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All Subjects Acute Otitis Media  Acute Pain  Concussion  Croup  Diabetic ketoacidosis  Emergency Medicine  Evidence-Based Medicine  Gastroenteritis  Head Injury  Infection  Otitis Media with Effusion  Otitis Media, Suppurative  Pediatrics  Psychiatry  Psychotic Disorders  Research  Severe Head Injury 


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Evidence-Based Treatments for Acute Otitis Media (more)

April 24, 2015

April 27, 2015 – This week's post is also available from the Cochrane Child Health blog.

Acute otitis media (AOM), or middle ear infection, is one of the most common diseases of childhood. AOM presents most frequently in children under the age of two, with 75% of children having at least one episode before one year of age [1,2]. Although AOM is very common, it can be challenging to accurately diagnose – symptoms of AOM often overlap with acute respiratory illness, visualization of the tympanic membrane can be obscured by cerumen, and slight changes in the tympanic membrane can be hard to detect [1]. 

The Canadian Paediatric Society recommends antibiotics for treatment in all children under the age of six months, and for children who are six months to two years when the diagnosis of AOM is certain [2]. For children older than six months with mild symptoms, the Canadian Paediatric Society recommends a ‘watchful waiting’ approach supported by a topical or oral analgesic [2]. Given the prevalence of AOM in these age groups, antibiotics are being prescribed very frequently. With increasing concern about antibiotic resistance, guidelines need to be created to prevent inappropriate prescription for children who have been misdiagnosed with AOM, and treatments need to be supported by strong evidence to justify their use.

Including six systematic reviews, covering 92 randomized controlled trials with 19,695 participants, a Cochrane overview investigated the available evidence on treatments for AOM in children. Below is the key evidence you need to know when treating a child with AOM.  

Effectiveness of Antibiotics

  • Compared to placebo,children treated with antibiotics reported less pain 2-7 days after treatment initiation.
  • Children taking antibiotics were more likely to have vomiting, diarrhea, and rash. 

Short-Course Antibiotics

  • There is no evidence to support one length of antibiotic treatment over another.

Immediate versus Delayed Antibiotics

  • Children who immediately received antibiotics had no difference in pain 3-7 days after treatment initiation compared to children who had a delay in antibiotic receipt.
  • Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of delayed start of antibiotic treatment. 

Decongestants and Antihistamines

  • There was no evidence in support of the use of decongestants or antihistamines to treat AOM.
  • The authors discouraged the use of decongestants and antihistamines in young children because of their potentially harmful side effect profile caused by unintentional overdose [3]. 

Topical Analgesia

  • There was some low quality evidence suggesting that topical analgesia may reduce pain after ten minutes of administration in children over five years. However, no adverse events were recorded.
  • Because the quality of the evidence was poor, no firm conclusions were made in the review about the risks and benefits of topical analgesia for AOM.

The authors of the overview concluded:

“The literature to date suggests that antibiotic use in young children with stringently diagnosed AOM appears to be justified, although benefits must be balanced with risk, particularly adverse events and bacterial resistance, and with a role for parental preferences. Improving the accuracy of diagnosis (e.g. training programs for otoscopy and cerumen removal), is thus an important mechanism for reducing inappropriate antibiotic use.”

In 2009, the Canadian Paediatric Society released a position statement with information on treatment and recommendations to guide proper diagnosis of AOM [2].

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Acute otitis media Bottom Line Recommendations (French & English)
Acute otitis media Evidence Repository
Acute otitis Media Cochrane Pediatric Emergency Medicine Reviews

 

References:

  1. Oleszczuk, M., Fernandes, R. M., Thomson, D., & Shaikh, N. (2012). The Cochrane Library and acute otitis media in children: an overview of reviews. EvidenceBased Child Health: A Cochrane Review Journal7(2), 393-402.
  2. Forgie, S., Zhanel, G., & Robinson, J. (2009). Management of acute otitis mediaPaediatrics & Child Health14(7), 457-460.
  3. Goldman, R. D., & Hazardous Substances Committee. (2011). Treating cough and cold: guidance for caregivers of children and youthPaediatrics & Child Health16(9), 564.

From team: News and Events

tags: Acute Otitis Media Otitis Media with Effusion Otitis Media, Suppurative    


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Making Medical Procedures Less Painful for Kids - Evidence for Clinicians (more)

April 17, 2015

April 20, 2015 – This week's post is also available from the Cochrane Child Health blog.

Today we are going to discuss a topic that will be familiar to any parent, or to anyone who’s ever been a kid: the pain from medical procedures.  These can range from immunizations and blood tests through to less common things like lumbar punctures, inserting a catheter or starting an intravenous line.  All of these procedures have an important goal: supporting diagnosis and treatment.  But they can be really stressful for both children and their caregivers.

Doctors used to think that very young children did not experience pain, and, even if they did, did not remember it.  This has been repeatedly disproven over the past twenty years or so, and we now know that inadequate pain treatment can have a lot of negative effects in both the short and long term.

The experience of pain for a child is complex and is usually accompanied by anxiety, fear and behavioural changes. In the case of pain from medical procedures, health care professionals have a range of options for preventing or reducing the negative experience.

The Child Health Field’s journal, Evidence-Based Child Health, has published an overview of Cochrane evidence on reducing and preventing procedural pain for kids.  The kids in the studies included in this synthesis ranged in age from infancy (but not newborns) up to 19 years. The overview found three main conclusions:

1)  Behavioural therapies, such as showing videos to kids to distract them during a procedure, are effective and inexpensive, and should be used.

2)  Sweet-tasting substances have proven pain-reducing effect for procedures in early infancy, but have not been shown to have similar effect in older children.

3)  Amethocaine, a topical anaesthetic, works and should be used.

Dr. Samina Ali, one of the authors of the synthesis, commented that, “Despite our understanding of the importance of pain relief in children, there remains a significant knowledge-practice gap in clinical practice.”  It is our hope that publishing this overview of evidence will help overcome this gap so that receiving care is less painful for kids!

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Cochrane Community Podcast:

  • Check out Dr. Ali's comments on the Cochrane overview in this podcast

Other Resources:

  • The Center for Pediatric Pain Research shares suggestions for reducing procedural pain in this video

References:

  1. Curtis, S., Wingert, A., & Ali, S. (2012). The Cochrane Library and procedural pain in children: an overview of reviews. Evidence‐Based Child Health: A Cochrane Review Journal, 7(5), 1363-1399. doi: 10.1002/ebch.1864

 

 

From team: News and Events

tags: Acute Pain    


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Treating Gastroenteritis: Evidence for Clinicians (more)

April 10, 2015

April 13, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Fever. Vomiting. Diarrhea.

These are the symptoms that characterize one of the most common pediatric illnesses – Acute Gastroenteritis (AGE). In Canada, AGE accounts for 10% of emergency department visits annually and results in the hospitalization of 1 in 25 children under the age of five, keeping primary care physicians busy as ever [1,2]. Although AGE is not a serious condition in the developed world, it exerts significant economic burden. Estimates suggest Canadian AGE specific costs are $3.7 billion annually [2].

Despite the prevalence of AGE, its cost, and the ubiquity of its symptomatic presentation, there is no unified approach to its management in emergency departments (ED) institutionally, nationally, or internationally. Standardized, clinical decision tools targeting improvement of gastroenteritis care are not routinely used in Canadian EDs, which can result in variation in clinical decisions for key treatment approaches [3]. In effort to bring easily accessible, up-to-date evidence for AGE treatment approaches to one place, a Cochrane overview of systematic reviews provides a cohesive summary of treatment options and their effectiveness to help clinicians in their evidence-based decision making. This overview included four systematic reviews containing 95 randomized controlled trials involving over 12,000 participants. Here is the key evidence you need to know when treating a child with AGE.

Oral Rehydration Therapy (ORT) versus Intravenous (IV) Rehydration Therapy

  • ORT is less invasive than IV rehydration and therefore is considered as first line treatment for children with AGE and associated mild-to-moderate dehydration.
  • There are no important clinical differences (e.g. length of hospital stay, adverse effects) between children who receive oral rehydration therapy (ORT) and those administered IV rehydration therapy.

Anti-Emetics

  • Oral ondansetron is the first line anti-emetic agent for children with dehydration and significant vomiting because it lowers hospital admission and IV rehydration rates.
  • IV ondansetron is associated with lower hospital ED admission rates, but should only be used for children who require IV rehydration.

Probiotics

  • Probiotics can reduce hospital duration by over 24 hours.
  • There are no known interactions between probiotics and other medications.
  • Existing evidence favors the use of probiotics as a safe adjunct treatment for AGE, but it is unclear which probiotic should be used, at what dose, and for what duration.
  • Current evidence suggests the use of formulations containing Lactobacillus sp or S. boulardii, but optimal dosage and duration of therapy is unknown.

Dr. Moshe Ipp, a pediatrician and academic clinician from Toronto, shares his conclusions about this overview in this Cochrane Community podcast:

 “In summary, oral rehydration therapy is considered to be the first line choice for rehydration in patients with acute gastroenteritis and mild to moderate dehydration. When there is significant vomiting, ondansetron is the recommended anti-emetic of choice. And probiotics have been shown to be safe and effective for hospitalized children.”

However, Dr. Ipp highlights that ondansetron may not be suitable for all children with AGE: “An interesting finding, and a note of caution, is that in 3 randomized controlled trials there was a higher frequency of diarrhea in the ondansetron group compared to placebo, and because of this finding it is suggested that ondansetron might not be the agent of choice when vomiting is associated with a significant amount of diarrhea.”

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Cochrane Community Podcast:

  • Check out Dr. Ipp’s comments on the overview in this podcast

References:

[1] Majowicz, S., McNab, W., Sockett, P., Henson, S., Dore, K., Edge, V., ... & Wilson, J. (2006). Burden and cost of gastroenteritis in a Canadian community. Journal of Food Protection, 69(3), 651-659.

[2] Alberta Provincial Pediatric Enteric Infection Team. APPETITE seminar series [PDF document]. Retrieved from: Got Gastro Online Website

[3] Kinlin, L., Bahm, A., Guttmann, A., & Freedman, S. (2013). A survey of emergency department resources and strategies employed in the treatment of pediatric gastroenteritis. Academic Emergency Medicine, 20(4), 361-366. doi: 10.1111/acem.12108

[4] Freedman, S., Ali, S., Oleszczuk, M., Gouin, S., & Hartling, L. (2013). Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evidence‐Based Child Health: A Cochrane Review Journal, 8(4), 1123-1137. doi: 10.1002/ebch.1932

From team: News and Events

tags: Gastroenteritis    


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Bicycle helmets – now that’s using your head! (more)

April 02, 2015

April 6, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Head injuries due to bicycle crashes are a common reason that children present to the emergency department. Bicycle helmets were designed to decrease head injuries. Different approaches to encourage bicycle helmet use have been evaluated. These range from legislation where individuals are required by law to wear a helmet when cycling to media campaigns and other health promotion activities, such as promoting the use of bicycle helmets in schools or offering free helmets through community-based programs.

An overview of Cochrane systematic reviews [1] was conducted in order to bring together evidence from reviews that focused on different aspects of the topic of bicycle helmet use. The reviewers identified three systematic reviews [2-4] that included 35 studies involving children. The reviews looked at:

  • the use of helmets for preventing head and facial injuries in bicyclists
  • bicycle helmet legislation to increase the uptake of helmet use and prevent head injuries
  • nonlegislative interventions to promote use of bicycle helmets in children (these included health education programs, subsidized or free helmets, and media campaigns)

Some of the key findings:

  • helmet use in children decreased medically reported head injuries by 63%
  • helmet use decreased brain injuries by 86%
  • mandatory helmet laws for children decreased the odds of head injury hospitalizations by 45%
  • after helmet legislation, the odds of traumatic brain injuries decreased by 18%
  • legislation resulted in an increase in the number of children wearing a helmet
  • nonlegislative helmet promotion activities also resulted in an increase in the number of children wearing a helmet
  • there were no risks involved with using bicycle helmets

The authors concluded that bicycle helmets are effective in reducing head injuries in children. They also concluded that both legislative and non-legislative interventions are helpful in reducing injuries and promoting helmet use. However, the authors noted that there are some who oppose helmet legislation. The main reasons are that they feel that this may encourage people to cycle more recklessly or less frequently.

Dr. Tony Woodward, Chief of Emergency Medicine at Seattle Children's Hospital states that "there's no question that the best way to protect your child when they're on a bike, scooter, or skates is to wear an appropriately sized helmet. In the emergency department, the children we see who are the most seriously injured are the ones that don't have helmets or have helmets that are inappropriately sized or inappropriately worn."

Finally, check out the TREKK resources on severe head injury. Helmets prevent injury, but accidents still happen! 

References:

[1] Russell, K., Foisy, M., Parkin, P., & Macpherson, A. (2011). The promotion of bicycle helmet use in children and youth: an overview of reviews. Evidence-Based Child Health: A Cochrane Review Journal, 6(6), 1780-1789. doi: 10.1002/ebch.901

[2] Owen, R., Kendrick, D., Mulvaney, C., Coleman, T., & Royal, S. (2011). Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD003985.pub3

[3] Macpherson, A., & Spinks, A. (2008). Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews, (3). doi:10.1002/14651858.CD005401.pub3

[4] Thompson D., Rivara, F., & Thompson, R. (1999). Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews, (4). doi:10.1002/14651858.CD001855

More Information:

TREKK (Translating Emergency Knowledge for Kids) Resources:

ChildSafetyLink. (2014). Keep Kids Safe: A Parent's Guide to Helmet and Recreation Safety.

Government of Manitoba. (2013). Bike Helmet Safety Video.

From team: News and Events

tags: Head Injury Severe Head Injury    


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