Investigators Shirley Y. Huang, M.D., and David S. Greenes, M.D., of Children's Hospital in Boston were surprised to find significantly higher measured temperatures in 187 infants who had been given antipyretics before arriving in the emergency department, compared with 287 infants who had not been pretreated.
Although parents reported giving fever reducers to 40% of study population, it turned out that the doses often were inadequate. Only 10% had received a therapeutic dose 1–5 hours prior to coming to the emergency department, according to the authors. Dr. Radetsky said the article addresses a common conundrum: how to manage a child after a parent reports antipyretic use.
“The results of the article are that even if you have a history of having Motrin or Tylenol, it doesn't alter what you measure,” he said. “You can trust your measurement. No fever is no fever. The management decision should depend on what you measure at the time you do the evaluation.”
Pulse Oximetry, Bronchiolitis Discharge
Dependence on pulse oximetry readings can delay discharge of infants hospitalized for bronchiolitis, reported Alan R. Schroeder, M.D., and his associates at the University of California, San Francisco (Arch. Pediatr. Adolesc. Med. 2004;158:527–30).
The retrospective chart study found 16 of 62 infants were kept in the hospital an average of 1.6 days until they reached a pulse oximetry goal despite having met all other criteria for discharge. The authors detected trends toward younger age, lower oxygen saturations at admission and discharge, and increased number of cutoffs in oxygen saturation among the patients with prolonged stays.
They could not determine whether the prolonged stays were beneficial or harmful, however. They noted wide variability among institutions in the setting of minimum saturation levels.
Dr. Radetsky warned against “the tyranny of the continuous pulse oximeter.” He said pediatricians should use it in the office when deciding whether to hospitalize a patient; once the infant is admitted, however, he said to use it sparingly, especially in stable or improving patients.
“When you should give oxygen and when you should discharge, no one knows,” he said, adding that physicians should “avoid entrapment by data that has no clinical importance.”
Diarrhea Etiology Elusive
Stool testing turned up a bacterial pathogen in just 12 (5.3%) of 226 Seattle children enrolled in a prospective study of diarrhea in pediatric outpatient settings (Pediatr. Infect. Dis. J. 2005;24:142–8). Additional screening of smaller subgroups identified 1 child with a parasite, 8 with Clostridium difficile toxin, and 16 with viruses.
Donna M. Denno, M.D., of the University of Washington, Seattle, and her associates reported comparable results from two study sites: a private practice and a clinic in a municipal hospital serving a largely immigrant population.
The investigators associated bacterial infection with visible fecal blood, increased stool frequency, abdominal tenderness, and white or red cells in the stool. They noted, however, that 75% of children without a bacterial infection had at least one of these risk factors. Their conclusion: “Exclusion criteria for stool testing in diarrhea remain elusive.” Dr. Radetsky said that in most patients, conventional laboratory testing did not turn up a cause. His conclusion: “Stool cultures are infrequently needed in ambulatory practice.”
New Treatment for Head Lice
Dale Lawrence Pearlman, M.D., a dermatologist in Menlo Park, Calif., reported a 96% cure rate and 94% remission rate in two open clinical trials of a new treatment for head lice (Pediatrics 2004;114:e275–9).
Dr. Pearlman holds patents for Nuvo lotion, which he tested in 133 children recruited as being hard to treat. He declared Nuvo lotion to be the first in a new class of nontoxic lotions that he called dry-on, suffocation-based pediculides.
The report has drawn an accusation of hype (Lancet 2005;365:8–10), and the product has been likened to hair conditioner, according to Dr. Radetsky. Nonetheless, he held out hope that controlled trials could prove it to be “the up-and-coming treatment of choice.”
A new treatment is needed, he said. “Things are not going well for those of us that treat head lice. The success rate is going down. There are failures for head lice all over the place.”
A Bacterial Cause of Conjunctivitis?
Investigators from the University of Amsterdam in the Netherlands have come up with a scoring system for predicting a positive bacterial culture in a patient with conjunctivitis (BMJ 2004;329:206–10).
General practitioner Remco P. Rietveld, M.D., and his colleagues have proposed point values for glued eyes in the morning, itch, and history of conjunctivitis. Physicians use a patient's total points, based on a scale of −3 to +5, to calculate the probability of the patient testing positive. Though widely used, purulent secretion is almost diagnostically noninformative, the investigators said.