Paediatric emergency research highlights 2006–2007

The following articles were selected from the paediatric emergency literature of the past year. They have been selected based on four criteria – scientific quality, relevance to physicians caring for children, problems dealing with high acuity or prevalence, and topics that may lead to a change in care. This was a retrospective case series of blood cultures obtained from previously healthy children aged three to 36 months taken in the outpatient clinic and emergency department (ED) setting over a five-year period (1998 to 2003) during the postpneumococcal vaccine era. Of 1077 unique blood cultures, 656 were identified as contaminants and 352 were positive for pathogenic bacteria. The percentage of blood cultures positive for Streptococcus pneumoniae decreased from 79% to 34%, while those positive for Escherichia coli rose from 7% to 34%. The overall pathogenic bacteremia rate decreased from 1.62% to 0.71% over the same period. The contamination-pathogen ratio increased from 1.2:1 to 2.3:1. A white blood cell count greater than 15×109/L had a 74% sensitivity and a 55% specificity for pathogenic bacteria during the past two years of the study. This study highlighted three main points – the diminishing rate of pathogenic bacteremia in this age group over the past five years, the redistribution of the types of bacteria, and the significant likelihood of obtaining a contaminated blood culture. In the postpneumococcal vaccine era, routine blood cultures, white blood cell counts and empirical use of antibiotics for fever without source appear to be less useful for the physician and patient, whereas urinalysis with culture appears to be more important. All children with E coli bacteremia had a positive urine culture with 50 times higher odds of having a positive urinalysis compared with the blood culture-negative group. This study will potentially reduce the number of blood cultures taken and increase the number of urine examinations. A note of caution is that the findings can only be extrapolated to febrile children who live in an area where pneumococcal vaccination is routinely given. This was a prospective, randomized trial of oral ondansetron versus placebo given to children six months to 10 years of age with gastroenteritis and mild to moderate dehydration on arrival in the ED. The primary outcome was the proportion of children who vomited in the first hour of treatment with oral rehydration. The ondansetron group vomited 14% of the time versus 35% of the children in the placebo group, P<0.001 (RR 0.40, 0.26–0.61). The mean number of vomiting episodes was 0.18 versus 0.65 in the ondansetron versus placebo group, P<0.001 (RR 0.30, 0.18–0.50). Hospitalization was not significantly different between groups. Ondansetron has worked well in the paediatric oncology wards. There is hope that it might work for children with vomiting-associated gastroenteritis. This was one of three studies (1,2) published or presented in 2006 on ondansetron use in children in the ED. The three studies had different primary outcomes. The results in this study were statistically significant but it is not clear if they are clinically significant. Per patient, the decrease in number of vomiting episodes was 0.47 with an increased oral intake of 43 mL in favour of ondansetron. These improvements may be offset by the 0.9 increase in the number of diarrheal episodes seen in the ondansetron group. This is a well-designed study suggesting a role for ondansetron, but a larger study is still needed before there is acceptance for ondansetron as routine therapy for the child arriving in the ED with gastroenteritis and vomiting. It is in keeping with a recent Cochrane review (3) on the subject. This was a prospective, randomized, double-blinded trial of children two to 16 years of age comparing the use of single-dose oral dexamethasone (0.6 mg/kg, maximum 18 mg) with five days of twice-daily prednisolone (1 mg/kg per dose, maximum 30 mg) in the management of mild to moderate asthma. The primary outcome was the number of days to return to baseline based on the patient self-assessment score. Results were nonsignficant – 5.21 days in the dexamethasone group versus 5.22 days in the prednisolone group, respectively. Overall admission rates were similar between the two groups. Prednisolone therapy for asthma is recommended in most paediatric guidelines for moderate and severe asthma. However, prednisolone is associated with vomiting or poor compliance with the prolonged regimen. Two days of oral or a single dose of intramuscular dexamethasone have been found to be effective in acute asthma therapy (4,5). The advantage of single-dose oral therapy is that it can be taken during the hospital visit, the need for a prescription may be eliminated, compliance is assured, and most importantly, the rate of vomiting may be reduced. However, it has a longer time to onset of action, potentially resulting in a prolonged ED stay or increased admission rates (not found in this study). This study included mild and moderate asthmatic patients. Routine steroid therapy is not recommended in mild asthma (6). Future studies limited to a large group of patients with moderate disease and varying doses of dexamethasone would be helpful. This article was written as a summary of seven peerreviewed articles selected from a MEDLINE search that yielded 54 articles on the topic. Low voltage was normally considered to be 120 V to 240 V through household outlets or through wire; however, the definition of low voltage is said to be less than 600 V to 1000 V. All of the articles were retrospective, involved some or all paediatric patients, and ranged in numbers from 35 to 224 patients; 672 of 720 patients (93%) were seen in a children's hospital. The article concluded that asymptomatic children exposed to low-voltage household electricity do not sustain significant injury. The conclusion was that asymptomatic children can be safely discharged from the hospital without an electrocardiogram or inpatient cardiac monitoring after a low-voltage household electrical exposure that is not associated with water contact. It is difficult to gather large data on this subject, and most ED physicians agree that the risk for this type of injury is low. Despite this, there is a great deal of practice variation. This article is valuable because the conclusion is written very clearly and is of practical value to all physicians faced with this problem. The question that arises is whether the child even needs to come to the hospital if the source of the electrical injury is clear and the child is well.

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