Category Archives: Pediatrics

Working While Sick: Red Badge of Courage or Scarlet Letter?

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With the respiratory virus season fast approaching, a recent study and editorial (J Szymczak et al. JAMA Pediatr 2105; 169: 815-21, editorial 809-10 -thanks to Ben Gold) are worth a look; they focus attention on the practice of working while sick.  In the study, the researchers use an anonymous survey of more than 900 physicians and advance practice clinicians working at a large children’s hospital. 83% reported working sick at least 1 time in the past year and 9% reported working while sick at least 5 times.  The authors note “some ambiguity persists around what constitutes being too sick to work, and a perception exists that sick leave is impractical.”  Most of the respondents understood that their illness could have an adverse effect on patients, but 97% did not want to let colleagues down and 94% did not want to create staffing shortages.

The editorial makes several more points:

  • Healthcare workers “will likely continue to come to work when mildly ill, especially when they identify their role as being essential for care and unique within the institution.”
  • “Working while sick was regarded as a badge of courage, and ill physicians who stayed home were regarded as slackers.”
  • The editorial argues for more clarity and/or use of key symptoms: conjunctivitis, vomiting, bloody diarrhea, fever >38.5, >2 episodes of watery diarrhea, or jaundice
  • “For many respiratory viruses, individuals are most contagious before they are highly symptomatic, so staying home after symptoms develop may not be effective or practical.”
  • For influenza, the CDC has recommended that employees “not return to work until 24 hours after they are fever free or 7 days, whichever is longer, with longer periods of time off for HCWs returning to work in a setting of high-risk individuals.”  However, with this approach, “staffing shortages would become critical.”

My take: These articles suggest a need for a culture change that supports paid sick leave that is adequate and non-punitive.  At the current time, adequate backup is often lacking.  Also, these articles serve as a reminder: it is a good idea to get your flu shot!

Why D5 1/2NS was the Right Choice in the 1950s!

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For many, a frequent practice is to order D5 1/2NS intravenous fluids for maintenance IVFs.  An expert review (ML Moritz, JC Ayus. NEJM 2015; 2015: 373: 1350-60) of this topic explains why this was right in the 1950s but is usually the wrong choice today.

Key points:

  • Use of hypotonic maintenance fluids (sodium concentration <130 mmol per liter), “has been associated with a high incidence of hospital-acquired hyponatremia and more than 100 reports of iatrogenic deaths or permanent neurologic impairment related to hyponatremic encephalopathy.”
  • Acutely ill patients have “disease states associated with excess arginine vasopressin.”
  • Recommendations on the use of hypotonic fluids were “based on theoretical calculations from the 1950s, before the syndrome of inappropriate antidiuresis was recognized as a common clinical entity.”
  • “More than 15 randomized, prospective trials involving more than 2000 patients have evaluated the safety and efficacy of isotonic fluids…most of these studies involved children…isotonic fluids were superior.” Limitations: these studies were typically <72 hours and excluded patients with renal disease, heart failure, and cirrhosis.
  • The authors also note potential problems with 0.9% NS for rapid infusion, perhaps related in part to the polyvinyl chloride bags which lowers the pH.  “0.9% saline, as compared with balance salt solutions, may produce a hyperchloremic metabolic acidosis, renal vasoconstriction, an increased incidence of acute kidney injury requiring renal-replacement therapy, and hyperkalemia.”
  • Hypotonic fluids may be appropriate in the setting of established hypernatremia or a clinically significant renal concentrating defect (with free-water losses).

My take: D5 1/2 NS and other hypotonic fluids should not be used commonly as a maintenance fluid.

Related blog posts:

Yellowstone Canyon

Yellowstone Canyon

How Much Morphine Should Be Prescribed?

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In comparison to other medications, opioid pain medications are more carefully regulated, have the potential for more severe adverse reactions, and written prescriptions are needed for dispensing. So, trying to provide the right amount is a little tricky. With this background, a recent study (M Aboud-Karam et al. J Pediatr 2015; 167: 599-604) examines the use of morphine after pediatric surgery.

This prospective study included 243 subjects. Findings:

  • 56% of participants who received a scheduled (“regular basis”) prescription administered the medication as ordered.  The most common reason for deviation was a lack of pain or mild pain relieved by acetaminophen.  33 of the 104 patients who received a scheduled prescription did not even pick up the medication from the pharmacy.
  • 85% of participants in the “as needed” prescription group were administered morphine as ordered; however, 76% of this group took two or fewer doses. In this “as needed” group, a subset of 77 participants had precise data about the amount of morphine that they received.  Less than 10 % of the prescription doses available were administered.

The authors note that morphine is covered in Canada by both private and government-based insurance plans such that there are unlikely to be financial constraints limiting medication usage.  They note that the unused medication is a safety hazard due to potential for accidental ingestions.

My take: this study suggests that prescriptions with fewer doses of morphine may be warranted.

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“Not Up For Debate: The Science Behind Vaccination”

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Wednesday’s well publicized debate unfortunately discussed vaccination.  Perhaps it is not surprising that a businessman/entertainer, Donald Trump, reiterated misinformation.  Yet, the two former physicians (Ben Carson and Rand Paul) on the stage also provided misleading information.  A good write-up of this issue from the NY Times: Not Up for Debate: The Science Behind Vaccination

Here’s an excerpt:

Here are the facts:

  • Vaccines aren’t linked to autism.
  • The number of vaccines children receive is not more concerning than it used to be.
  • Delaying their administration provides no benefit, while leaving children at risk.
  • All the childhood vaccines are important.

Parenteral Nutrition and False Positive Newborn Screens, Plus One

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Briefly noted:

“Stopping Parenteral Nutrition for 3 Hours Reduces False Positives in Newborn Screening” T Tim-Aroon et al. J Pediatr 2015; 167: 312-6. By stopping parenteral nutrition (PN), the authors reduced false-positive results for amino acid disorders among newborn screenings. In patients receiving PN, holding PN (and using IVFs) was associated with a false-positive rate of 2/65 compared with 29/245 who continued PN (3.1% vs. 11.8%; P=.037)

“Age at Weaning and Infant Growth: Primary Analysis and Systemic Review” B Vail et al. J Pediatr 2015; 167: 317-24. UK prospective study with n=571 singletons along with systemic review which identified two trials. Conclusion: “In high-income countries, weaning between 3 and 6 months appears to have a neutral effect on infant growth.  Inverse associations are likely related to reverse causality.”

 

 

Just Saying…Vaccines Don’t Trigger Inflammatory Bowel Disease

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The other day I was having a fun discussion on words that we may choose before providing information that others might not like.  Some examples:

  • “No offense but”…
  • “Don’t take this the wrong way”…
  • “Just saying”…

A recent report (GP de Chambrun et al. Clin Gastroenterol Hepatol 2015; 13: 1405-15) debunks claims that vaccines increase the risk of inflammatory bowel disease (IBD).  A report by Thompson NP et al (Lancet 1995; 345: 1071-74) suggested that measles vaccination could increase risk of IBD.  In the current study, the researchers examined 11 previous studies for review and meta-analysis.  Vaccines included: BCG, DPT, smallpox, poliomyelitis, pertussis, H1N1,measles, mumps, rubella, and combined MMR.  This study included 2399 patients with IBD and 33,747 controls. Bottomline: “Results of this meta-analysis show no evidence supporting an association between childhood immunization or H1N1 vaccination in adults and risk of developing IBD.” With regard to the measles vaccine in particular, the relative risk was 1.33 (CI 0.31 -5.80) in cohort studies and the relative risk was 0.85 (CI 0.60 -1.20) in case-control studies.

What types of words do you hear people use before saying something someone is not going to like?

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Picky Eating and Underlying Psychological Problems

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Several news outlets have summarized a recent study which showed increased risk of psychological problems associated with being a picky eater.

An excerpt of a summary is from NBC news:

Picky eating, even at moderate levels, is linked with psychiatric problems, including anxiety and symptoms of depression in kids, according to a study published Monday in the journal Pediatrics. It found the mental problems worsened as the picky eating became more severe.

“We need to do a better job of giving advice to these parents,” Nancy Zucker, study co-author and associate professor of psychology at Duke University, told NBC News.

“The first take-home message is that you’re not to blame. The second take-home message is that it’s more complicated than we think.”

The study screened more than 1,000 children ages 2 to 5, and found 20 percent were picky eaters. The researchers stress this goes beyond kids who just hate broccoli or have certain dislikes.

More than 17 percent of kids were classified as moderate picky eaters: These children had a very limited range of foods they would eat and they would not try anything else, Zucker said.

About 3 percent were considered severe picky eaters: Their sensitivities to smell or taste were so strong that even eating outside of the home was difficult. As they get older, it could be hard for them to go out with friends or eat at school. …

The researchers also note the term “picky eating” may now be obsolete. They suggest the condition might be better described as avoidant/restrictive food intake disorder (ARFID).

Also from NPR: When a Child’s Picky Eating Becomes More Than a Nuissance

 

Why a Temporary Nursery Name is a Bad Idea

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An interesting study in Pediatrics has found that avoiding temporary NICU names can result in fewer errors.  Here is the NY Times summary:

More than 80 percent of neonatal intensive-care units, or NICUs, use temporary first names for patients — Babygirl Jackson or Babyboy Goldsmith, for example — a convention that may lead to errors in prescribing medicines. A new study has found that a simple change in this procedure can significantly reduce such errors.

The NICUs at Montefiore Medical Center in the Bronx instituted a new system two years ago. They started naming babies using the mother’s first name — Jennifersgirl Jackson and Karensboy Goldsmith. Researchers compared the number of wrong-patient electronic orders of medicines in the year before the change with the number in the year after. The study, in Pediatrics, included 158,000 orders before the change and 142,000 after.

Over all, the new system reduced errors by 36.3 percent.

My Take: Both with electronic records and with ‘paper’ records, the lack of a specific name leads to errors.  With electronic records, another frustration is when multiple records for the same patient have not been merged into a single entity, allowing key information to be unavailable.

Uncle Tom's Point, Yellowstone

Uncle Tom’s Point, Yellowstone

Complex Family of CFTR-Associated Disorders

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While most clinicians are familiar with cystic fibrosis (CF), much fewer are familiar with a group of disorders related to the cystic fibrosis transmembrane conductance regulator (CFTR) that do not meet the criteria for cystic fibrosis.  A summary of these disorders is provided in a recent editorial (Levy H, Farrell PM. J Pediatrics 2015; 166: 1337-40).  In addition, the editorial provides insight into a related study: Groves T et al.. J Pediatrics 2015; 166: 1469-74.

The editorialists note that new disorders have been created due to newborn screening and due to the use of CF mutation analysis.  New disorders:

  • CRMS -CFTR-related metabolic syndrome.  CRMS describes infants with elevated immunoreactive trypsinogen and inconclusive sweat testing and DNA results.  Inconclusive sweat testing includes sweat tests 30-59 mmol/L if age <6 months or 40-59 mmol/L if >6 months on at least 2 occasions.  DNA testing is inconclusive if there are fewer than 2 CF disease-related mutations identified.  DNA testing is also considered inconclusive if there are 2 CFTR mutations but sweat testing is normal.
  • CFTR-RD -CFTR related disease.  CFTR-RD describes symptomatic individuals beyond infancy who have sweat testing <60 mmol/L and up to 2 CFTR mutations, at least one of which is not clearly categorized as a CF-causing mutation.  Thus, these individuals do not fulfill criteria for CF but could have congenital bilateral absence of vas deferens, acute recurrent or chronic pancreatitis, or disseminated bronchiectasis.
  • Delayed CF -Delayed CF describes patients eventually diagnosed with CF who had initially intermediate sweat chloride values.  Over time, their condition evolves to fulfill the criteria for CF.  In the retrospective study by Groves et al, 14 of 29 (48%) evolved to a diagnosis of CF.  These patients with delayed CF had less pancreatic insufficiency (OR 0.06), milder obstructive lung disease, less colonization with Pseudomonas aeruginosa (OR 0.04), and overall disease severity as measured by Shwachman scores at 2 years.
  • Nutritional outcomes were improved at 2 years in this Delayed CF cohort in comparison to 28 matched patients diagnosed with CF in the newborn period, but did not persist to later ages.

The editorial notes that nearly 20% of patients with CF are being enrolled in the CF foundation patient registry without sweat chloride testing results.  They do not favor this approach because the diagnosis of CF requires proof of CFTR dysfunction, not simply CF DNA mutations.

Take-home message: Patients who do not meet the criteria for CF  but who have intermediate sweat testing or abnormal CF DNA mutations need to be followed.  Some will fulfill the criteria with time and others may develop other clinical problems even without having CF.

Using NSAIDs After Tonsillectomy & More on Coffee

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Many times all of the treatment choices are flawed and choosing the least worst option is required.  A recent study (Kelly LE et al. Pediatrics 2015; 135: 307-13) helps provide some useful data regarding pain management in the setting of tonsillectomy.  I chose to highlight this study because the findings seem at odds with what I would have predicted; that is, I was surprised that, in this small study, use of ibuprofen was not associated with increased bleeding risk.

Background: More than 500,000 tonsillectomies are performed on pediatric patients each year in the U.S.  Pain control afterwards has been problematic.  Codeine-containing products now have a black-box warning for post-tonsillectomy analgesia due to risk of life-threatening respiratory failure.  So choosing between a different narcotic agent like morphine or using a nonsteroidal anti-inflammatory drug (NSAID) which could contribute to bleeding is not clear cut.  While morphine’s metabolism is more predictable than codeine, all narcotics have the potential to suppress breathing.  In addition, patients undergoing tonsillectomy have a higher risk of breathing abnormalities than the general population.

Design: Randomized control trial with 91 children aged 1 to 10 years.

Key findings:

  • No significant difference in reported pain control
  • Similar frequency of tonsillar bleeing –3 in children with ibuprofen and 2 who received morphine.
  • Children in the ibuprofen group were much more likely to see an improvement in oxygen desaturations on the first postoperative night: 68% compared to 14%.
  • One child in the morphine group had a severe drug reaction requiring admittance to the intensive care unit.

Take-home point: The researchers concluded that ibuprofen is as effective as and safer than morphine for post tonsillectomy analgesia in children, without a higher risk of bleeding.

Related blog posts:

More on coffee:

I often have discussed with families how coffee can improve bowel frequency.  Here is a link on that topic from Huffington Post:  “Why Does Coffee Make You Poop?”

Previous blogs on coffee:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.