Can clinical signs predict hypoxaemia in Papua New Guinean children with moderate and severe pneumonia?

Pulse oximetry was performed on 77 children admitted with acute lower respiratory tract infections (ALRI) to the children's ward in Port Moresby General Hospital, Papua New Guinea over a 4-month period in 2002. Clinical findings were correlated with different levels of hypoxaemia, <93%, <90% and <85%. Cyanosis, head nodding and drowsiness were good predictors of hypoxia but lacked sensitivity. Decisions to use oxygen based on these signs would therefore result in a significant number of children with hypoxia not receiving oxygen. Pulse oximetry is the best indicator of hypoxaemia in children with ALRI and, although relatively expensive, its use might be cost-effective in controlling oxygen requirements.     

Can clinical symptoms or signs accurately predict hypoxemia in children with acute lower respiratory tract infections?

OBJECTIVES: To determine clinical predictors of hypoxemia in children with acute lower respiratory tract infection (ALRI). DESIGN: Cross-sectional study. SETTING: Emergency department of All India Institute of Medical Sciences, a tertiary care hospital. SUBJECTS: 109 under five children, with ALRI. METHODS: Clinical symptoms and signs were recorded. Oxygen saturation was determined by a pulse oximeter. Hypoxemia was defined as oxygen saturation less than 90%. The ability of various clinical symptoms and signs to predict the presence of hypoxemia was evaluated. RESULTS: Twenty-eight (25.7%) children were hypoxemic. No symptoms were statistically associated with hypoxemia. Tachypnea, suprasternal indrawing, intercostal indrawing, lower chest indrawing, cyanosis, crepitations, and rhonchi were statistically significantly associated with hypoxemia. A simple model using the presence of rapid breathing (> or =80/min in children < or =3 m, > or =70/min in >3-12 m and > or =60/min in >12 m) or lower chest indrawing had a sensitivity of 78.5% and specificity of 66.7% for detecting hypoxemia. No individual clinical symptom/sign or a combination had both sufficient sensitivity and specificity to identify hypoxemia. CONCLUSION: None of the clinical features either alone or in combination have desirable sensitivity and specificity to predict hypoxemia in children with acute lower respiratory tract infection.     

Can the metabolic syndrome identify children with insulin resistance?

OBJECTIVE: The metabolic syndrome is associated with insulin resistance in adults. We defined pediatric metabolic syndrome using criteria analogous to Adult Treatment Panel III. The purpose of this study was to determine whether these criteria are reliable for insulin resistance in children. RESEARCH DESIGN AND METHODS: Out of 167 children (6.7 +/- 3 yr), 73 overweight [body mass index (BMI) > 95 percentile], 41 at risk of overweight (BMI > 85 < 95 percentile), and 53 normal-weight (BMI < 85 percentile) children matched for sex and age were examined. The results for waist circumference, blood pressure, oral glucose tolerance test, C-reactive protein, adiponectin, insulin, and lipids were obtained. RESULTS: There was a comparable prevalence of the metabolic syndrome in both sexes. The prevalence of the metabolic syndrome was 11.3% [95% confidence interval (CI) 6.56-16.19%] among the whole group and 21.9% (95% CI 12.24-31.0%) among overweight children. Waist circumference >75 percentile 53.2% (95% CI 45.73-60.86%) and low high-density lipoprotein 27.5% (95% CI 20.77-34.32%) were common in this sample. Compared with patients without any component of the metabolic syndrome, homeostasis model assessment insulin resistance (HOMA-IR) for patients with one through four components was higher (beta = 0.6, 95% CI 0.4-0.7, p < 0.0001, R(2) = 0.185). A logistic regression analysis using the metabolic syndrome as the dependent variable showed that HOMA-IR (odds ratio 1.52, 95% CI 1.2-2.0, p = 0.007) was the only independent risk factor for the metabolic syndrome, adjusted for age and sex. CONCLUSIONS: The importance of insulin resistance in the metabolic syndrome is supported by the results of logistic regression analysis. Early identification of children may be useful to predict future cardiovascular disease and type 2 diabetes.     

Can waist circumference identify children with the metabolic syndrome?

OBJECTIVE: To determine in children the association between waist circumference (WC) and insulin resistance determined by homeostasis modeling (HOMA-IR) and proinsulinemia and components of the metabolic syndrome, including lipid profile and blood pressure (BP). METHODS: Eighty-four students (40 boys) aged 6 to 13 years and matched for sex and age underwent anthropometric measurements; 40 were obese; 28, overweight; and 16, nonobese. Body mass index (BMI), WC, BP, and Tanner stage were determined. An oral glucose tolerance test, lipid profile, and insulin and proinsulin assays were performed. Children were classified as nonobese (BMI < 85th percentile), overweight (BMI, 85th-94th percentile), and obese (BMI > or = 95th percentile). RESULTS: There was univariate association (P < .01) between WC and height (r = 0.73), BMI (r = 0.96), Tanner stage (r = 0.67), age (r = 0.56), systolic BP (r = 0.64), diastolic BP (r = 0.61), high-density lipoprotein cholesterol level (r = 0.45), triglyceride level (r = 0.28), proinsulin level (r = 0.59), and HOMA-IR (r = 0.59). Multiple linear regression analysis using HOMA-IR as the dependent variable showed that WC (beta coefficient = 0.050 [95% confidence interval, 0.028 to 0.073]; P = .001) and systolic BP (beta coefficient = 0.033 [95% confidence interval, 0.004 to 0.062]; P = .004) were significant independent predictors for insulin resistance adjusted for diastolic BP, height, BMI, acanthosis nigricans, and high-density lipoprotein cholesterol level. CONCLUSION: Waist circumference is a predictor of insulin resistance syndrome in children and adolescents and could be included in clinical practice as a simple tool to help identify children at risk.     

Are mothers encouraged to identify the risk signs of diarrhea?

OBJECTIVES: To acknowledge the mothers' perception of the diarrhea episode and their ability in identifying the signs of risk; to characterize, in the health services, at ambulatory level, the activities that stimulate a timely attention to the disease.METHODS: An inquiry was applied to a representative sample of 1026 children under 5 years old who live in the pilot areas of Pernambuco selected to receive interference concerning diarrhea, and an interconnected transversal study in 14 health services: 11 health centres and 3 hospitals.RESULTS: A high proportion of the mothers of children with diarrhea give importance clinical manifestations that do not allow an early identification of dehydration. Only one fourth of them mentions dehydration as a complication. The mothers perception of the episode has a striking influence on the adopted conduct, particularly in the Metropolitan Area, in which, in the absence of preoccupation, no children were taken to the physician and a significant smaller proportion received care to hydration. In the health services, in general, collective educational programs are not the routine, the consult with the physician is limited to the main complaint, there is no post-consult with the nurses nor articulation with community health agents. Besides that, half of the mothers did not know the signs of dehydration.CONCLUSIONS: The findings of both the inquiry and the evaluation of the health services showed a quite critical situation: mother's little perception of the mothers of diarrhea worsening signs, as well as the insufficiency of these services concerning educational activities towards stimulating mothers to recognize and valorize them.     

How accurate are neonatologists in identifying clinical jaundice in newborns?

This study reevaluates the clinical ability to accurately identifyjaundice in neonates. Three hundred seventy-one term infants were clinically asseseed forjaundice, before discharge home on day 2 to 3 of life. Bilirubin levels obtained at the same time were significantly higher in the newborns clinically diagnosed as beingjaundiced. Our neonatologists were able to diagnose jaundice at clinically low levels, and not to misdiagnose significant hyperbilirubinemia in the majority of the infants. The trained human eye can still discriminate between the jaundiced and nonjaundiced newborn, and clinical impression of jaundice remains a reliable primary screening tool for significant neonatal hyperbilirubinemia.     

What clinical signs best identify severe illness in young infants aged 0-59 days in developing countries? A systematic review

Despite recent overall improvement in the survival of under-five children worldwide, mortality among young infants remains high, and accounts for an increasing proportion of child deaths in resource-poor settings. In such settings, clinical decisions for appropriate management of severely ill infants have to be made on the basis of presenting clinical signs, and with limited or no laboratory facilities. This review summarises the evidence from observational studies of clinical signs of severe illnesses in young infants aged 0-59 days, with a particular focus on defining a minimum set of best predictors of the need for hospital-level care. Available moderate to high quality evidence suggests that, among sick infants aged 0-59 days brought to a health facility, the following clinical signs-alone or in combination-are likely to be the most valuable in identifying infants at risk of severe illness warranting hospital-level care: history of feeding difficulty, history of convulsions, temperature (axillary) ≥37.5°C or <35.5°C, change in level of activity, fast breathing/respiratory rate ≥60 breaths per minute, severe chest indrawing, grunting and cyanosis.     

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.     

Neurological ’soft' signs may identify children with sickle cell disease who are at risk for stroke

Stroke is one of the most frequent complications of sickle cell disease (HbSS), occurring in 7–17% of children. Recent studies recognized more minor lesions on MRI, not associated with clinical signs on standard neurological examination, which however have been found to be a risk factor for developing stroke later. The aim of this study was to evaluate whether minor lesions observed on imaging could be associated with soft neurological signs not detectable on conventional neurological examination. Fourteen children with HbSS were assessed with MRI, standard neurological examination and evaluation of soft signs (Zurich Neuromotor Test) and motor function (Movement ABC). Eight of the 14 children scanned showed lesions on MRI but only 3 of the full cohort were abnormal on standard neurological examination. However, all of the eight children with MRI lesions also showed abnormal signs on at least one of the two tests (Zurich and Movement ABC). All the children with normal MRI were normal on all the tests performed. The sensitivity of Zurich Neuromotor Test and Movement ABC in the group of children with MRI lesions is 0.88 and 0.75, respectively, and increases to 1 when the two tests are used together. The specificity of both tests is 1 even when the tests are used separately.     

Drug withdrawal in newborns - clinical data of 49 infants with intrauterine drug exposure: what should be done?

BACKGROUND: Infants of drug abusing mothers are at high risk to suffer from neonatal abstinence syndrome (NAS). Depending on the drug signs of neonatal withdrawal vary but mainly include central nervous system irritability. NAS causes long duration of hospital stay. Severe withdrawal signs are seen in infants exposed to methadone, infants exposed to other opioids like heroin or buprenorphine have been shown to be less symptomatic. Between the years 1997 and 2003 following the border opening there was a dramatic increase in drug exposed newborns seen in the area of Leipzig (East Germany). METHODS: In a retrospective study maternal and infant characteristics, severity of symptoms, duration of withdrawal and hospital stay, duration and kind of treatment as well as modalities for release from hospital were analyzed. RESULTS: From 1997 to 2003 49 drug exposed newborns were admitted to our neonatal care unit. There was an increase of the number of affected infants within these years ( ). Maternal drug abuse (n=48) included mainly methadone (n=33), in second line heroine and benzodiazepines, in a few cases also cocaine and cannabinoides. 3 mothers received substitution therapy with buprenorphine. Additional drug use to substitution therapy was seen in 15 mothers. Drugs of abuse were detected in infant urine specimen (36/48). 35 of exposed newborns showed signs of NAS (incidence of NAS 71%). For evaluation of withdrawal signs and conduction of therapy the Finnegan score was used. As first line pharmacological treatment phenobarbitone was administered (n=42), secondary morphine was used (n=14, treatment failure 33%). Mean duration of hospital stay was 21 days. Mean duration of pharmacological treatment was 14 days with longer duration for methadone exposed infants vs. non-methadone exposed infants (16 vs. 10 days). Hospital stay was longer for non-methadone exposed infants. Maternal intake of more than 20 mg methadone per day vs. up to 20 mg per day caused longer duration of hospital stay (28 vs. 20 days, p=0,015). CONCLUSION: Long duration of hospital stay and pharmacological treatment call for optimised principal guide lines for diagnosis, treatment and long term follow-up. The results also underline the need for further research for an effective pharmacological treatment.     

Can preschool developmental screening identify children at risk for school problems?

Screening preschool children for potential school problems may allow early intervention. Children beginning first grade (N=980) were tested with Denver II. All with normal/questionable results had satisfactory school performance while 26% of those with abnormal Denver II had low school scores. 43%, 27% and 0% of children with abnormal, questionable, and normal Denver II respectively had IQ<90 on WISC-R (p=0.05). Preschool Denver II can be recommended for populations at risk.     

Can we identify acute severe viral lower respiratory tract infection clinically?

Two hundred children below five years of age hospitalized with a clinical diagnosis of acute severe lower respiratory tract infection were enrolled in the study. Nasopharyngeal (NP) aspirate was collected for viral isolation by centrifugation enhanced culture technique. Viruses were isolated from 89 NP aspirates. Clinical features of these 89 children were compared with 111 children whose NP aspirates were negative for viruses. There was significantly higher incidence of breathlessness and rhonchi in children whose nasopharyngeal aspirates yielded virus. Sensitivity,specificity, positive and negative predictive values of breathlessness for severe viral ALRTI were 98%, 10.8%, 46.8% and 85%, respectively. The values for rhonchi were 60%, 56.8%, 58.2%, and 74.1%, respectively. It is concluded that clinical features do not have desirable sensitivity and specificity for identification of ALRTI due to viral etiology.