Bite Sized Pearls from a Little Patients · • Apple juice/preferred fluids –16.7% • Electrolyte maintenance fluid – 25% When assessed by age, benefit of the apple juice/preferred

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Bite Sized Pearls from a Doctor with Little Patients

Dr. Sam Wong

October 2017

Faculty/Presenter Disclosure

• Presenter: Sam Wong

• Relationships that may introduce potential bias and/or conflict of interest:

• Grants/Research Support: N/A

• Speakers Bureau/Honoraria: Sam Wong has received a speaker fee and expense support from the Alberta College of Family Physicians.

• Consulting Fees: N/A

• Other: N/A

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Disclosure of Commercial Support

• This program is presented by the Alberta College of Family Physicians (ACFP) without any commercial or in‐kind support.

• The ACFP provides a speaker fee and expense support for presenting at the Practical Evidence for Informed Practice.

Mild Gastroenteritis & Hydration

Effect of Dilute Apple Juice and Preferred Fluids vsElectrolyte Maintenance Solution on Treatment Failure Among Children with Mild Gastroenteritis: A Randomized Clinical Trial

Freedman, Stephan, et al. JAMA 2016 :315(18) 1966‐1974

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Electrolyte solution is expensive and palatability limits its efficacy


Hypothesis• Would the use of dilute apple juice in hospital followed by their preferred fluid in mild gastroenteritis be as efficacious as treatment with electrolyte maintenance solution as measured by treatment failure

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Single centre, randomized, single blind non inferiority trial in the Emergency department of a pediatric tertiary care hospital in Toronto


Eligible children were aged 6 months to 60 months who presented with the following:

• 3 or more episodes of diarrhea or vomiting in the preceding 24 hours

• Less than 96 hours of symptoms

• Weight 8 kg or greater

• Minimal dehydration as determined by Clinical Dehydration Scale with scores less than 5 and with a cap refill of <2 seconds

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Exclusion criteria• Hx of chronic GI disease or other disease that could complicate the clinical picture eg. IDDM

• Prematurity with corrected postnatal age < 30 weeks

• Bilious vomiting

• Hematemesis

• Hematochezia

• Clinical concern for an acute abdomen

• Need for immediate IV rehydration


Randomization• Received either half strength apple juice/preferred fluids or apple flavoured electrolyte maintenance solution in a 1:1 ratio in computer generated blocks of 8

• Solutions prepared in the pharmacy in identical bottles but numbered randomly with appropriate post discharge instructions numbered to correlate with the bottle

• Randomized discharge instructions for each solution given to the parents to be opened at home

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Procedure• Study initiated following triage and pre physician evaluation

• Intervention group – half strength apple juice

• Control group – apple flavoured sucralose sweetened pediatric electrolyte solution

• All received 2 L of their solution for use in Emergency and at home

• Pts were to receive 5 mLs of the fluid every 2‐5 minutes

• Pts with emesis also received oral ondansetron


• All children were evaluated by a physician• If consumption or hydration status not satisfactory, physician could initiate oral rehydration with electrolyte solution or IV hydration

• Instructed to give appropriate fluids to replace losses (2 mL/kg per emesis and 10 mL/kg per diarrhea episode)

• Option for pts to be evaluated by research nurse 72‐84 hrs after enrollment

• Parents told to give preferred fluid (juice/milk/sports drinks) in the intervention group and electrolyte solution in the control group at home

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Study outcome was treatment failure as indicated by the following within 7 days of enrollment

• Hospitalization or IV rehydration

• Subsequent unscheduled physician encounter for the same episode of vomiting and diarrhea

• Protracted symptoms occurring > 7 days after enrollment

• Physician request to administer cross over fluid at index visit

• 3% or greater weight loss or Clinical Dehydration Scale score >5 or higher at an in person f/u encounter


Demographics• 3688 enrolled

• 647 randomized with a mean age of 28 months

• 323 randomized to apple juice/preferred fluids

• 324 randomized to electrolyte maintenance solution

• 644 participants (99.5%) had data obtained from at least one follow up method

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Treatment failure• Apple juice/preferred fluids – 16.7%

• Electrolyte maintenance fluid – 25%

When assessed by age, benefit of the apple juice/preferred fluids was most pronounced in children 24 months and older (9.8% treatment failure) vs electrolyte maintenance fluid (25.9%)


Overall 7 day IV rehydration rate• Apple juice/preferred fluids ‐ 2.5%

• Electrolyte solution ‐ 9%

Hospitalization rates• Apple juice/preferred fluids ‐ 0.9%

• Electrolyte solution – 2.8%

IV rehydration at index visit• Apple juice/preferred fluids – 0.9%

• Electrolyte solution – 6.8%

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Take home point• Sweet news!

• ½ strength apple juice and preferred fluids at home may be the better option in the treatment of mild gastroenteritis for most kids

Pertussis and Infants

Effectiveness of Vaccination during Pregnancy to Prevent Infant PertussisBaxter, R et al. Pediatrics 2017 May 139:e20164091

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Hypothesis• Can we prevent infant pertussis by vaccinating during pregnancy without interfering with infant’s response to the pertussis vaccination in infancy?


Study population• Retrospective cohort study of 148,981 newborns in the Kaiser Permanente Northern California network born between 2010 and 2015

• 79,292 ‐ No Tdap vaccination in pregnancy

• 1521 – Tdap vaccine 1‐7 days before birth

• 68,168 – Tdap vaccine 8 + days before birth

Recommendation was for Tdap to be given in the last trimester of pregnancy

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• 2 follow up periods studied• Birth to 2 months

• Birth to 12 months

• Infant follow up continued until pt tested positive for pertussis, reach 2 months or 12 months of age or reached the end of the study date


• Two major pertussis outbreaks in 2010 and 2014 in the region covered by the health network

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Study results

• 17 infants tested positive by 2 months of age• Only one was from a mom who had been vaccinated >7 days before birth and was treated as an outpatient

• Other 16 patients had severity of illness ranging from mild to requiring hospitalization

• 102 infants tested positive by 12 months of age• 22 were from moms who had been given Tdap in pregnancy


Maternal Tdap vaccination reduced pertussis risk by an estimated 91.4% in first two months of life and by 69% in the first year of life even after adjusting for the effects of DTaP vaccination in the first year of life

Maternal Tdap did not affect infant response to DTaPvaccinations

Maternal Tdap after pregnancy did not significantly reduce pertussis risk in infants

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Take Home Point• Infant pertussis in the first 2 months of life could be drastically reduced with Tdap vaccine in the last trimester of pregnancy

Treatment of Impacted Ear Wax

What is the best way to treat impacted ear wax?

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Clinical Practice Guidelines (update): Earwax (cerumen impaction)Schwartz, SR et al. Otolaryngology Head Neck Surgery 2017 Jan. 156:S1


• 10% of children, 5% of adults and almost 1/3 of geriatric patients will be diagnosed with impacted ear wax

• A problem when it causes hearing loss, tinnitus, itching, pain, cough or impedes visual examination of the tympanic membrane

• No need to treat if asymptomatic

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Contraindication for removal of ear wax• Anticoagulant therapy

• Immunocompromised state

• Diabetes mellitus

• Prior radiation therapy to the head and neck

• Ear canal stenosis

• Non intact tympanic membrane


• Options for wax removal• Cerumenolytic agents

• Water based eg. Hydrogen peroxide

• Oil based eg. Mineral oil

• Irrigation

• Manual removal eg. curettage

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Most efficacious method• 1 week of a cerumenolytic agent followed by irrigation

For those at high risk of relapse consider prophylactic measures

• Prophylactic ear drops

• Periodic ear irrigation


Interesting facts• Ear wax does not interfere significantly with in ear thermometers (Swedish study showed a 0.2 C difference)

• Water based cerumenolytics induces hydration and disintegration of the corneocytes within the cerumenwhile oil based preparation just softens cerumen

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Candling can be potentially harmful (eg. setting hair on fire, hot wax burns, etc), is not effective, and can result in debris left behind in the ear canal.


Take home point• For symptomatic impacted ear wax one week of cerumenolytic therapy followed by irrigation works best

• Candles should be left on the table.

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Hypertonic saline & Bronchiolitis

Does hypertonic saline really work for reducing hospital admissions for patients with bronchiolitis?


Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical TrialAngoulvant, Francois et al. JAMA Pediatrics 2017: 171(8):e171333

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Multicentre, double blind randomized clinical trial on 2 parallel groups during 2 bronchiolitis seasons from 2012‐2014 at 24 French pediatric emergency departments


Participants• 777 infants with a first episode of acute bronchiolitis with respiratory distress and no chronic medical conditions

• 385 randomized to HS• 387 randomized to NS

Method

• Two 20 min nebulization treatments of either• 4 mL of hypertonic saline (3%) • 4 mL of NS (control)

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Main Measurement Outcome• Hospital admission rate in the 24 hours after enrollment


Admission Rate at 24 hours• HS ‐ 48.1%

• NS ‐ 52.2%

Mean length of stay• HS ‐ 3.8 days

• NS ‐ 3.7 days

Risk difference for hospitalization and length of stay were not statistically significant

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• Slight improvement in clinical scores with HS compared to NS but higher rate of minor adverse effects with HS


Take Home Point• Supportive care with oxygen and hydration remains the mainstay of bronchiolitis treatment (unfortunately)

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Other Clinical Pearls

Eczema Treatment• Applying moisturizing lotion to wet skin (not just damp skin) improves the moisturizing effectiveness of the lotion

• Wet wraps at night can improve moderately severe eczema

• Melatonin has some anti‐inflammatory effects and can be useful for inducing sleep instead of Benadryl or Atarax

• Use steroid cream for exacerbations only to avoid thinning of the skin (5‐7 days)

• Bleach baths may be useful (1‐2 caps in ½ tub of water) especially if MRSA +

Other Clinical Pearls

Food Allergies

• Do not do any allergy panels!

• Do IgE levels only for specific foods where the patient has clinical signs of allergy upon exposure

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Thanks!

Documents

Bite Sized Pearls from a Little Patients · • Apple juice/preferred fluids –16.7% • Electrolyte maintenance fluid – 25% When assessed by age, benefit of the apple juice/preferred