Publications

This review examines recent research suggesting that intranasal administration of midazolam is at least as effective as the intravenous route for seizure cessation. Intranasal administration delivers the drug directly to the blood and cerebrospinal fluid via the nasal mucosa. It has been found to be safe, effective, and easy to use by parents and paramedics.

Detecting and quantifying pain in infants and young children is a complex task because young children cannot communicate this subjective phenomenon. In the 1950s, it was postulated that there might be "wound hormones" produced in injured tissues that activated the pituitary-adrenal axis. Research in adults demonstrated that plasma levels of different hormones, including corticosteroids, cathecholamines, growth hormone, and insulin, changed in response to emotionally and physically stressful stimuli. Stress response is the term given to those hormonal and metabolic changes that follow injury or trauma, but the debate as to whether increased stress response is a sign of pain or whether decreased stress response is a sign of diminished pain has not yet been resolved. Following the study of systemic response to surgery, the ability of anesthetic agents to substantially attenuate intraoperative and postoperative stress response has been reported. In newborns, a strong correlation between preoperative stress and postoperative complication rate was found. The full extent of the vulnerable infant's pain is still poorly understood, but further research of known biologic markers and newly discovered ones could promote our understanding of the pain response and increase our ability to prevent undesirable outcomes.

This study evaluated the efficacy and safety of naproxen (10-20 mg/kg/d) for the treatment of arthritis and fever related to rheumatic fever in 19 children. Fever and arthritis resolved within a median of 1 day of beginning treatment (range, 1-2 and 1-30 days, respectively). The sole patient with prolonged arthritis had small joint involvement. No gastrointestinal, dermatologic, liver, or renal side effects were observed. None of the patients developed carditis over the following 6 months. Naproxen appeared to be effective for the treatment of arthritis and fever related to rheumatic fever and was well tolerated.

No evidence indicates that killed influenza vaccine is teratogenic, even if given during the first trimester. Since 1996, Health Canada's Centre for Disease Control and Prevention has recommended that pregnant women in their second and third trimesters be vaccinated. This should not be interpreted as evidence that the vaccine is teratogenic in the first trimester because such evidence does not exist.

Acetaminophen is used frequently to treat children with fever. Rectal administration of acetaminophen is useful when a child has a fever and oral administration is impossible for various reasons (e.g. vomiting). This survey of 231 parents who had come to an emergency department (ED) because their children had fever showed that only 33.6% of them knew acetaminophen was available as a rectal suppository. Educating parents about the possibility of giving acetaminophen rectally might serve to lower the number of parents attending emergency departments.

Some authorities recommend that patients who require colchicine therapy during pregnancy undergo amniocentesis with karyotyping. This is because colchicine passes through the placenta in humans, is teratogenic in animals, and raises rates of male and female infertility. However, an increasing body of evidence suggests that colchicine use throughout pregnancy carries no substantial teratogenic or mutagenic risk when used at recommended doses. Its use prevents febrile attacks of FMF and reduces the frequency of renal complications.

The study's aim was to evaluate the antipyretic effects and safety of ibuprofen compared with acetaminophen in febrile children. Ibuprofen was significantly more effective than acetaminophen in reducing fever after a single dose. Ibuprofen was found to be more effective after 6 hours, but not after a longer period of time. Studies with multiple doses have also failed to show that one drug is better than the other. The efficacy and effectiveness of acetaminophen and ibuprofen in their recommended dosages are similar, with slightly more beneficial effects shown with ibuprofen.

Nasal administrations of drugs have several significant advantages over oral administration. The current review summarizes available information on the use of intranasal drug delivery for children with acute illness. Midazolam (Versed), Fentanyl, Diamorphine and Ketamine are discussed.

This study’s aims were to document accuracy of parental administration of acetaminophen to febrile children after visiting the emergency department (ED), as well as identify parents who did not administer an optimal dose to their children and thus deciding not to visit the ED if the fever diminished at home. We found that a significant portion of our population underdose acetaminophen, reflecting lack of knowledge or misuse, and the majority of visits for fever might have been prevented if parents had been successful in their efforts to reduce temperatures to below what they considered a 'fever'.

The study evaluated the role of a liposomal lidocaine (ELA-max) in local anesthesia in children and compared it with eutectic mixture of local anesthetics (EMLA). ELA-max has been shown to be as effective as EMLA for venipuncture in children, but with a faster onset. Adverse effects, such as transient blanching with redness and erythema, have been reported. Further investigation is needed to determine the safety and effectiveness of ELA-max on other painful procedures in children.

Reduction of inguinal hernia in children is an urgent painful procedure. No recommendations exist for analgesia during this procedure. Of the 96.7% of surveyed pediatric emergency physicians (PEP) and pediatric surgeons (PS) that give analgesia or sedation during reduction, PS were more likely to use intravenous drugs, try for a longer time, wait longer between trials, and conduct more trials compared to the PEP. Clinically related variables were more important for PEP and system-related variables for PS for analgesia and sedation.

Intramuscular epinephrine injection is the mainstay of treatment for anaphylaxis, being both safe and effective. Treatment should be administered as soon as possible following a reaction, as delays have been shown to cause an increase in mortality and rate of biphasic reaction. Efforts should be made to ensure that auto-injectors have not expired.

Acetaminophen and ibuprofen are the most common over the counter (OTC) drugs for pediatric fever and pain. Their use is driven mainly by parental “fever phobia” as denoted by Schmidt1. Although many clinicians suggest not being so vigorous about managing fever, others recommend an antipyretic as soon as fever begins. The recommendations in the recent literature varied between the “very safe” acetaminophen to the “slightly more effective” ibuprofen. However, answering a parent’s question about which drug is “better” was difficult. Previous systematic reviews could find no definite clinical difference between the two drugs because few prospective, methodologically-sound papers were published about it. Moreover, drug dose was different in these studies, and comparing the different outcome measures was almost unpalatable.

This meta-analysis uses a methodological foundation and statistical approach that allows the authors to compare the effectiveness of the drugs, mainly to evaluate change in fever. Using a higher point-estimate of the mean effect-size, they conclude that ibuprofen 10 mg/kg is better than, and as safe as, acetaminophen 10-15 mg/kg. This recommendation seems to tilt the balance in favour of ibuprofen. However, these results should be taken with a pinch of salt. Firstly, the ten papers used in the meta-analysis for fever management suffer from a small sample size and low power. The assortment of outcome measures used in these studies could have underpowered the meta-analysis, especially since Perrott, et al. used the ‘standardized effect,’ a method with questionable reliability. Secondly, the variety of doses used in the studies to date could also make the interpretation challenging. In many institutions, acetaminophen is used at 15 mg/kg, 50% more than administered in most studies, and a difference that could alter the findings is illustrated here. Thirdly, adverse events are traditionally under-reported, and almost all studies have suffered from under-description of adverse event types and methods used to collect the information. The battle between the “safe camp” and the “efficacious camp” is not over, although both drugs seem to be relatively safe. Most importantly for readers of this well-written paper is the arguable fact that the analysis included only a single dose comparison. Studies with multi-dose acetaminophen or ibuprofen are scarce but represent the “reality show” at home, in the office, or in the pediatrics ward. Is the safety of multiple doses still close-to-equivalent between the two drugs? Is the effectiveness of ibuprofen still slightly better? These questions are still to be answered in future large, prospective studies and leave us somewhat uncertain about what to say when parents inquire which drug is "better".

The objective is to document the use of analgesia for children with acute abdominal pain in the Pediatric Emergency Department (ED) and to compare children with suspected appendicitis in a high versus low probability. Probability of appendicitis before any imaging was recorded. A follow-up call was made to verify final diagnosis. Of 438 patients, 16% with appendicitis and analgesics were given only 154 times to 112 patients. 15% received multiple dosages. Underdosing was recorded in 14% of medications, mostly morphine (24%). Analgesia was given significantly more often to children with high probability of appendicitis. Age was not a factor in analgesia administration. The conclusion is that children with abdominal pain receive more analgesia when the physician suspects appendicitis, but only in half of the cases. Furthermore, only 15% receive opioids.

Topical anesthetics such as EMLA, amethocaine gel and ELA-Max have been shown to significantly reduce pain from venipuncture in children. However, additional studies are still required to confirm its safety and efficacy in pediatric procedures.

While there is currently no definitive answer, the risk of Bell’s Palsy becoming permanent seems exceptionally small in children (even smaller than in adults), and the best evidence demonstrates no benefit from steroids. Given the natural history of spontaneous recovery in most pediatric patients, steroid therapy is currently not indicated for Bell's palsy. A large randomized controlled trial is needed to establish whether steroids benefit children with Bell’s palsy. Family physicians and pediatricians should consider referring these patients to neurologists and instituting supportive measures that protect the cornea, such as daytime eye drops, nighttime eye ointment, and avoiding placing eye patches and tape directly on the eyelid.

Desmopressin reduces nocturnal enuresis. When used in combination with conditional alarm therapy and behavior therapy, long-term and intermittent use of desmopressin can help achieve a good remission of nocturnal enuresis.

Vitamin E is the main lipid-soluble antioxidant in the skin. Several anecdotal reports have suggested that topical use of vitamin E cream can reduce scar formation. Current evidence from the literature, however, does not support that proposition. In fact, studies report some adverse effects with use of vitamin E. Further research is needed before application of vitamin E cream becomes the standard of care.

This review discusses the effects of opioid analgesia administration on pain relief in children with acute abdominal pain, and the diagnostic accuracy of their illness. In the past, recommendations to suspend analgesia in children suspected of having surgical emergencies were made in order to avoid masking physical signs prior to surgical evaluation. These recommendations have been recently challenged and current evidence does not support withholding analgesia in these children.

The purpose is to document analgesic use for limb and clavicle injuries in the pediatric emergency department (ED) and to determine whether a physician-oriented pain scale form on the patient’s chart would enhance the administration of analgesia. We used 4 crossover periods, 2 with the pain scale form on the patient's chart and 2 without. A total of 310 patients were recruited, 62% had sustained fractures. Only 24 (20%) in the study group and 22 (14%) in the control group received sufficient analgesia (P = .13). The median time to physician-initiated analgesia after arrival was 2.0 hours (1.0 to 3.3 hours), without a significant difference between groups. Pain control was 4-fold more appropriate in children receiving opioids versus nonopioids. Physician pain reminders did not enhance the administration of analgesia and other measures should be taken to increase the dispensing of analgesia.

Several significant differences exist between the pediatric residents and emergency medicine residents in using analgesia and sedation for painful procedures. Pediatric residents use less injectable local anesthesia for lumbar puncture in children and more sedation for the procedure and have had notably less training in the use of sedation. Pediatric residents have more teaching responsibilities than their emergency medicine resident colleagues and are inconsistently recommending the use of local anesthetics for lumbar puncture.

Amphotericin B is the treatment of choice for severe systemic fungal infections. Nephrotoxicity is the most clinically significant adverse effect. Nephrotoxicity includes decreased glomerular filtration rate and distal tubulopathy with urinary loss of potassium and magnesium, renal tubular acidosis, loss of urine concentrating ability, and sometimes Fanconi's syndrome. Mechanisms to prevent nephrotoxicity include the use of lipid formulations such as amphotericin B lipid complex, amphotericin B colloidal dispersion, liposomal amphotericin B and the concurrent use of volume repletion. Amiloride can be considered in serious potassium loss.

Amphotericin B, an amphoteric polyene macrolide antibiotic, is the treatment of choice for severe systemic fungal infections: meningitis suspected to be due to fungi, fungal peritonitis, and bladder fungal infections. Nephrotoxicity is an important adverse effect of amphotericin B, and although risk factors for nephrotoxicity in adults have been investigated, studies examining nephrotoxicity in the pediatric population are scarce. The results show a relatively high rate of nephrotoxicity among our children treated with amphotericin B. This could be a result of ontogenic differences in its pharmacokinetics and contrary to the protocol used in our hospital—most notably, fluid resuscitation while treating with amphotericin B. To avoid nephrotoxicity, clinicians should consider the use of amphotericin B for patients with proven fungal infection and limit the use of the drug as a prophylactic agent. Future research should determine if fluid resuscitation and close monitoring in children can limit the role of costly alternatives to amphotericin B, such as lipid preparations or liposomal amphotericin

The purpose of the study is to document prehospital analgesia for children with extremity injuries at home or en route to the hospital. Two parallel groups of patients with fractures or soft-tissue injuries were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. A total of 310 patients were recruited and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and soft tissue injury. Of the patients, 78% had prehospital analgesia, 73% received first aid (icing, immobilization), and 37% received medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures. In conclusion, most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.

In children with acute otitis media, intramuscular ceftriaxone is favorable as a second-line therapy to amoxicillin, when there is possible drug malabsorption and problematic drug administration in non-compliant families.

The aim of this study is to determine the rate of opioid analgesia in children with abdominal pain presented to the pediatric Emergency Department (ED), and to identify factors associated with administration of opioids. Few pediatric patients with abdominal pain are treated with pain medications. The decision to use opioid analgesia for acute abdominal pain in the pediatric ED is influenced by acuity level, pain score documentation in triage, and location of abdominal pain.

Due to the lack of evidence revealing the benefits of codeine and its tendency to have more side effects than other cough suppressants, codeine should not be the first choice for antitussive therapy in children.