Safety of airway clearance combined with bronchodilator and hypertonic saline in non-hospitalized infants with acute bronchiolitis

Background: Acute viral bronchiolitis (AVB) is associated with significant morbidity and no study has addressed the safety of airway clearance techniques (ACT) for non-hospitalized infants. This study aimed to evaluate the safety of the use of ACT combined with bronchodilator and hypertonic saline in non-hospitalized children with the first episode of AVB.Methods: A quasi-experimental study of infants aged 2–12 months, with a clinical diagnosis of AVB (mild to moderate), was performed. The Wang score, breathing frequency, oxygen saturation (SpO₂), heart rate (HR), and the presence of adverse events were evaluated before, 10 and 20 min after the application of a protocol including ACT (nasal irrigation, prolonged slow expiration, and provoked cough), bronchodilator and hypertonic saline inhalation. A total of 265 infants, mean age 6.86±3.01 months, were included.Results: A reduction (p<0.001) in the Wang score and in the breathing frequency as well as an increase in SpO₂ were found. There was also a transient HR increment at 10 min followed by a reduction at 20 min (p<0.05). The proportion of patients presenting with chest retraction and wheezing decreased (p<0.001) after treatment. Most of the children (88.3%) did not experience adverse events. A post-treatment increment (p<0.001) of patients classified as having normal values, as well as a decrease in those with mild and moderate AVB, was found for the Wang score levels.Conclusion: The use of ACT combined with bronchodilator and hypertonic saline was safe, immediately after treatment, for non-hospitalized children with mild to moderate AVB. No clinically important deterioration or adverse events were identified in the follow-up period.     

Comparative efficacy of terbutaline sulphate delivered by Turbuhaler dry powder inhaler or pressurised metered dose inhaler with Nebuhaler spacer in children during an acute asthmatic episode

Aims: To compare the efficacy of terbutaline sulphate delivered via Turbuhaler with a pressurised metered dose inhaler (pMDI) connected to Nebuhaler spacer in a population of asthmatic children presenting to emergency departments because of an acute episode of asthma. Methods: Randomised double blind, double dummy, parallel study of acute asthma in the emergency department. A total of 112 children (6–16 years), who had a diagnosis of asthma, a baseline FEV₁ of 25–60% of predicted normal value (PNV), and the ability to perform spirometry were studied. Patients received two doses of 0.5 mg/10 kg (maximum 2.0 mg) of terbutaline sulphate at time 0 minutes and time 30 minutes. The two groups were also stratified into subgroups based on FEV₁: 25–45% and 45.1–60% PNV. FEV₁ before treatment and at two 15-minute intervals after each treatment was the main outcome measure. PIF, PEF, heart rate, SpO₂, and tremor were also measured at these times. Results: Both the Turbuhaler and pMDI+Nebuhaler groups showed significant increases from baseline to final value in their FEV₁ results, 49% and 50% change from baseline to t = 60 min, respectively (p < 0.001) using last value carried forward. No significant difference was found between the two groups for these results. Subanalysis of the stratified groups revealed similar results. In addition, no significant difference was found in the group and subgroup comparisons for heart rate, SpO₂, and tremor. Conclusion: Results show that Turbuhaler and pMDI+Nebuhaler are similar in terms of benefit and side effects in the treatment of acute moderate to severe asthma attacks in this study population.     

Wheezing as a sign of cor triatriatum sinister culminating in multiple organ failure

Cardiac asthma or cardiac wheezing (CW) refers to a syndrome of dyspnea and wheezing that mimicks asthma clinically. Reported herein is the case of a 2‐month‐old boy who presented with refractory wheezing as a sign of cor triatriatum sinister (CTS) that culminated in overwhelming multiple organ failure in a short time. On the day of admission, oxygen saturation (SpO₂) was <80%. Heart rate was 198 beats/min and respiratory rate 58 breaths/min. Chest radiogram showed pulmonary edema. Electrocardiogram showed right atrial enlargement and right ventricular hypertrophy. N‐terminal pro‐brain natriuretic peptide (NTproBNP) was very high at >20 000 pg/mL. Two‐dimensional echocardiography with Doppler showed CTS, which was complicated with severe pulmonary arterial hypertension due to flagrant pulmonary venous obstruction. Cardiac surgery was undertaken, after which pulmonary edema subsided, SpO₂ increased to ≥96%, and NTproBNP dropped to normal. He was discharged 11 days later, and was free of cardiac, pulmonary, renal, and neurological sequelae at 24 month follow up.     

Influence of nose and mouth leaks on peripheral oxygen saturation during continuous positive airway pressure in neonates

Background

Nose and mouth leaks impair effective pressure transmission during neonatal continuous positive airway pressure (CPAP), but little is known about how these leaks affect physiological parameters. This study investigated the influence of nose leaks and spontaneous mouth opening on peripheral oxygen saturation (SpO₂) and respiratory rate (RR) using nasopharyngeal CPAP.

Methods

In 32 neonates with a gestational age of 30 (24–38) weeks and a birth weight of 1435 (710–2730) g, SpO₂ and RR measurements were taken with and without occlusion of the contralateral nostril in a randomized cross-over trial in 1-minute intervals over a 10-minute period during each condition. Mouth opening and newborn activity were documented.

Results

SpO₂ with open nostril was comparable to that with occluded nostril [93 (78.5–99.5)% vs. 94 (80–100)%, P=0.20]. RR decreased from 51 (26–82)/min to 48 (32–85)/min (P=0.027). In infants with an SpO₂≤93% during open nostril (n=17), SpO₂ increased after nostril occlusion [91 (80–96)% vs. 89.5 (78.5–93)%, P=0.036]. The mouth was open in 78.5% of measurements with open nostril, and in 87.4% of measurements after nostril occlusion (P=0.005). No significant influence of mouth opening or closure on SpO₂ or RR was detected.

Conclusions

In neonates on unilateral nasopharyngeal CPAP with an SpO₂ ≤93%, occlusion of the contralateral nostril significantly increased SpO₂ and reduced RR. The beneficial physiological effects further support using binasal prongs to minimize nose leaks in this population. Future studies should investigate the beneficial effects of reducing mouth leaks when applying CPAP to these infants.     

Prospective pediatric study comparing glomerular filtration rate estimates based on motion-robust dynamic contrast-enhanced magnetic resonance imaging and serum creatinine (eGFR) to 99mTc DTPA

Background

Current methods to estimate glomerular filtration rate (GFR) have shortcomings. Estimates based on serum creatinine are known to be inaccurate in the chronically ill and during acute changes in renal function. Gold standard methods such as inulin and ^99mTc diethylenetriamine pentaacetic acid (DTPA) require blood or urine sampling and thus can be difficult to perform in children. Motion-robust radial volumetric interpolated breath-hold examination (VIBE) dynamic contrast-enhanced MRI represents a novel tool for estimating GFR that has not been validated in children.

Objective

The purpose of our study was to determine the feasibility and accuracy of GFR measured by motion-robust radial VIBE dynamic contrast-enhanced MRI compared to estimates by serum creatinine (eGFR) and ^99mTc DTPA in children.

Materials and methods

We enrolled children, 0–18 years of age, who were undergoing both a contrast-enhanced MRI and nuclear medicine ^99mTc DTPA glomerular filtration rate (NM-GFR) within 2 weeks of each other. Enrolled children consented to an additional 6-min dynamic contrast-enhanced MRI scan using the motion-robust high spatiotemporal resolution prototype dynamic radial VIBE sequence (Siemens, Erlangen, Germany) at 3 tesla (T). The images were reconstructed offline with high temporal resolution (~3 s/volume) using compressed sensing image reconstruction including regularization in temporal dimension to improve image quality and reduce streaking artifacts. Images were then automatically post-processed using in-house-developed software. Post-processing steps included automatic segmentation of kidney parenchyma and aorta using convolutional neural network techniques and tracer kinetic model fitting using the Sourbron two-compartment model to calculate the MR-based GFR (MR-GFR). The NM-GFR was compared to MR-GFR and estimated GFR based on serum creatinine (eGFR) using Pearson correlation coefficient and Bland–Altman analysis.

Results

Twenty-one children (7 female, 14 male) were enrolled between February 2017 and May 2018. Data from six of these children were not further analyzed because of deviations from the MRI protocol. Fifteen patients were analyzed (5 female, 10 male; average age 5.9 years); the method was technically feasible in all children. The results showed that the MR-GFR correlated with NM-GFR with a Pearson correlation coefficient (r-value) of 0.98. Bland–Altman analysis (i.e. difference of MR-GFR and NM-GFR versus mean of NM-GFR and MR-GFR) showed a mean difference of −0.32 and reproducibility coefficient of 18 with 95% confidence interval, and the coefficient of variation of 6.7% with values between −19 (−1.96 standard deviation) and 18 (+1.96 standard deviation). In contrast, serum creatinine compared with NM-GFR yielded an r-value of 0.73. Bland–Altman analysis (i.e. difference of eGFR and NM-GFR versus mean of NM-GFR and eGFR) showed a mean difference of 2.9 and reproducibility coefficient of 70 with 95% confidence interval, and the coefficient of variation of 25% with values between −67 (−1.96 standard deviation) and 73 (+1.96 standard deviation).

Conclusion

MR-GFR is a technically feasible and reliable method of measuring GFR when compared to the reference standard, NM-GFR by serum ^99mTc DTPA, and MR-GFR is more reliable than estimates based on serum creatinine.

     

Which clinical signs and symptoms predict hypoxemia in acute childhood asthma?

Objective To find the clinical signs that are the best predictors of hypoxemia (SpO₂=92%) in acute asthma in children. Methods Color of skin, dyspnea (by single breath counting), alertness, respiratory rate, presence of audible wheeze, wheezing on auscultation, accessory muscle use, nasal flaring, pulse rate, systolic and diastolic blood pressure, pulsus paradoxus and oxygen saturation at room air (by pulse oximetry) were recorded at the time of presentation and one hour after presentation after completion of 3 doses of nebulized salbutamol and budesonide. Results Hypoxemia (SpO₂≤92%) was seen in 45% children at presentation and 14(28.6%) after one hour. The clinical signs that correlated significantly with hypoxemia at both time points were dyspnea assessed by single breath count (OR 3.3, 95% Cl 0.9–12.9), accessory muscle use score ≥3 (OR 3.0, 95% Cl 0.9–15.4) and pulsus paradoxus >10 (OR 3.0, 95% Cl 0.7–13.6). In a multiple logistic regression model accessory muscle score >-3 and pulsus paradoxus >10 were identified as independent predictors of hypoxemia (sensitivity 64.3%, specificity 91%). Conclusion Physical assessment in a child with acute exacerbation of asthma should at least include accessory muscle use and pulsus paradoxus, since these predict hypoxemia the best.     

Effect of rewarming in oxygenation and respiratory condition after neonatal exposure to moderate therapeutic hypothermia

BackgroundTo assess changes in clinical condition and oxygenation in neonates after rewarming following moderate therapeutic hypothermia (MTH) for neonatal encephalopathy.MethodsRetrospective study of 28 neonates receiving MTH in a tertiary neonatal intensive care unit in Israel. We compared pre-and 24 h post-rewarming arterial oxygen saturation (SaO₂) as measured by the blood gases analyzer, pulse-oximetry saturation (SpO₂), and cardio-respiratory condition.ResultsThe SpO₂ declined from 96.9% (±2.9) before rewarming to 95.2% (±2.6) after rewarming (p < 0.001). Twelve neonates (42.9%) had clinical respiratory impairment (needing higher respiratory support or had new onset desaturations). In 16 neonates (57.1%) with no change in respiratory support after rewarming, SpO₂ decreased from 98.3 ± 1.9% to 95.6 ± 3.0% (p < 0.001) and SaO₂ decreased from 97.1 ± 1.7% to 96.0 ± 2.3% (p = 0.002). The mean SpO₂ decrease was greater than mean SaO₂ decrease (2.63 ± 1.8 and 1.1 ± 1.3 respectively, p = 0.021).ConclusionNeonates who underwent MTH showed reduction in oxygenation after rewarming either by decreasing SpO₂ or increasing FiO₂ requirements. The SpO₂ decline was larger than the SaO₂ decline. We suggest careful monitoring of neonates after rewarming.     

Parental and child factors associated with inhalant and food allergy in a population-based prospective cohort study: the Generation R Study

The prevalence of allergic diseases in children is markedly increasing to epidemic proportions. The aim of this study is to describe the presence and examine associated parental and child characteristics of allergic sensitization and physician-diagnosed allergy in Dutch children at age 10 years. This study among 5471 children was performed in a population-based prospective cohort from fetal life onwards. Allergic sensitization was measured by skin prick tests. Physician-diagnosed allergy and parental and child characteristics were collected by questionnaires. In children aged 10 years, inhalant and food allergic sensitization was present in 32.2% and 7.1%, and physician-diagnosed inhalant and food allergy in 12.4% and 2.3%. Maternal and paternal history of allergy, eczema or asthma was associated with increased risks of physician-diagnosed inhalant allergy (aOR (95% CI) 1.44 (1.23–1.70) and 1.59 (1.30–1.94), respectively), but not with food allergy. Asthma and eczema ever at age 10 years were associated with increased risks of physician-diagnosed inhalant allergy (4.60 (3.55–5.96) and 2.42 (1.94–3.03), respectively). Eczema ever at age 10 years was associated with an increased risk of physician-diagnosed food allergy (5.78, 3.04–9.52), with the highest risk of cashew (7.36, 3.20–16.94) and peanut (5.58, 3.08–10.10) food allergy.

Conclusions: We found strong effects of parental history of allergy, eczema or asthma on the presence of physician-diagnosed inhalant allergy in children at age 10 years. Eczema ever at age 10 years was a strong risk factor for the development of physician-diagnosed inhalant and food allergy.

T1ρ-mapping for assessing knee joint cartilage in children with juvenile idiopathic arthritis — feasibility and repeatability

Background

Ongoing arthritis in children with juvenile idiopathic arthritis (JIA) can result in cartilage damage.

Objective

To study the feasibility and repeatability of T_1ρ for assessing knee cartilage in JIA and also to describe T_1ρ values and study correlation between T_1ρ and conventional MRI scores for disease activity.

Materials and methods

Thirteen children with JIA or suspected JIA underwent 3-tesla (T) knee MRI that included conventional sequences and a T_1ρ sequence. Segmentation of knee cartilage was carried out on T_1ρ images. We used intraclass correlation coefficient to study the repeatability of segmentation in a subset of five children. We used the juvenile arthritis MRI scoring system to discriminate inflamed from non-inflamed knees. The Mann-Whitney U and Spearman correlation compared T_1ρ between children with and without arthritis on MRI and correlated T_1ρ with the juvenile arthritis MRI score.

Results

All children successfully completed the MRI examination. No images were excluded because of poor quality. Repeatability of T_1ρ measurement had an intraclass correlation coefficient (ICC) of 0.99 (P<0.001). We observed no structural cartilage damage and found no differences in T_1ρ between children with (n=7) and without (n=6) inflamed knees (37.8 ms vs. 31.7 ms, P=0.20). However, we observed a moderate correlation between T_1ρ values and the juvenile arthritis MRI synovitis score (r=0.59, P=0.04).

Conclusion

This pilot study suggests that T_1ρ is a feasible and repeatable quantitative imaging technique in children. T_1ρ values were associated with the juvenile arthritis MRI synovitis score.

     

A comparison of oxygen saturation measurements obtained from a 'blue sensor' with a standard sensor

Aim: The study aims to investigate pulse oximetry measurements from a ‘blue’ pulse oximeter sensor against measurements from a ‘standard’ pulse oximeter sensor in newly born infants. Methods: Immediately after birth, both sensors were attached to the infant, one to each foot. SpO₂ measurements were recorded simultaneously from each sensor for 10 min. Agreement between pairs of SpO₂ measurements were calculated using Bland–Altman analysis. Results: Thirty‐one infants were studied. There was good correlation between simultaneous SpO₂ measurements from both sensors (r²= 0.75). However, the mean difference between ‘blue’ and ‘standard’ sensors was ?1.6%, with wide 95% limits of agreement +18.4 to ?21.6%. The range of mean difference between sensors from each infant ranged from ?20 to +20. Conclusion: The mean difference between the blue and standard sensor SpO₂ measurements is not clinically important.     

Simple method of <100% oxygen resuscitation for preterm infants

Background: The aim of this study was to determine the feasibility of 50–60% oxygen resuscitation by a simple method using a self‐inflation bag without oxygen reservoir for positive pressure ventilation (PPV) or using a constant distance and flow rate for blow‐by oxygen. Methods: Newborn infants ≤35 weeks gestational age were eligible. Infants requiring PPV were initiated with bag‐mask PPV without oxygen reservoir. Nearly 100% oxygen was given by attaching oxygen reservoir if heart rate < 100 beats/min after PPV for 90 s or SpO₂ < 75% at 3 min. For those requiring blow‐by oxygen, oxygen flow 5 L/min via facemask was given 5 cm from the nose. Almost 100% oxygen was given by close‐fitting facemask to nose if SpO₂ < 80% at 5 min. Results: Ninety‐one infants were eligible; 67 of them required resuscitation. Thirty‐five infants required PPV; 27 (77.1%) responded to bag‐mask PPV without oxygen reservoir. For 32 infants requiring blow‐by oxygen, 28 (87.5%) reached the targeted SpO₂. No significant differences in clinical outcomes were observed between responders and non‐responders. Conclusions: The technique of <100% oxygen supplementation was effective for preterm newborn resuscitation with a high success rate. This technique may be useful for a limited‐resource setting.     

Expressed breast milk vs 25% Dextrose in procedural pain in neonates: A double blind randomized controlled trial

Objective

To compare the effect of expressed breast milk (EBM), 25% dextrose (25 D) and sterile water (SW) on procedural pain in neonates as assessed by the premature infant pain profile (PIPP), changes in heart rate (HR), oxygen saturation (SpO₂) and duration of crying.

Design

Prospective, double blind, randomized controlled trial.

Setting

Postnatal ward of a tertiary-care hospital.

Participants

210 babies who required venipuncture for blood sampling and who were on oral feeds were recruited into the study after parental informed consent.

Methods

The enrolled babies were randomized into intervention groups (EBM, 25% dextrose) and control group (sterile water). Two ml of test solution was given to baby by paladay (a traditional cup with a spout) 2 min before venipuncture. The face and crying of baby were video graphed by an independent, blinded observer. The facial response to pain (brow bulge, eye squeeze, nasolabial furrow) was analysed from the video. Maximum HR and minimum SpO₂ were recorded during, and 1, 3 and 5 min after venipuncture by another blinded observer.

Outcome variable

PIPP score, HR, SpO₂ and crying time at 0/1/3/5 min after sampling.

Results

160 babies were considered for final analysis with 50 in 25 D, 62 in EBM and 48 in SW group. The mean PIPP score in the 3 groups were 5.22, 6.84 and 11.22 at 0–30 sec after venipuncture; 4.52, 6.34, and 10.88 at 1–1 ½ min; 3.96, 6.15 and 9.35 at 3–3 ½ min; and 3.12, 4.68 and 7.83 at 5–5 ½ min; respectively (P< 0.001). The median crying time was 10,37.5 and 162 seconds in 25 D, EBM and SW groups, respectively (P< 0.001).

Conclusions

EBM significantly reduces procedural pain in neonates though to a lesser extent as compared to 25% dextrose.     

Effect of Group-Task-Oriented Training on Gross and Fine Motor Function,and Activities of Daily Living in Children with Spastic Cerebral Palsy

Abstract

Aims: To determine the effects of group-task-oriented training (group-TOT) on gross and fine motor function, activities of daily living (ADL) and social function of children with spastic cerebral palsy (CP).

Methods: Eighteen children with spastic CP (4–7.5?years, gross motor function classification system level I–III) were randomly assigned to the Group-TOT (9 children received group-TOT for 1?hour, twice a week for 8?weeks) or the comparison group (9 children received individualized traditional physical and occupational therapy). The Gross Motor Function Measure (GMFM)-88, the Bruininks-Oseretsky Test of Motor Proficiency 2^nd edition (BOT-2), and the Pediatric Evaluation of Disability Inventory (PEDI) were administered before and after the intervention, and in the Group-TOT, 16?weeks after the intervention.

Results: Children in the Group-TOT showed significant improvements in the GMFM-88 standing and walking/running/jumping subscales, the BOT-2 manual dexterity subscale, and the PEDI social function subscale (p?<?0.05); changes were maintained 16?weeks after the intervention ended. In contrast, the comparison group improved in only the BOT-2 fine motor integration subscale (p?<?0.05).

Conclusions: The findings provide evidence of effectiveness of group-TOT in improving gross and fine motor function, and social function in children with CP.     

Oxygen Saturation Immediately after Birth in Infants Delivered in Tertiary Care Hospital in India

Objective

To study the sequential changes in SpO₂ values in newborns delivered in a teaching hospital in India.

Methods

Full-term infants born by normal vaginal delivery to registered mothers at KLE University Hospital, Belgaum with birth weight more than 2,500 g, no congenital anomalies and who had received only routine care at birth were included in the study. After delivery, newborn infants were placed on a resuscitation trolley under a radiant warmer; the oxygen saturation sensor was attached (Nellcor DURA-Y multisite oxygen sensor) and then connected to the monitor (Planet 55 multiparameter recorder).

Results

The mean (SD) gestational age of infants included in the study was 38.8 (1.1) wk and birth weight was 2,800 (300) g. The median (IQR) oxygen saturation level (SpO₂) at 2 min of age was 69 % (68 %–79 %). The median level of SpO₂ at 90 % and 95 % saturation was attained at 6.5 min and at 11 min of life, respectively.

Conclusions

Infants delivered in resource poor facilities of developing countries take 11 min to reach 95 % saturations after birth but they are within the reference range values of Neonatal Resuscitation Program 2010 guidelines.     

Asthma control in the quality of life levels of asthmatic patients’ caregivers: a systematic review with meta-analysis and meta-regression

ObjectiveTo perform a systematic review with meta-analysis and meta-regression to correlate the total scores of asthma control with the increase in the total scores of health-related quality of life levels of parents of asthmatic children.SourcesThe search was carried out in the following databases: PubMed (MEDLINE); Embase and ScienceDirect (Elsevier); SciELO and LILACs (Bireme) in June 2017. The included studies assessed asthma control through the Asthma Control Questionnaire (ACQ), Asthma Control Test (C-ACT/ACT), and Global Initiative for Asthma (GINA) questionnaires, whereas the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ) was applied to assess the HRQoL of parents and family members.Summary of the findings294 articles were evaluated in the selected databases, of which (n = 38) were excluded for duplicity; (n = 239) after the reading of the titles and abstracts and (n = 5) after reading the studies in full, totaling 12 studies eligible for the meta-analysis. Of the 12 eligible articles, 11 (92%) were published in the last five years, and evaluated children and adolescents aged 1–20 years, totaling 2804 samples. In the evaluation of the correlation between the disease control scores by ACQ and C-ACT/ACT, the results were satisfactory for both ACQ analyses [R²: ?0.88; p < 0.001], and for C-ACT/ACT [R²: 0.82; p < 0.001].ConclusionsThe results show that asthma control levels can influence the total HRQoL scores of parents or relatives of children and adolescents with asthma.     

Ketamine

Ketamine is used extensively in the developing world (DW) because of its effectiveness, availability, relatively low cost, and presumed safety. This report is a prospective, objective assessment of the efficacy and safety of ketamine when used as the sole anesthetic agent in a general medical practice hospital in the DW in children less than 16 years of age undergoing nonemergent operative procedures. Children undergoing laparotomy, thoracotomy, or craniotomy were excluded. Data analysis included serial arterial hemoglobin saturation (SpO₂) and pulse rate, amount of ketamine utilized, adequacy of anesthesia, and perioperative complications. One hundred thirty-one children undergoing a total of 210 anesthetics were studied. The level of anesthesia was adequate in all cases. The SpO₂ dropped below 90% in 40 (19%) children, below 85% in 25 (12%), and below 80% in 13 (6%). SpO₂ drops occurred significantly (P = 0.004) more often after IM than after IV injection. All drops in SpO₂ were abrupt without premonitory signs. Thirty-three (82.5%) of these 40 children responded readily to airway manipulation with a jaw thrust, and only 7 (3.3% of the total series) required face-mask O₂. None required intubation or positive-pressure ventilation. Transient laryngospasm occurred in 1 child, but there were no other complications. In particular, there was no mortality, apnea, emesis, excessive salivation, or significant early or delayed emergence phenomena. Ketamine is quite effective when used as the sole anesthetic agent in DW children. It is relatively safe, but hypoxemia may go undetected unless technologically sophisticated monitoring equipment is available. Proper suction and ventilatory support equipment should be readily available prior to ketamine injection. The first step when hypoxemia is detected is simple airway manipulation, followed by oxygen administration by face mask if needed. Rarely will intubation be indicated. Ketamine is also a good drug for the management of pediatric emergency department procedures in the United States, but all children in these more developed centers should be monitored with a pulse oximeter, since a significant number of children have a precipitous drop in SpO₂.     

Utilization of computed tomography imaging in the pediatric emergency department

Background

In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s.

Objective

In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center.

Materials and methods

We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006.

Results

A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008–2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study.

Conclusion

CT utilization decreased throughout the 2008–2017 study period.

     

First case of methemoglobinemia caused by a ClO2‐based household product

When new household products are developed and distributed, new injuries often occur in children. We report the first known case of methemoglobinemia caused by a chlorine dioxide (ClO₂)‐based household product. A 1‐year‐old boy presented to the emergency department with vomiting and poor complexion after accidentally ingesting a ClO₂‐based household product. The patient had profound hypoxia that did not respond to oxygen therapy and required endotracheal intubation to maintain a normal oxygen level. Although oxygen saturation (SpO₂) fluctuated at approximately 95% after intubation, arterial oxygen pressure (PaO₂) was high on arterial blood gas analysis. We suspected methemoglobinemia based on the gap between SpO₂ and PaO₂, and subsequently detected increased methemoglobin at 8.0%. The patient was admitted to the pediatric intensive care unit for further management. After supportive treatment, he was discharged without any complications. He had no cognitive or motor dysfunction on follow up 3 months later.