I’d really appreciate some advice about moving to Australia from the UK to do Paeds EM and wondered if I could email anyone? Many thanks,
Jenny

Thank you for that informative discourse on reflux and cows milk protein allergy. I’m not convinced that “up to 44% of reflux is secondary to CMPA”. I might take that one with a pinch of salt… I guess it depends on the population studied but I would be flabbergasted if that were the case for our usual refluxing infants presenting to the Emergency Department or Family Medicine.
Thanks for declaring your potential conflict of interest.

Cheers

Colin

Take a careful feeding history to establish when the baby started vomiting. Did it relate to the onset of artificial feeding or if the baby has been artificially fed, how many different feeds have they been on? Is there a family history of atopy/ allergy? Did the baby start to feed and then cry in pain and now it cries as soon as the teat is put to the mouth? Does the mother try to feed the baby when it is sleepy? Is the baby constipated? It is often the reaction to the babies symptoms that leads to “overfeeding” (though there are some genuine cases)
CMPA (cows milk protein allergy) frequently presents with crying, possetting, adversive feeding and reflux. Up to 44% of reflux is secondary to CMPA. Furthermore an Australian study about 4-5 tears ago clearly showed that PPIs are ineffective in the treatment of reflux, which is logical as the drugs are not designed to prevent reflux but to supress acid secretion. The trials on feed thickeners and of comfort milk have failed to show they are efficacious too, but may be worth trying.

Paradoxically CMPA has been shown to cause constipation.
The cure is either an extensively hydrolysed whey formula or an artificial feed such as Neocate (and other). Remember some of these formulae contain lactose but of course under the age of a year this does not matter for congenital lactase deficiency is very rare, 1:100,000 and the children have profound diarrhoea and waste away. Breastmilk contains approx 7g/100ml of lactose so babies must have the enzyme. what is true is that in the majority of people worldwide the levels of lactase decline significantly in the second year of life.
With the correct therapy the vomiting will stop at around three days, the skin and constipation take up to two weeks. If they are on a synthetic feed and the baby is not significanly better then the symptoms are not due to CMPA.

Declaration of Interest: I have given international lectures on CMPA for Niutricia

We hope to keep bringing you some good stuff this year…

Cheers
Colin

Excellent website, excellent podcasts, keep it up!

Really enjoyed this one. As a beginning paediatric nurse with no kids of my own babies are scary squishy little people to me and the pemcasts have really helped me get a feel for what I need to be on the look out for.
I was lucky enough to work with some of you in the ED a while back as a student and pass on my encouragement in person, but since working upstairs I’ve come accross a few situations I’d love to hear a pemcast focus on in the future.

First up – congenital cardiac kids .. a sort of how to guide would be useful for docs and nurses to work out what to do with them investigations/treatment/observations wise when they’re well and unwell and present to us. Or even a rough guide of what to expect from the various congenital cardiac defects at different stages of life and/or repair.. what to be aware of and look for.

Secondly .. a primer on clotting and bleeding disorders in kids? or siezure disorders.. might be useful.

Keep up the great work,

Regards,
Ben

In regards to all of your podcasts (not specifically this one),
I love the topics and content so much that I wish I could listen to a whole podcast. Unfortunately, the sound quality is poor and volume variation between speakers is so great, that I find myself constantly raising and lowering the volume.

It’s rather unsafe for me to do this while driving, so please fix it so I can listen to your wonderful podcasts.

Thanks,
SD

Thanks for your comment, and the link from your related excellent post on your Broome Docs blog – well worth a read and adds a lot to our PEMcast.
Keep up the webucation!

Cheers

Colin

I think I will try to change my departmental preferences / practice, but still look at the individual kid before throwing Panadol at them.

Casey

Good to hear an antipodean accent on there for a change Colin!

BTW, I forgot who taught me that pen lid trick…

Chris

While the benefits of vaccination against rotavirus has been well established, the recent study by Patel et al. (1) compared the historical intussusception data from the rotavirus vaccine, RotaShield, as approximately 1 case of intussusception in 10,000 recipients (2,3) to the current more favorable intussusception data for RV1 in Mexico and Brazil within 7 days of the first dose. This is misleading to the reader since a more recent re-evaluation of RotaShield (4) would indicate that the magnitude of the relative risk of intussusception with RotaShield may be dependent on the age at which the infants received their first dose of the rotavirus vaccine. In the RotaShield studies (2,3,4) the mean age of infants receiving their first dose was 97 days, in the Patel et al. report (1), the median age of infants receiving the first dose of RV1 was 68 days in Mexico and 64 days in Brazil. Because of the rapid increase in the background rate of intussusception in this age range, these age differences at first dose may be very significant. The background rate for intussusception tends to increase very rapidly after 2 months of age and peaks at or near 6 months of age worldwide. In the previous analysis of RotaShield (4), of the 71,000 infants that had received their first dose of RotaShield when they were younger than 60 days of age, there were no cases of intussusception within a 30 day period following their first dose. The majority (>80%) of intussusception cases associated with RotaShield within 7 days of receiving the vaccine occurred in infants that were older than 90 days of age on receiving their first dose. Therefore, the cited example of 1 case of intussusception in 10,000 recipients of RotaShield is only valid for older infants (mean age of 97 days) receiving their first dose. If the RotaShield data is analyzed for intussusception based on a younger age of vaccination (4), the safety data is very comparable to RotaTeq and Rotarix.

The background rate of intussusception is basically zero at or near birth and a viable strategy to minimize or eliminate the risk of intussusception by immunizing infants against rotavirus during the neonatal period was proposed by leading rotavirus researchers a number of years ago (6) and has now been tested in a Phase II clinical trial in Ghana with 1,000 infants using a neonatal dosing protocol with RotaShield. Retrospective analyses (4) indicates that RotaShield may be safely administer to neonates and younger infants. This Phase II trial has been successfully completed and while not powered to evaluate the relative risks of intussusception, there were no cases of intussusception following the first dose. The results of the Phase II trial should be published in the near future.

Neonatal immunization (administration of the first dose at or near birth) may be the only viable strategy to minimize or eliminate the risk of intussusception. This is the strategy that is being used by the International Medica Foundation to bring RotaShield back to the market as a safe, effective and affordable rotavirus vaccine.

1. Patel MM, López-Collada VR, Bulhões MM et al. Intussusception Risk and Health Benefits of Rotavirus Vaccination in Mexico and Brazil. N Engl J Med 2011; 364:2283-2292
2. Murphy TV, Gargiullo PM, Massoudi MS, et al. Intussusception among infants given an oral rotavirus vaccine. N Engl J Med 2001;344:564-572
3. Peter G, Myers MG. Intussusception, rotavirus, and oral vaccines: summary of a workshop. Pediatrics 2002;110:e67-e67
4. Simonsen L, Viboud C, Elixhauser A, Taylor RJ, Kapikian AZ. More on RotaShield and intussusception: the role of age at the time of vaccination. J Infect Dis 2005;192:Suppl 1:S36-S43
5. Buttery JP, Danchin MH, Lee KJ, et al. Intussusception following rotavirus vaccine administration: post-marketing surveillance in the National Immunization Program in Australia. Vaccine 2011;29:3061-3066
6. Kapikian AZ, Simonsen L, Vesikari T, et al. A hexavalent human rotavirus-bovine rotavirus (UK) reassortant vaccine designed for use in developing countries and delivered in a schedule with the potential to eliminate the risk of intussusception. J Infect Dis 2005;192:Suppl 1:S22-S29

Purssell E.
Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child. 2011 Aug 24. [Epub ahead of print] PubMed PMID: 1868405.
http://www.ncbi.nlm.nih.gov/pubmed/21868405

There are 2 things in Dr Purssell’s conclusions that I love:
“While it is tempting to conclude that further research should be undertaken, based on the small
size and short duration of most existing studies, this is not really necessary.”
and
“there is little to recommend the unnecessary use of polypharmaceutical methods to treat a symptom that does not require treatment, when effective monotherapies exist.”

This systematic review included six studies looking at potential benefits and harms of combining antipyretic agents. Unfortunately the small sample size, heterogeneity and inpatient setting of these studies all stand in the way of being able to combine their data and generalise to our ED patient population. Although there was no evidence of harm, the included studies were underpowered (and not specifically designed) to detect adverse effects. The author correctly points out that it would be uncool to embark on a large study to look for evidence of harm, when the potential benefits are dubious. Nice work.

But if you are an asthma sufferer, it can seem at times that anything – even something as mysterious as acupuncture – is worth trying. Breathing is something that most us never think about. It’s an unconscious process and unless we’re ill, we easily get the oxygen we need. But for people with asthma, breathing is always on their minds. There is always the chance that an asthma attack will leave them gasping for air. Sometime these attacks are predictable and sometimes they are not, sometimes they are minor and easily handled at home, and sometimes asthma suffers end up in an emergency room. It’s no wonder that some asthma sufferers have turned to acupuncture for asthma.

Asthma is a chronic disease with no cure. There are different types of asthma, but they all produce the same signs and symptoms: rapid breathing, sweating, rapid heartbeat, and the uncomfortable sensation of suffocation. The exact cause of asthma is not known (there may be a genetic factor at work), but there is no doubt that environmental factors – cold, dust, pollution, etc – trigger the attacks. During the attacks, inflammation and constriction of the respiratory passages limit the amount of air that can be inhaled, the attacks can last for minutes or hours and as mentioned earlier, there is no cure. But although there is no cure, there are constant efforts to find new methods of treatment, and there are practitioners and patients who believe that acupuncture for asthma is the answer.

Acupuncture (the word comes from the Latin words acus, meaning needle, and pungere, meaning to puncture) is a very old system of medicine. It is not clear where acupuncture originates from, but it has been most closely associated with China. In acupuncture, very narrow needles are inserted into the skin (just barely penetrating the surface) at certain key points in the body. The needles are said to correct a disharmony in the flow of energy through the body, a disharmony that is said to be the cause of disease. Traditional, Western medicine has several theories about how acupuncture works (e.g., it may stimulate the release of natural pain relievers, endorphins) but has not yet completely explained how acupuncture.

Of course, the big question is, does acupuncture work? And can acupuncture successfully treat asthma? Well, not unlike the search for an explanation for how asthma works, the answers are not clear – and they depend on whom you ask. According to traditional acupuncturists, yes, acupuncture for asthma is an effective treatment, especially with asthma in young children. There are dozens of websites and thousands of testimonials that all attest to the effectiveness of acupuncture as a treatment for asthma. Acupuncture, they say, has worked where nothing else has.

But ask the same question – does acupuncture for asthma work – of doctors and scientists who have been trained in traditional, Western medicine and scientific methodology, and the answer will be quite different. Acupuncture, they say, is as interesting phenomenon, but the question of how it works is less important than the question does it work, and their answer to that is no. There is no conclusive evidence that acupuncture for asthma works, and a review of the scientific studies that have attempted to answer this question have not proven acupuncture to be a viable technique for treating asthma. If there are reports that it works, these can be explained by the placebo effect (The placebo effect states that medications or medical techniques/ procedures may be perceived by the patient as effective because they believe they are effective, but there is no measurable effect).

So can acupuncture truly help someone who suffers from asthma? That seems to depend on your point of view. If you feel that illness is caused by disruption in energy flow and you are convinced by anecdotal reports, the only reasonable answer is: try it and find out. Acupuncture for asthma is very safe; serious adverse effects are very rare. But if you are the type of person who needs proof in the traditional sense, it may make more sense to stick with the medications/therapies you are taking and wait for solid evidence that acupuncture can help treat your asthma. your car receiving a tune-up before it is in need of a repair.

My main concerns are more related to antipyretic use in general:
-Increasing fever phobia in parents, by emphasising the apparent role of lowering the temperature
-Antipyretics may prolong the duration of illness and are not free of side-effects
When it comes to combining different agents, there is a possibility of doing errors, especially for tired/stressed parents, with multiple different formulations and strengths for both agents.

Both the American Academy of Pediatrics and the NICE Guideline on Feverish Illness condemn the practice of alternating antipyretics.
http://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Medications-Used-to-Treat-Fever.aspx
http://egap.evidence.nhs.uk/CG47/section_1#section_1_6

Until we see some definite evidence of harm, it’s up to you, the clinician, to balance these concerns against the perceived benefits of comfort, for symptomatic children with fever.

Fleming S, Thompson M, Stevens R, Heneghan C, Plüddemann A, Maconochie I,
Tarassenko L, Mant D. Normal ranges of heart rate and respiratory rate in
children from birth to 18 years of age: a systematic review of observational
studies. Lancet. 2011 Mar 14. [Epub ahead of print] PubMed PMID: 21411136.

http://www.ncbi.nlm.nih.gov/pubmed/21411136

These researchers from Oxford, UK and Oregon, USA have analysed data from 69 original studies, to produce a new evidence-based set of centile charts for normal respiratory rate and normal heart rate ranges according to age.

Be sure to get the webappendix supplement; page 13 of the document contains a table of cutoff values for various centiles, by age range.

I wonder whether this will result in a change to the established cutoffs used by international bodies such as APLS, and how long this will take?

Fleming S, Thompson M, Stevens R, Heneghan C, Plüddemann A, Maconochie I,
Tarassenko L, Mant D. Normal ranges of heart rate and respiratory rate in
children from birth to 18 years of age: a systematic review of observational
studies. Lancet. 2011 Mar 14. [Epub ahead of print] PubMed PMID: 21411136.

http://www.ncbi.nlm.nih.gov/pubmed/21411136

These researchers from Oxford, UK and Oregon, USA have analysed data from 69 original studies, to produce a new evidence-based set of centile charts for normal respiratory rate and normal heart rate ranges according to age.

Be sure to get the webappendix supplement; page 13 of the document contains a table of cutoff values for various centiles, by age range.

I wonder whether this will result in a change to the established cutoffs used by international bodies such as APLS, and how long this will take?

Markers for bacterial infection in children with fever without source
Sergio Manzano, Benoit Bailey, Alain Gervaix, Jocelyne Cousineau, Edgar Delvin, Jean-Bernard Girodias
Archives of Disease in Childhood (advanced online publication 29 January 2011) – no PubMed listing yet!

Their results suggest that blood tests are superior to clinical evaluation by a Paediatric Emergency Physician… but I have some concerns:

Firstly, the clinical evaluation did not include a urinalysis or urine microscopy – and the commonest SBI (by far) was UTI (48 out of 54 Serious Bacterial Illness patients, 89%). Perhaps we could have avoided blood tests in these children.

Secondly, more than 20% of the study population were excluded from analysis due to insufficient blood sample quantities – 93 out of 457 patients. Seven percent of the excluded patients had SBI (all were UTIs). This reminds me of the awkward situation where you decide to do blood tests, but are unable to get the required samples – do you bail out and revert to clinical observation, or keep trying repeatedly to get the blood sample?

Thirdly, despite the authors minimising the importance of clinical evaluation, their results show (in Table 5 and Table 6) that a strong clinical suspicion of SBI (as evidenced by a Visual Analogue Scale of greater than 50%) increased the likelihood of SBI two-fold (LR+ 2.2) overall, and seven-fold (LR 7.5) when UTIs were excluded. This means that the child’s risk of SBI goes from 3% to 19%, when you exclude the UTIs, and the clinician is worried.
I do accept that clinical evaluation is less helpful at excluding SBI though, with negative Likelihood Ratios (LR-) of 0.7 when the clinical suspicion of SBI was less than 25%. This takes the risk of SBI from 3% to 2% when UTI patients are excluded.

This is a good prospective effort at figuring out how useful these blood tests are at predicting SBI in the FWS situation, but it would have been great if these tests were included as part of a clinical strategy including urine microscopy before blood tests, in all except the sickest and youngest patients. The urine microscopy may have missed a small number of UTIs, but I suspect that if one of the tests examined in this cohort of patients was “urgent microscopy of catheter specimen urine “, it would have out-performed all the other tests, including clinical evaluation.

I worry that the pendulum is going to swing back towards doing more blood tests as a Risk Minimiser approach, if we accept these findings at face value.

What do you think?

Kuzik BA, Flavin MP, Kent S, Zielinski D, Kwan CW, Adeleye A, Vegsund BC, Rossi C.
Effect of inhaled hypertonic saline on hospital admission rate in
children with viral bronchiolitis: a randomized trial.
CJEM. 2010; 12:477-84.
http://www.ncbi.nlm.nih.gov/pubmed/21073773

The first by Ralston, Hill and Martinez was published online in Pediatrics in August 2010 – a retrospective cohort study which showed a low rate of adverse events when nebulised hypertonic saline was given without adjunctive bronchodilators:
Ralston S, Hill V, Martinez M. Nebulized hypertonic saline without adjunctive
bronchodilators for children with bronchiolitis. Pediatrics. 2010; 126:e520-5.
http://www.ncbi.nlm.nih.gov/pubmed/20713480

The second paper by Al-Ansari and colleagues prospectively compared 5% hypertonic saline to normal saline. Unfortunately the patient group may not be representative of our usual bronchiolitis patients, with a median age of 3 months, relatively less severe disease, and relatively late enrolment (around 4 days of prior symptoms):
Al-Ansari K, Sakran M, Davidson BL, El Sayyed R, Mahjoub H, Ibrahim K.
Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in
infants. J Pediatr. 2010; 157: 630-4, 634.e1.
http://www.ncbi.nlm.nih.gov/pubmed/20646715