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ABSTRACT: Question In the summer months I see many children with uncomplicated acute otitis externa (AOE). I am aware of the multiple ototopical preparations. Which is the best first-line agent to treat AOE, and is there a role for an oral antibiotic? Answer There are no specific Canadian guidelines for the management of AOE. However, current American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated AOE; suggest there is little difference between the various ototopical preparations; and recommend the choice of treatment be based on the specific clinical situation. In practice, this often results in prescribing an antibiotic-steroid formulation for 7 to 10 days. This ototopical treatment option is supported by a recent Cochrane review that has documented the superiority of an antibiotic-steroid combination when compared with placebo or acetic acid in providing clinical resolution of AOE.
Canadian family physician Medecin de famille canadien 11/2012; 58(11):1222-1224. · 1.19 Impact Factor
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Jocelyn Gravel,
Eleanor Fitzpatrick,
Serge Gouin,
Kelly Millar,
Sarah Curtis,
Gary Joubert,
Kathy Boutis,
Chantal Guimont, Ran D Goldman,
Alexander S Dubrovsky,
Robert Porter,
Darcy Beer,
Quynh Doan,
Martin H Osmond
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ABSTRACT: STUDY OBJECTIVE: We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs). METHODS: This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category. RESULTS: A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay. CONCLUSION: The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.
Annals of emergency medicine 07/2012; · 4.23 Impact Factor
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Jocelyn Gravel,
Serge Gouin, Ran D Goldman,
Martin H Osmond,
Eleanor Fitzpatrick,
Kathy Boutis,
Chantal Guimont,
Gary Joubert,
Kelly Millar,
Sarah Curtis,
Douglas Sinclair,
Devendra Amre
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ABSTRACT: The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity.
This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED.
A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay.
The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.
Annals of emergency medicine 02/2012; 60(1):71-7.e3. · 4.23 Impact Factor
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ABSTRACT: QUESTION: Many children are affected by atopic dermatitis (AD) at a very young age. I often consider whether nonpharmacologic interventions could prevent or mitigate the development of AD. Do breastfeeding or changes to the maternal diet help prevent the development of childhood AD? ANSWER: The American Academy of Pediatrics suggests that lactating mothers with infants at high risk of developing AD should avoid peanuts and tree nuts, and should consider eliminating eggs, cow's milk, and fish from their diets. The World Health Organization also recommends breastfeeding infants up to 2 years of age. Studies have shown that breastfeeding can have a protective effect for AD in children; however, other studies have found insignificant or reversal effects. More research in this area is required.
Canadian family physician Medecin de famille canadien 12/2011; 57(12):1403-5. · 1.19 Impact Factor
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ABSTRACT: The aim of the present retrospective, cross-sectional, descriptive study was to determine the characteristics of febrile 3- to 36-month-old children who were admitted to the emergency department (ED) with the chief complaint of fever and returned with the same complaint within 72 hours (returning group), compared with age-matched children who did not return to the ED (nonreturning group). Demographics and predischarge evaluation extent were focused on.
Compared with the nonreturning group (n = 305), the returning group (n = 92) demonstrated higher mean temperature at home (P = 0.008), longer fever duration (P < 0.0001), and greater pain frequency (P = 0.03). Demographics and predischarge evaluation extent were similar in both groups. Within the returning group, fever duration was longer at the time of the second visit (P = 0.004).
Higher fever causes higher rate of return visits. Among the investigated groups, pain was the sole differentiating symptom. Further studies should identify patterns that diminish children's ED readmission.
Pediatric emergency care 11/2011; 27(12):1126-9. · 0.92 Impact Factor
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ABSTRACT: Previous studies have demonstrated associations of frequency of vasoocclusive crisis with weather conditions in adults, although relationships have been inconsistent.
Our objective was to determine if there is an association between weather conditions and pediatric emergency department (ED) visits, hospital admissions, and day and severity of pain precipitation for vasoocclusive crisis (VOC).
A retrospective observational study was performed at a large tertiary care pediatric center. We reviewed health records of all VOC patients under the age of 18 years with a chief complaint of pain and performed correlations between daily and average weekly and monthly weather conditions and frequency of painful crises.
A total of 430 visits for VOC to the ED were documented from January 2005 to December 2006. Significant correlations were noted between the daily and weekly number of painful crises and colder temperatures (ρ=-0.11, p=0.004 for daily data and r=0.25, p=0.01 weekly) and wind speed (ρ=0.13, p<0.001 and r=0.25, p=0.01). The monthly number of painful crises was moderately correlated with temperatures (r=-0.42, p=0.04). The average monthly pain score was higher in more humid months (r=0.44, p=0.03).
We found significant correlations of VOC with weather conditions where colder temperatures and higher wind speed were associated with a higher incidence of VOC in children. Health care providers as well as parents should be aware of these findings and ensure that preventive measures are instituted in patients at risk.
Journal of Emergency Medicine 11/2011; 41(5):559-65. · 1.31 Impact Factor
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ABSTRACT: QUESTION: As concern about antimicrobial resistance grows, I am aware of the need to reduce unnecessary antibiotic treatment; however, in my practice I see many children with acute otitis media (AOM) and this is the most common reason I prescribe antibiotics. Most of these children are young and otherwise healthy, and I am uncertain about when to prescribe antibiotics and when to endorse "watchful waiting." Which children will benefit from antibiotic treatment? ANSWER: Current Canadian guidelines recommend all children younger than 2 years of age with otalgia due to AOM and fever greater than 39°C be considered for treatment with amoxicillin. Watchful waiting is indicated only for children older than 6 months with mild-to-moderate AOM. Recent evidence suggests young children with a definitive diagnosis of AOM will benefit from antibiotics and experience fewer treatment failures compared with placebo, regardless of the severity of otitis. These studies do not challenge watchful waiting directly, and determining which children will improve spontaneously remains an enigma.
Canadian family physician Medecin de famille canadien 11/2011; 57(11):1283-5. · 1.19 Impact Factor
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ABSTRACT: QUESTION: I prescribe oral steroids for children in my community when they suffer asthma exacerbation. How many doses of steroids are recommended? Do all children need to take steroids for 5 days? ANSWER: Traditionally, mild-to-moderate pediatric asthma exacerbations have been treated with a short course of oral steroids-often 5 days of prednisone or prednisolone. However, recent evidence suggests a similar outcome can be acheived with a single dose of dexamethasone, which has a longer half-life and powerful anti-inflammatory effects, along with easier administration and compliance. Single-dose dexamethasone offers a simple and reliable treatment for these patients in office, urgent care, and emergency department settings.
Canadian family physician Medecin de famille canadien 10/2011; 57(10):1134-6. · 1.19 Impact Factor
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ABSTRACT: QUESTION: What is the role of intramuscular botulinum toxin injections in the management of spasticity and related morbidity in children with cerebral palsy? ANSWER: When botulinum toxin A is injected into the limbs of children with spastic paresis, it induces temporary reduction in muscle tone. It also promotes better motor function when used in combination with conservative treatments such as physiotherapy. Although there is a growing body of evidence for its effective and safe treatment, there is still a lack of consensus on dose, treatment regimens, and the best integration with other clinical modalities.
Canadian family physician Medecin de famille canadien 09/2011; 57(9):1006-73. · 1.19 Impact Factor
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ABSTRACT: Children returning to the emergency department (ED) within 72 hours of their visit may increase overcrowding and health care costs. Identifying the characteristics of returning children who need admission may help distinguish who might need admission on their first visit. The objective of this study was to compare the characteristics of children who returned to the ED and needed admission to the characteristics of those discharged.
The study used a retrospective chart review of patients 19 years and younger visiting a tertiary pediatric ED during a 1-year period. We excluded patients who left without being seen and those leaving against medical advice. We determined the rate of return visits and then performed χ² and Student t test analyses. Main outcome measures were return and subsequent hospital admission rate to the ED.
Of 47,655 eligible children, 2115 (4.4%) returned to the ED within 72 hours. The admission rate for the second visit was 353 (16.7%). There was no significant difference in age, sex, language spoken at home, or time elapsing from the first visit to the re-presentation to the ED between children who needed admission on the returned visit and those discharged when returning. The acuity was significantly lower among children discharged after returning (P < 0.001) but not among those admitted (P < 0.22).
More than 4% of our pediatric ED visits are for children returning within 72 hours. Progression of illness resulting in higher acuity, not age, sex, time from previous visit, or change in chief complaint category, was associated directly with admission on the second visit.
Pediatric emergency care 08/2011; 27(9):808-11. · 0.92 Impact Factor
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ABSTRACT: QUESTION: A 4-year-old child was diagnosed by polysomnography as experiencing mild obstructive sleep apnea (OSA). Despite the child being inattentive and distracted during the day at school, his parents prefer to avoid surgical treatment (adenotonsillectomy). Are there any non-surgical treatments for mild OSA in young children? ANSWER: Obstructive sleep apnea in children is caused mainly by adenotonsillar hypertrophy and can lead to considerable morbidities, including neurocognitive and behavioural disturbances. Surgical removal of the tonsils and adenoids is the treatment of choice. In recent years, however, a new understanding of the inflammatory components of OSA has led to the assumption that anti-inflammatory treatment can reduce adenotonsillar size and improve OSA symptoms. Evidence from a few studies suggests that intranasal steroids and oral leukotriene receptor antagonists have beneficial effects, but data from randomized controlled trials are still lacking.
Canadian family physician Medecin de famille canadien 08/2011; 57(8):891-3. · 1.19 Impact Factor
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ABSTRACT: QUESTION: What advice should I give parents of overweight children about physical activity? How can we encourage these children to become more physically active? ANSWER: The Canadian Paediatrics Society 2002 position statement on healthy living for children and youth, which is currently being revised, recommends that physicians advise children and adolescents to increase the time they spend on physical activities by at least 30 minutes a day, with at least 10 minutes involving vigorous activities, and that goals should be reset to reach at least 90 minutes a day of total physical activity. The extent to which children and youth are physically active is influenced by a multitude of complex, interrelated factors. Addressing physical inactivity and its contribution to childhood obesity requires a comprehensive and holistic approach.
Canadian family physician Medecin de famille canadien 07/2011; 57(7):779-82. · 1.19 Impact Factor
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ABSTRACT: QUESTION: A 10-year-old boy with atopic dermatitis (AD) came for consultation with an exacerbation. He suffered from pruritus and multiple erythematous skin lesions, identified as inflamed but not infected. Because skin colonization with Staphylococcus aureus is very common in AD and can worsen the skin condition, is it reasonable to add topical antibiotic treatment to the anti-inflammatory treatment in this case? ANSWER: Skin colonization with S aureus is prevalent in children and adults with AD, and can aggravate skin inflammation. Although topical combination creams with steroids and antibiotics are widely used for AD flare-ups, their superiority over anti-inflammatory treatment alone is not well established. Antibiotic treatment, whether systemic or topical, should be reserved for cases in which explicit signs of infection are present.
Canadian family physician Medecin de famille canadien 06/2011; 57(6):669-71. · 1.19 Impact Factor
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ABSTRACT: QUESTION: A 7-year-old child and his parents visit my clinic owing to the child's frequent bed-wetting. During the day, he has no problem controlling his urination. The family has tried behavioural methods but has failed to achieve dryness during the night. They ask to begin medical treatment. Is oxybutynin a safe and effective drug for treating nocturnal enuresis? ANSWER: Oxybutynin is an anticholinergic drug that has not been proven to be effective for treatment of nocturnal enuresis not accompanied by daytime symptoms, such as urgency. It can be added as a second-line drug and is effective for treating children with both daytime and nighttime wetting. Nevertheless, its common adverse effects, which can involve the central nervous system, should be considered when deciding whether or not to use it, especially in young children.
Canadian family physician Medecin de famille canadien 05/2011; 57(5):559-61. · 1.19 Impact Factor
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ABSTRACT: QUESTION: Dimenhydrinate is an over-the-counter drug that is commonly used for the treatment of nausea and vomiting. Many of my adult patients use it, but is it safe and useful in the pediatric population? ANSWER: Dimenhydrinate appears to be safe for use in the pediatric population. While little literature has been published about adverse effects of this medication, family physicians need to identify the cause of the vomiting before considering if the drug will be effective and need to ensure that patients safely use the medication and avoid potential interaction of the drug with other products.
Canadian family physician Medecin de famille canadien 04/2011; 57(4):431-2. · 1.19 Impact Factor
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ABSTRACT: QUESTION: I see many children with infantile hemangiomas and have read about new therapeutic options such as propranolol. Is this medication effective and safe for treating hemangiomas in children? ANSWER: Most infantile hemangiomas resolve spontaneously without any need for therapy. In many case series, propranolol has been shown to be effective and safe in treating hemangiomas that cause complications. Further studies are required to determine the optimal dose and duration of propranolol treatment for problematic hemangiomas.
Canadian family physician Medecin de famille canadien 03/2011; 57(3):302-3. · 1.19 Impact Factor
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ABSTRACT: Question There is a large population of overweight and obese children in my clinic. What medications for treatment of obesity are effective and can be used in children? Answer Orlistat is the only medication indicated by the US Food and Drug Administration for the treatment of obesity in adolescents. It is approved by the Food and Drug Administration for use in adolescents aged 12 years and older. There is no single approach to successful treatment of obesity, and lifestyle modification should be maintained throughout the pharmacologic treatment.
Canadian family physician Medecin de famille canadien 02/2011; 57(2):195-7. · 1.19 Impact Factor
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ABSTRACT: North American tick-borne illnesses are a group of important emerging diseases whose incidence has been increasing for the past decade. Emergency physicians may be the first contact for patients with symptoms of tick-borne illness, thus it is important that these diseases remain on a physicians' differential diagnosis when presented with an appropriate clinical presentation. This CME activity provides an overview of the most common tick-borne illnesses in North America and will help physicians evaluate their clinical presentation, order appropriate diagnostic tests, develop pediatric treatment recommendations, and prepare to include tick-borne illnesses in the differential diagnosis of pediatric patients presenting with multisystem disease.
Pediatric emergency care 02/2011; 27(2):141-7; quiz 148-50. · 0.92 Impact Factor
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Ran D Goldman
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ABSTRACT: QUESTION: Owing to Health Canada's recent recommendations to avoid the use of over-the-counter cough and cold medications in preschool children, I was looking at other antitussive medications for acute cough. Codeine was recommended in the past for this indication. What is the evidence for its use and how effective and safe is it? ANSWER: Cough is one of the most common symptoms in children, and the opioid codeine has known antitussive qualities mediated by a central nervous system pathway. However, current evidence finds codeine to be no more effective than placebo for acute cough in children. Its safety profile and recent advances in understanding codeine's variable effectiveness prohibit recommending codeine for cough in children.
Canadian family physician Medecin de famille canadien 12/2010; 56(12):1293-4. · 1.19 Impact Factor
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ABSTRACT: QUESTION: Parents of children with asthma are encouraged by many health organizations to vaccinate their children against seasonal influenza viruses. Is the influenza vaccine efficient in preventing asthma exacerbation? Are current vaccinations safe to administer to children with asthma? ANSWER: Infection with influenza viruses can cause substantial respiratory morbidity in children with underlying chronic disease such as asthma. Although vaccination against influenza does not reduce or shorten asthma exacerbations, the intramuscular trivalent vaccine is safe and has a beneficial effect on the quality of life of children with asthma.
Canadian family physician Medecin de famille canadien 11/2010; 56(11):1137-9. · 1.19 Impact Factor
