Office management of acute pediatric poisonings

Over the past five years, the role of the office practitioner in diagnosis and management of acute poisoning has developed into an important first line of defense in preventing serious morbidity and mortality associated with these exposures. The prime role of the practitioner is to accurately identify and quantify a poisoning exposure, to institute appropriate initial stabilization and management, and to recognize individuals who require further treatment and transfer to hospital settings. Beyond the obvious importance of initial stabilization of severely poisoned patients, the most important step in approaching the acute overdose is to identify what was taken, how much was taken, and when it was taken. To ensure appropriate treatment, the practitioner must use all the resources possible to obtain accurate identification and quantification of these exposures. Nontoxic exposures judged by the product (see Table 5) or by the quantity ingested (see Table 4) may safely be discharged with follow-up care. With toxic exposures, all attempts must focus on terminating the exposure by gastrointestinal decontamination with oral poisonings, adequate aeration with inhalational poisonings, and copious washing with topical and/or ocular exposures. The skillful approach of the office practitioner will provide the most effective initial management of the poisoned child. Appropriate referral to an emergency department for further evaluation and treatment may then be considered.     

Montelukast in pediatric asthma management

Leukotriene modifiers (receptor antagonist and biosynthesis inhibitor) represent the first mediator specific therapeutic option for asthma. Montelukast, a leukotriene receptor antagonist is the only such agent approved for use in pediatric patients. Montelukast modifies action of leukotrienes, which are the most potent bronchoconstrictors, by blocking Cysteinyl leukotriene receptors. Systemic drug like mountelukast can reach lower airways and improves the peripheral functions which play a crucial role in the evolution of asthma. Review of existing literature showed that montelukast compared to placebo has proven clinical efficacy in better control of day time asthma symptoms, percentage of symptom free days, need for rescue drugs and improvement in FEV₁. Studies also demonstrated improvement in airway inflammation as indicated by reduction in fractional exhaled nitric oxide, a marker of inflammation. Studies comparing low dose inhaled corticosteroids (ICS) with montelukast are limited in children and conclude that it is not superior to ICS. For moderate to severe persistent asthma, montelukast has been compared with long acting beta agonists (LABA) as an add-on therapy to ICS, montelukast was less efficacious and less cost-effective. It has beneficial effects in exercise induced asthma and aspirin-sensitive asthma. Montelukast has onset of action within one hour. Patient satisfaction and compliance was better with montelukast than inhaled anti-inflammatory agents due to oral, once a day administration. The recommended doses of montelukast in asthma arechildren 1–5 years: 4 mg chewable tablet, children 6–14 years: 5mg chewable tablet, adults: 10 mg tablet; administered once daily. The drug is well tolerated. Based on the presently available data montelukast may be an alternative treatment for mild persistent asthma as monotherapy where ICS cannot be administered. It is also an alternative to LABA as an add-on therapy to ICS for moderate to severe persistent asthma. The other indications for use of montelukast include: allergic rhinitis, exercise induced bronchoconstriction and aspirin-induced asthma.     

Leukotriene modifiers in pediatric asthma management

Cysteinyl leukotrienes (Cys-LTs) are mediators released in asthma and virus-induced wheezing. Corticosteroids appear to have little or no effect on this release in vivo. Cys-LTs are both direct bronchoconstrictors and proinflammatory substances that mediate several steps in the pathophysiology of chronic asthma, including inflammatory cell recruitment, vascular leakage, and possibly airway remodeling. Blocking studies show that Cys-LTs are pivotal mediators in the pathophysiology of asthma. Cys-LTs are key components in the early and late allergic airway response and also contribute to bronchial obstruction after exercise and hyperventilation of cold, dry air in asthmatics. LT modifiers reduce airway eosinophil numbers and exhaled nitric oxide levels. Together these findings support an important role for the Cys-LTs in the asthma airway inflammation. Cys-LT receptor antagonists (Cys-LTRA) are generally well-tolerated. Phase III randomized, controlled clinical trials (RCT) show that LT modifiers are moderately effective, apparently with a particular between-patient variability in their clinical response. The clinical effects of LT modifiers are additive to those of beta-agonists and corticosteroids. The onset of action of LT modifiers is within 1 to several days, and not rapid enough to make them useful as rescue treatment. Although LT modifiers possess some antiinflammatory activity, they cannot substitute for corticosteroids for inflammation control. LT modifiers are alternatives to long-acting beta-agonists as complementary treatment to inhaled corticosteroids in pediatric asthma management because they provide bronchodilation and bronchoprotection without development of tolerance, and complement the antiinflammatory activity unchecked by steroids. In addition, the Cys-LTRA montelukast has been shown to ameliorate asthmatic symptoms and provide bronchoprotection in asthmatic preschool children from 2 years of age, which is of particular importance in this difficult-to-manage group of asthmatics. Given their efficacy, antiinflammatory activity, oral administration, and safety, LT modifiers will play an important role in the treatment of asthmatic children.     

Comprehensive environmental management of asthma and pediatric preventive care

To cite this article: Roy A, Downes MJ, Wisnivesky JP. Comprehensive environmental management of asthma and pediatric preventive care. Pediatr Allergy Immunol 2011; 22 : 277–282. Indoor environmental triggers can increase asthma morbidity. National guidelines recommend comprehensive use of environmental control practices (ECPs) as a component of asthma management. The purpose of this study was to examine the association between preventive asthma care and comprehensive ECP use among children with asthma. We used data from the National Asthma Survey, including 1,921 children with asthma. Comprehensive use was defined as using at least five of eight ECPs: (i) air filter, (ii) dehumidifier, (iii) mattress cover, (iv) pillow cover, (v) pet avoidance, (vi) smoke avoidance, (vii) removing carpets, and (viii) washing sheets in hot water. Univariate and multiple regression analyses were conducted to examine the association between comprehensive use of ECPs and receipt of preventive asthma care, as measured by number of routine asthma visits in the prior year and physician advice to modify the environment. Overall, 17% (95% CI: 14–19%) of participants had comprehensive ECP use. The most commonly used practices were ‘smoke avoidance’ (85%), ‘pet avoidance’ (59%), and ‘washing sheets in hot water’ (46%). Comprehensive use of ECPs was associated with having received physician advice [odds ratio (OR) 3.1, 95% CI: 2.2–4.4] and increased asthma visits (1–2 visits: OR 1.5, 95% CI: 1.0–2.4; 3–4 visits: OR 2.2, 95% CI: 1.3–3.8; ≥5 visits: OR 2.7, 95% CI: 1.5–4.8). Only a minority of parents implement comprehensive ECPs, and receipt of preventive asthma care is associated with comprehensive use. Further research is needed to determine the factors mediating these associations in order to inform more effective asthma counseling.     

The CGHA asthma management program and its effect upon pediatric asthma admission rates

Asthma is the most common reason for admission to the hospital for children nationally. This hospitalization rate is stable despite availability of appropriate outpatient treatments. Our Cincinnati Group Health Associates (CGHA) asthma management program has evolved since 1989. We have measured our pediatric population along with asthma admissions since 1993. Our admission pattern is compared to the community in general and to our managed care population in particular. Our urban center's admission pattern is also studied. Our CGHA pediatric asthma admissions have been declining steadily over the 1993-2000 period by 60%. This decrease is in contrast to national trends in this time period. Comparison to total admissions from 1993 through 2000 still shows a 50% decline whether 0-18 years or 0-5 years is studied. Our urban pediatric center also had a fall in pediatric asthma admission rates of 80% in this time frame; all of these results are statistically significant. Our major managed care network also showed a decline of 55% in pediatric asthma admissions from 1996 to 1999. Our CGHA asthma management program has had a positive influence on our pediatric asthma admission rates. This effect is favorable in comparison to national trends in pediatric asthma admissions. This trend is independent of disease acuity, region of the city where patients live, insurance selection, or age.     

New Japanese pediatric guidelines for the treatment and management of bronchial asthma

There have been a number of guidelines for asthma treatment published throughout the world. However, childhood asthma guidelines must be developed in consideration of the background of the individual countries. The second version of the Japanese Pediatric Guideline for the Treatment and Management of Bronchial Asthma 2002 (JPGL 2002) was published by the Japanese Society of Pediatric Allergy and Clinical Immunology (JSPACI) in November 2002, and was popular among Japanese physicians. After the publication of the JPGL, the incidence of pediatric asthma deaths decreased in Japan. In JPGL 2005 the recommendations were re-edited based on Global Initiative for Asthma (GINA) and the JPGL 2002. In comparison to the GINA guidelines, the JPGL 2005 include a classification system of asthma severity, recommendations for long-term management organized by age, a special mention of infantile asthma, and an emphasis on prevention and early intervention.     

Japanese pediatric guideline for the treatment and management of bronchial asthma 2012

A new version of the Japanese pediatric guideline for the treatment and management of bronchial asthma was published in Japanese at the end of 2011. The guideline sets the pragmatic goal for clinicians treating childhood asthma as maintaining a “well‐controlled level” for an extended period in which the child patient can lead a trouble‐free daily life, not forgetting the ultimate goal of obtaining remission and/or cure. Important factors in the attainment of the pragmatic goal are: (i) appropriate use of anti‐inflammatory drugs; (ii) elimination of environmental risk factors; and (iii) educational and enlightening activities for the patient and caregivers regarding adequate asthma management in daily life. The well‐controlled level refers to a symptom‐free state in which no transient coughs, wheezing, dyspnea or other symptoms associated with bronchial asthma are present, even for a short period of time. As was the case in the previous versions of the guideline, asthmatic children younger than 2 years of age are defined as infantile asthma patients. Special attention is paid to these patients in the new guideline: they often have rapid exacerbation and easily present chronic asthmatic conditions after the disease is established.     

Japanese pediatric guidelines for the treatment and management of bronchial asthma 2008

The fourth version of the Japanese Pediatric Guidelines for the Treatment and Management of Bronchial Asthma 2008 (JPGL 2008) was published by the Japanese Society of Pediatric Allergy and Clinical Immunology in December 2008. In JPGL 2008, the recommendations were revised on the basis of the JPGL 2005. The JPGL 2008 is different to the Global Initiative for Asthma guideline in that it contains the following items: a classification system of asthma severity; recommendations for long‐term management organized by age; a special mention of infantile asthma; and an emphasis on prevention and early intervention. Here we show a summary of the JPGL 2008 revising our previous report concerning JPGL 2005.     

健康相关生命质量评价在儿童哮喘中的研究现状

健康相关生命质量(HRQoL)是指患者关于疾病以及治疗如何影响其行使自身功能的感受,它是评价除了症状、体征、实验室指标以外的临床转归的指标,用于了解疾病对患儿心理、社会适应等方面的影响,从而帮助f临床医生对患儿进行全面的于预,促进健康的转归.哮喘作为儿童时期的常见疾病,对儿童的身心发展都有重要的影响,因此,众多的HRQoL评价都涉足这一领域.该文主要涉及HRQoL在儿童哮喘中的研究现状,其中包括哮喘、哮喘的干预措施对儿童HRQoL的影响以及目前的研究和应用于临床所面临的问题.     

Management of pediatric asthma

Bronchial asthma, in adults and children, is a major health problem, with prevalence rates ranging from 4% to 7% in western Europe. Observational studies suggest that in Italy, like in the other countries, asthma is poorly controlled: most patients report frequent symptoms and limitation to daily activities; the utilization of healthcare resources (hospitalization, emergency room visits, unscheduled urgent care visit) is high. Recent international guidelines (GINA) for asthma management, together with an up-date by NIH, point to the primary role of inhaled corticosteroids for the control of the disease. Early interention with anti-inflammatory drugs is important, also in pre-school children with frequent or persistent symptoms, in order to prevent irreversible structural alterations of the airways and to improve long-term prognosis. In the presence of more severe asthma, inhaled corticosteroids can be associated with long-acting beta2-agonists bronchodilators. These 2 drug classes target different and complementary aspects of the pathophysiology of asthma (inflammation and bronchial obstruction) in a synergistic manner, i.e. by mutual potentiation of their pharmacological activity. Thus, combination therapy may optimize beneficial actions, allowing a more effective control of asthma.     

Acute asthma: observations regarding the management of a pediatric emergency room

Because inadequate assessment and inappropriate treatment of acute asthma have been implicated as contributing factors in morbidity and even deaths, the management of acute asthma, as practiced in an emergency room, were reviewed. The study population comprised 1,864 children (mean age 5.6 years; 65% boys) who attended the emergency room with acute asthma on 3,358 occasions during a 16-month period. Visits occurred more commonly in winter and usually in the evenings; 93% were self-referred and the mean duration of symptoms was 41 hours. Most acute episodes were associated with infection. Although chest auscultation, heart rate, and respiratory rate were recorded during the majority of visits, evidence that pulsus paradoxus had been measured could be found for only 1% of visits. Results of lung function and blood gas values were rarely recorded, but chest radiographs were obtained in 18% of visits. Drugs used in the emergency room included beta 2-agonists (93% of visits), theophylline (16%), and systemic steroids (4%), but no child received anticholinergic therapy. In 26% of patient visits, admission to hospital occurred; one patient died. The erratic fashion in which asthma severity appears to have been assessed and the failure to document whether lung function had been measured are causes for concern. The surprisingly high hospitalization rate may have been avoided if bronchodilators and corticosteroids had not been underused in the emergency room.     

儿童哮喘规范化管理治疗效果评价

目的评价儿童哮喘规范化管理治疗的效果。方法对150例哮喘患儿建立哮喘医疗管理档案,按是否接受规范化管理治疗分为管理组和对照组,对管理组78例患儿及家长进行哮喘基本知识教育、健康教育并定期随访等综合教育管理,同时进行哮喘的规范化治疗;对照组72例未进行哮喘教育管理,仅接受一般临床治疗。观察1年,比较两组儿童哮喘临床疗效、家长知信行变化及患儿用药依从性情况。结果管理组患儿哮喘控制率明显高于对照组(χ2=54.68,P0.01);在随访1年内,管理组患儿哮喘发作次数、急诊次数、住院次数均明显减少,与对照组比较差异有统计学意义(P均0.01);两组比较,管理组患儿家长对哮喘知识的了解和对患儿治疗及管理执行情况等知信行水平显著提高(P0.01);同期管理组患儿用药依从性也显著高于对照组(χ2=66.27,P0.01)。结论推广儿童哮喘规范化管理治疗,可提高哮喘患儿家长的知信行水平,改善患儿治疗依从性,从而有效控制哮喘。