatoes. CONCLUSIONS: This study demonstrates the potential scale and significance of seven frequently consumed foods or food additives as triggers for primary headache in children. Also this is the first study to show that headaches can be triggered by the cumulative effect of a food that is frequently consumed, rather than by single time ingestion.

Should a near-patient test be part of the management of pharyngitis in the pediatric emergency department?

OBJECTIVE: The study's objective was to evaluate the efficacy of a rapid streptococcal test as a single diagnostic agent in the diagnosis of streptococcal pharyngitis in patients presenting to a pediatric emergency department. METHODS: We performed a rapid streptococcal test as part of the diagnostic workup for patients presenting with clinical findings consistent with streptococcal pharyngitis. In addition to undergoing the study intervention, each patient had a standard throat swab sent to the laboratory for formal culture. A questionnaire detailing the clinical features was to be completed in each case. RESULTS: Two hundred ten near-patient tests were performed. Complete laboratory results were available in 177 cases (77%). Clinical data were available for analysis in 94 patients (53%). In our patient population, the near-patient test had a high specificity (98.6%) but a low sensitivity (71%). The clinical presentation of confirmed group A ß-hemolytic streptococcal pharyngitis is very variable. CONCLUSIONS: The QuickVue In-Line Strep A test for streptococcal pharyngitis is unreliable in our patient population. Clinical findings are unhelpful in confirming the diagnosis. Formal laboratory culture is the criterion standard for identifying the organism, but the results are not clinically significant in every case. Acute pharyngitis presenting to the pediatric emergency department can be managed in accordance with the recommendations in the Scottish Intercollegiate Guideline Network guideline.

Use of a hand-held bladder ultrasound scanner in the assessment of dehydration and monitoring response to treatment in a paediatric emergency department.

BACKGROUND: Dehydration is a common concern in paediatric emergency care. Limited tools are available to assess reduced urine production, which is commonly cited as a reliable marker of dehydration. OBJECTIVES: To evaluate the utility of a hand-held bladder ultrasound scanner in monitoring urine production in children attending the emergency department with suspected dehydration. METHODS: A prospective pilot study was undertaken on a convenience sample of patients presenting with suspected dehydration. Serial bladder ultrasound scanning was performed to monitor urine output. Dehydration was assessed clinically using the WHO guide to dehydration assessment. Decisions about treatment and admission were made independently of the urine output measurements obtained using the bladder scanner. RESULTS: 45 children were studied. Using the WHO guide, 33 (73%) had mild dehydration, 8 (18%) had moderate dehydration and 4 (9%) had severe dehydration. There was a significant difference in estimated urine production between those admitted and those discharged (0.9±1.2 ml/kg/h vs 1.8±1.5 ml/kg/h, p=0.01) and between those with mild dehydration versus moderate/severe dehydration (2.3±1.5 ml/kg/h vs 0.6±0.7 ml/kg/h, p=0.0011). Urine output had been significantly reduced in those who had received an intravenous fluid bolus compared with those who had not (0.4±0.46 ml/kg/h vs 1.9±1.6 ml/kg/h, p=0.001). CONCLUSIONS: The hand-held bladder scanner is a convenient, non-invasive and objective adjunct in the assessment and management of children attending the emergency department with suspected dehydration.

Saline-Lock Versus Continuous Infusion: Maintaining Peripheral Intravenous Catheter Access in Children.

OBJECTIVES: In children, peripheral intravenous catheters (PIVs) are maintained by either a continuous infusion of fluid "to keep vein open" (TKO) or a saline lock (SL). There is a widespread perception that TKO prolongs PIV patency, but there is a lack of evidence for this. We hypothesized that there would be no significant difference in duration of PIV patency between TKO and SL. PATIENTS AND METHODS: This prospective, time-allocated study included patients from newborn to 17 years of age admitted to our pediatric ward. Patients enrolled in the first 3 months were assigned to TKO, and patients in the latter 3 months were assigned to SL. Primary outcome was duration of functional patency of the first PIV during the time of TKO or SL. Secondary outcomes included PIV-related complications and patient and caregiver satisfaction. RESULTS: Complete PIV data were available on 172 (n = 85 TKO, n = 87 SL) of 194 enrolled patients. The mean (SD) duration of PIV patency was 41.68 (41.71) hours in the TKO group and 44.05 (41.46) hours in the SL group, which was not significantly different (P = .71). There were no significant differences in complication rates or overall patient and caregiver satisfaction. One patient in the TKO group had their PIV removed because of risk of strangulation from tubing. CONCLUSION: There were no significant differences between TKO and SL in the duration of PIV patency, complication rates, and overall patient and caregiver satisfaction in our pediatric population. Overall, SL is a safe and reasonable alternative to TKO in maintaining PIV patency in children.

Reliability of urine collection pads for routine and metabolic biochemistry in infants and young children.

The aim of our study was to evaluate whether specifically designed urine collection pads give reliable results for routine and metabolic biochemistry tests in paediatric urine. Urine collected by bag or clean-catch from infants and children <2 yrs without metabolic disorders was divided into two aliquots, one of which was added to a collection pad, incubated for 15 min at 37 degrees C (simulating in vivo collection conditions), then recovered by aspiration. Urine from adults with phaeochromocytoma and aqueous solutions of catecholamines were similarly treated. Routine, catecholamine, and metabolic analyses were performed on pad/non-pad aliquots. Selected metabolic analyses were also performed on pad/non-pad urine from patients with diagnosed inborn errors and urine containing added metabolites to simulate metabolic disorders. Routine tests (urea, electrolytes, creatinine, osmolality, calcium:creatinine, phosphate:creatinine, magnesium:creatinine, urate:creatinine [n = 32], oxalate:creatinine [n = 10]), and catecholamines (n = 12) showed good or acceptable concordance with no clinically significant pad/non-pad differences. Metabolic tests in infants and children without metabolic disorders all showed good pad/non-pad concordance for amino acids (n = 10), organic acids (n = 12), and glycosaminoglycans (n = 8). In patients with metabolic disorders (phenylketonuria [n = 1], homozygous/heterozygous cystinuria [n = 3], mucopolysaccharidoses II [n = 2] and III [n = 1], organic acid disorders [n = 6]) and urine containing added orotic acid to simulate urea cycle disorders, there was also good pad/non-pad concordance for diagnostic urinary metabolites. No extraneous organic acids were eluted from the pads. Sugar chromatography showed identical staining intensity in pad/non-pad samples. In conclusion, urine collection pads give reliable results for a wide range of routine and metabolic biochemistry tests in urine from paediatric patients.

Chronic kidney disease stage affects small, dense low-density lipoprotein but not glycated low-density lipoprotein in younger chronic kidney disease patients: a cross-sectional study.

BACKGROUND: Small, dense low-density lipoprotein (sd-LDL) and glycated LDL (g-LDL) have been associated with cardiovascular disease (CVD) in chronic kidney disease (CKD) in patients >60 years of age. Since young adult and paediatric patients have shorter exposure to Framingham-type risk factors, our study aims to determine whether younger CKD patients exhibit the same sd-LDL and g-LDL pattern. METHODS: After ethics board approval, this cross-sectional study was conducted at two universities with 44 patients (mean ± standard deviation age 12.6 ± 4.9, range 2-24 years) with CKD stage of 1-5. Laboratory parameters studied were Cystatin C (CysC), CysC estimated glomerular filtration rate (eGFR) (calculated from the Filler formula), sd-LDL, g-LDL and albumin. Lipid samples were measured for sd-LDL and g-LDL using ELISA. Non-linear correlation analysis was performed to determine the relationship between g-LDL, sd-LDL and eGFR. Clinical Trials Registration is at clinicaltrials.gov, NCT02126293, https://clinicaltrials.gov/ct2/show/NCT02126293. RESULTS: Triglycerides, but not total cholesterol and calculated LDL, were associated with CKD stages (ANOVA P = 0.0091). As in adults, sd-LDL was significantly associated with CKD stages (ANOVA P = 0.0133), CysC eGFR (r = -0.6495, P < 0.00001), and body mass index (r = -0.3895, P = 0.0189), but not with age. By contrast, there was no significant correlation between g-LDL and CKD stages or CysC eGFR (P = 0.9678). CONCLUSIONS: Our study demonstrates that only triglycerides and sd-LDL were associated with CKD stages in this young cohort without confounding Framingham-type CVD risk factors. While larger studies are needed, this study suggests that lowering sd-LDL levels may be a potential target to ameliorate the long-term CVD risks in paediatric CKD patients.

A complex case of congenital cystic renal disease.

This case outlines the potential complexity of autosomal recessive polycystic kidney disease (ARPKD). It highlights the challenges involved in managing this condition, some of the complications faced and areas of uncertainty in the decision making process. With a paucity of published paediatric cases on this subject, this should add to the pool of information currently available.

Biochemical risk factors for stone formation in a Scottish paediatric hospital population.

BACKGROUND: Renal stones in children, although rare, may be associated with morbidity and renal damage. Scottish children have a different ethnic composition and diet compared with paediatric populations previously studied. Urinary stone promoters include calcium, oxalate and urate. Postulated inhibitors include citrate and glycosaminoglycans (GAGs). We tested the hypothesis that Scottish paediatric stone-formers have higher excretion of urinary stone promoters (calcium/oxalate/urate) and/or lower excretion of stone inhibitors (citrate/GAGs) than children with isolated haematuria and controls. METHODS: In this case-controlled study, we measured creatinine, calcium, oxalate, urate, citrate and GAGs in random urine samples from 24 stone-formers (excluding inherited metabolic disorders), median age 10.2 (range 1.0-17.2) y; 25 patients with isolated haematuria, 6.3 (0.6-13.7) y; and 32 controls, 7.5 (0.8-14.7) y. RESULTS: Excretion of urinary promoters and inhibitors differed among stone-formers, haematuria and control groups for (median (range)): calcium (0.82 (0.02-2.19), 0.43 (0.08-2.65), 0.31 (0.04-2.12) mmol/mmol creatinine, respectively, P = 0.005), citrate (0.42 (0.13-0.72), 0.33 (0.05-0.84), 0.61 (0.11-1.75) mmol/mmol creatinine, P = 0.001), calcium:citrate ratio (1.68 (0.19-4.81), 1.30 (0.19-9.57), 0.54 (0.10-2.27) mmol/mmol, P < 0.0001) and the promoter:inhibitor ratio (calcium x oxalate)/(citrate x GAGs) (8.3 (1.0-82.5), 4.3 (1.2-69.5), 2.8 (0.3-13.2) mmol/g, P < 0.0001). CONCLUSIONS: Scottish paediatric stone-formers had lower urinary citrate excretion and higher urinary calcium excretion, calcium:citrate ratio and promoter:inhibitor ratio compared with controls. Urinary calcium excretion and promoter:inhibitor ratio was also higher than children with isolated haematuria. Nevertheless, marked overlap between the stone-former and haematuria groups for promoter:inhibitor and calcium:citrate ratios suggests that some patients with isolated haematuria may be at future risk of urolithiasis.