Clinical Pediatrics

A prospective consecutive case series of patients aged 5 to 20 years who presented to a pediatric emergency department with diabetic ketoacidosis (DKA) was studied to determine the actual percent loss of body weight during an episode of DKA to determine the degree of dehydration and thereby provide a guide for hydration therapy during such an episode. Patients' weights at the time of presentation, inpatient discharge, and at the first follow-up clinic visit were used to calculate the percent loss of body weight. Data from 33 episodes of DKA showed that the majority of patients with DKA had moderate (4% to 8%) dehydration. Clinical assessment was a poor predictor of severity of dehydration and overestimated the percent dehydration in 67% of patients. Based on these data it is recommend that initial fluid therapy for DKA should assume moderate dehydration with adjustment made according to clinical response.

Objectives Although febrile seizures are common in children, attitudes may change among parents. The management of a child may differ depending on the specialty of the attending physician. This study was carried out to analyze attitudes of Turkish parents and physicians toward febrile seizures.

Material and Methods 308 children with febrile seizure who were admitted to the Department of Pediatric Neurology at Dr Sami Ulus Children's Hospital and Gazi University in Turkey between January 2006 and March 2007 were enrolled.

Results Prior to seizure, approximately half of the parents took appropriate steps in reducing fever. The data also showed that there was a wide variation of treatment practice depending on the specialty of the attending physician.

Discussion Educational level and economic status are important variables affecting attitudes of parents toward fever and febrile seizure. The management of the child with a febrile seizure differs even within the same specialty in Turkish physicians.

Urinary tract infection (UTI) in children is a common diagnosis in general pediatric practice. Because of the potential severity and proven morbidity of such infections, the American Academy of Pediatrics (AAP) developed guidelines to better direct clinicians in the workup. This retrospective study sought to evaluate the uniformity of adherence to these guidelines at our teaching institution. A total of 104 charts were reviewed, and data were collected based on the parameters outlined by the AAP. It is found that at the authors' teaching institution, there is at least 70% adherence to the recommendations for method of urine collection and 97% adherence to performance of urinalysis. However, imaging workup, which may be the most important follow-up of a first-time UTI, has only a 61% adherence rate.

Attention deficit hyperactivity disorder (ADHD) is a condition typically arising in childhood, which untreated, can have consequences reaching into adolescence and beyond. Effective pharmacological treatment is available and has become widespread in the West. Outcomes for both the child with ADHD and the parent may be influenced by the nature of interaction between them. The authors of this article aim to review published research examining the interaction between parents and their children with ADHD. A PubMed search was conducted of studies written in English between 2000 and 2007 with the keywords ADHD and parenting. Child ADHD elicits high levels of parental stress and maladaptive parenting. The presence of parental psychopathology is common and influences the parent's response to the child's ADHD symptoms. Optimizing parent—child interaction and parental psychiatric status may improve outcomes for both parent and child.

Objective To determine rates of breast-feeding in the first 2 months of life at an inner-city pediatric practice.

Methods Using retrospective chart reviews, we examined all visits through 2 months of age for infants seen from April 1, 2007, to June 29, 2007, at the Pediatric Practice of Rainbow Babies and Children's Hospital, Cleveland, Ohio, which serves a low-income urban population. Rates of breast-feeding were analyzed by visit number and by infant age category.

Results We reviewed all 557 visits occurring between birth and 2 months of age for all 223 eligible infants. At visit 1 (median age 5 days), the rates of exclusive and any breast-feeding were 22.0% and 40.8%, respectively. By visit 3 (median age 43 days), the rates of exclusive and any breast-feeding were 10.6% and 24.5%, respectively.

Conclusions These inner-city breast-feeding rates are substantially below reported regional and national rates. Barriers to implementing urgently needed interventions are discussed.

Research conducted in 10 cities assessed long-term pediatric asthma outcomes from a peer teaching intervention for physicians to improve their asthma-related clinical and counseling skills. Hypotheses were better outcomes for patients, symptom reduction, less health care use, and enhanced view of the physician. Peers trained 53 intervention group pediatricians (seeing 418 patients); 48 pediatricians (seeing 452 patients) were controls. Patients provided baseline and 2-year follow-up data, collected by telephone interview and from medical records. Intent-to-treat analyses used Poisson regression and general estimation equations. Treatment physicians' patients gave them higher performance ratings ( P = .02). Patients had fewer sleep disruptions from asthma symptoms ( P = .03). Those with baseline health care use had fewer ED visits ( P = .005), hospitalizations (P = .03), and urgent office visits (P = .001), and they made fewer phone calls to the doctor's office (P = .02). Treatment physicians spent no more patient visit time than control physicians. Peer training increased patient's positive views of clinician's performance and reduced children's symptoms and health care use up to two years post program.

There were 65 third-year medical students and 59 pediatric residents who participated. The intervention was a 40-minute multimedia program that teaches how to counsel parents about childhood aggression. Comparing pre- and 2-month postintervention data, there was an increase in the proportion of medical students (11% pre vs 92% post; P < .001) and residents (3% pre vs 95% post; P < .001) who felt that their ability to counsel parents about hurtful behavior was high or very high. Compared with baseline, a higher proportion of trainees at the 2-month follow-up recommended redirecting (11% pre vs 69% post; P < .001), promoting empathy (13% pre vs 42% post; P < .001), and not using physical punishment (25% pre vs 50% post; P < .001). A brief, independently viewed curriculum addition expanded the repertoire of health care trainees related to counseling parents about childhood aggression. These findings have implications for violence prevention.

This study sought to determine the microbiology of recurrent acute otitis media (AOM) and AOM treatment failure (AOMTF) in the context of widespread use of heptavalent pneumococcal conjugate vaccine (PCV7). In this retrospective cohort study, 244 AOM isolates obtained by tympanocentesis during 3 respiratory seasons—2003-2004 (n = 126), 2004-2005 (n = 52), 2005-2006 (n = 66)—from three geographically diverse pediatric populations were compared. Most isolates were from children less than 2 years old, who had received PCV7. For the 3 seasons the proportion of Streptococcus pneumoniae isolates was 35%, 35%, and 46% and for Haemophilus influenzae was 55%, 58%, and 39%, respectively (change in trend, P = .09). A total of 37%, 39%, and 50% of S. pneumoniae were penicillin nonsusceptible (PNSP) and 48%, 67%, and 50% of H. influenzae produced β-lactamase, respectively. Although H. influenzae remains the most frequently isolated pathogen in children with AOMTF or recurrent AOM, S. pneumoniae that are PNSP are reemerging as important organisms.

Methods A prospective, randomized double-blind placebo control study comparing the efficacy of acetaminophen to acetaminophen alternated with ibuprofen in 38 healthy outpatient children 6 months to 6 years presenting to the outpatient clinic with fever >38°C was conducted. Temperatures were recorded at 0, 3, 4, 5, and 6 hours. Side effect diaries and parental perception of efficacy were filled out hourly by parents.

Results There were no significant differences in temperature between the 2 groups at times 0, 3, and 6 hours. The alternating group had significantly lower mean temperatures at both 4 hours (38.0°C vs 37.4°C; P = .05) and 5 hours (37.1°C vs 37.9°C; P = .0032). Parents did not perceive any difference in fever control between the groups.

Conclusions An alternating regimen of acetaminophen with ibuprofen significantly decreased fever at 4 and 5 hours compared with acetaminophen alone. However, parents did not perceive a difference in efficacy.

Background Apparent life-threatening events (ALTEs) can encompass many different diagnoses. Nonaccidental trauma (NAT) is one potential serious diagnosis.

Objective (1) To identify key elements in the history and physical exam in infants presenting with an ALTE that aid in the subsequent diagnosis of NAT; and (2) to evaluate the role of diagnostic studies in these infants in confirming the diagnosis of NAT.

Design/Methods A retrospective chart review analysis, over a 2-year period, of infants with an ALTE was performed. From this group, all children with a discharge diagnosis of child physical abuse, shaken infant syndrome, or NAT were included in the study.

Results 4 patients were found to be victims of NAT based on their clinical histories and physical examinations. Although confirmatory, ophthalmologic exams, skeletal surveys, and head CT scans had a lower sensitivity for NAT.

Conclusions NAT should be considered when an infant is admitted for evaluation of an ALTE.

Because pediatric cardiologists can accurately diagnose innocent murmurs by physical exam alone, the authors developed a system for remote cardiac auscultation. They hypothesized that their system could accurately classify auscultatory findings as normal/innocent or pathologic. Patients undergoing evaluation underwent examination, echocardiography, and heart sound recording. Pediatric cardiologists evaluated the heart sounds and classified the case as either normal/innocent or pathologic. They reviewed103 heart sound data sets; 85% of the cases were accurately classified as either normal/innocent or pathologic, with a sensitivity of 82% and specificity of 86%. However, when accounting for clinical diagnosis, reviewer uncertainty, and ECG abnormalities, the sensitivity and specificity improved to 91% and 88% (accuracy 89%), respectively. Degree of certainty with the telecardiology diagnosis correlated with correct interpretation (P < .005). Digital heart sound recordings evaluated via telemedicine can distinguish normal/innocent murmurs from pathologic ones. Such a system could improve the use of pediatric cardiology services.

When organizing new health care interventions among a rural population, a careful planning process respecting community-specific considerations should be used. The project objective centered on the successful implementation of a school-based telehealth clinic serving a rural, health-disparate population. Using an American Academy of Pediatrics Community Access to Child Health planning grant, a needs assessment of the Delta community was conducted. In synthesizing the results of this planning project, consensually addressed issues led to establishing a pilot school-based telehealth clinic within the rural county schools. Seven essential steps emerged as a set of guidelines that entities might consider in introducing a telemedicine school-based service in a rural community. The steps included assessing local and regional needs, securing community support and establishing goals, evaluating resources, configuring logistics, training staff, informing parents, and launching the clinic. Proper planning is crucial to the establishment of a rural school-based telehealth clinic.

Objectives The authors sought to understand which informational sources pediatric health care providers perceive as most influential in how they stay current with health care innovations.

Methods Rochester, New York, area pediatric health care providers were surveyed using a self-administered questionnaire. Two items pertained to the health care provider's ability to interpret primary research, and 9 items pertained to the influence and relative importance of various sources of information.

Results A 61% response rate was obtained. Most (83%) respondents felt adequately trained to interpret primary research, fewer (31%) felt they have the time to do so. Almost all respondents (92%) felt that American Academy of Pediatrics (AAP) guidelines were a major influence, and 44% felt that AAP guidelines were the single most influential source of information in how they altered their practice over time.

Conclusions In the setting of time constraints, and the volume and complexity of published therapeutic research, AAP guidelines are playing an increasing role in knowledge transfer.

Background Pelvic radiographs are obtained frequently in pediatric blunt trauma. The authors hypothesize that there are clinical indicators that can predict pelvic fracture on a pelvic radiograph in the pediatric blunt trauma patient with a Glasgow Coma Scale score of 14 or 15.

Methods A retrospective case-control study of 33 patients with pelvic fractures and 63 patients without pelvic fractures was performed.

Results 8 evaluated clinical indicators showed that pelvic contusions and abrasions (P = .026), hip/pelvic pain (P<.001), abdominal pain and distension (P = .006), back pain (P = .080), hip held in rotation at presentation (P = .026), and femur deformity/pain (P = .002) were independently predictive of pelvic fracture. In combination, absence of hip/pelvic pain, pelvic contusions and abrasions, abdominal pain/distension, and femur deformity/pain showed a negative predictive value of 87%.

Conclusion Clinical indicators may be useful in determining the need for pelvic radiographs in awake and alert pediatric blunt trauma patients.

Ondine's curse or central alveolar hypoventilation (CCAH) syndrome is a disorder of the autonomic nervous system resulting in respiratory dysregulation. The clinical outcome is typically poor, with few individuals living into adulthood and even fewer surviving to adulthood with normal neurological function. Our patient initially presented following an uncomplicated delivery with hypotonia, poor respiratory effort, and hypoxemia that required ventilatory support. Laboratory workup, radiographic evaluation, and ancillary testing ruled out brain stem lesions, neuromuscular diseases, cardiovascular and pulmonary disease, and metabolic disorders, resulting in a diagnosis of CCAH syndrome. The patient underwent tracheotomy and chronic ventilatory support. Close long-term management and appropriate treatment modifications have provided for an excellent outcome and good quality of life. The patient is currently 22 years old and is earning her teaching degree for K-12 art education. A combination of early recognition and a multidisciplinary approach may lead to a successful outcome in patients with CCAH syndrome.

Objective Infants with respiratory syncytial virus (RSV) infection are at risk for developing apnea. The authors compared patients with RSV infection who develop apnea with those who do not, to help ambulatory physicians risk stratify their patients with RSV infection.

Methods Entry criteria were age less than 1 year, RSV infection, and presentation to the authors' pediatric emergency departments. Random and weighted sampling techniques were used to identify the study group and provide the control sample. Charts were abstracted for 34 clinical variables.

Results The study group consisted of 42 patients with apnea, and the control group consisted of 198 patients without apnea. Logistic regression analysis identified 2 independent variables associated with apnea: young age and presentation with apnea. Most patients with apnea were less than 2 months of age and were ill for less than 5 days.

Conclusions Age and duration of illness may help clinicians determine which previously healthy infants are at risk for apnea.