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.     

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.     

Do rates of arthritis and chorea predict the incidence of acute rheumatic fever?

Background: Acute rheumatic fever (ARF), a major cause of acquired heart disease worldwide, remains a significant public health problem. However, the precise incidence of ARF in Africa, where a large number of cases occur, remains unknown. We hypothesize that focused attention on non‐cardiac features of ARF, namely joint manifestations and chorea, might enhance its detection in settings with limited resources. Methods: This hypothesis was tested by reviewing the medical records at Vanderbilt Children's Hospital from 1998 to 2008. In addition, an extensive literature review of published studies was performed to assess rates of joint findings or chorea in confirmed cases of ARF. Results: Fifty‐nine new cases of ARF were diagnosed in children at Vanderbilt from 1998 to 2008. Of these cases, 91% presented with joint manifestations or chorea, and 80% satisfied major Jones criteria findings of polyarthritis or chorea. These findings are consistent with literature published from our region and internationally. Conclusions: Most patients presenting with ARF have either joint symptoms or chorea, features that could be recognized by community health workers and individuals with limited medical training. The referral of patients presenting with these manifestations for further evaluation might improve detection rates of ARF in resource‐limited countries and lead to improved estimates of disease burden.     

Do clinical variables predict pathologic radiographs in the first episode of wheezing?

OBJECTIVE: To determine if clinical variables assessed in relation to Albuterol aerosol treatments accurately identify children with pathologic radiographs during their initial episode of bronchospasm. METHODS: A prospective convenience sample of children with a first episode of wheezing. Data collected included demographics, baseline and post-treatment clinical score and physical examination, number of aerosols, requirement for supplemental oxygen, and disposition. Chest radiographs were obtained and interpreted, and patients were divided into 2 groups based on a pathologic versus nonpathologic radiograph interpretation. Chi2 testing was performed for categoric variables, and the student t test was performed for continuous variables. A discriminant analysis was used to develop a model. RESULTS: Pathologic radiographs were identified in 61 patients (9%). Between groups, a significant difference was noted for pretreatment oxygen saturation only. Clinical score, respiratory rate, and presence of rales both pretreatment and posttreatment were not significantly different between groups. The discriminant analysis correctly predicted 90% of nonpathologic radiographs but only 15% of pathologic radiographs. CONCLUSIONS: Clinical variables, either isolated or as components of a model, could not identify all children with pathologic radiographs.     

Do grip and pinch strength predict neurologic complications in children with spina bifida and hydrocephalus?

BACKGROUND: Neurological complications occur commonly in children with meningomyelocele and can cause significant morbidity and mortality. An earlier study suggested that acute changes in grip and pinch strength could be used to identify individuals at increased risk for developing a neurological complication. OBJECTIVE: To evaluate the use of grip and pinch measurements to screen for neurological problems in children with spina bifida and hydrocephalus. DESIGN: A prospective evaluation of screening tests. PATIENTS: 92 children, born since 1976, who had meningomyelocele and hydrocephalus and were treated at the University of Rochester Medical Center. METHODS: Grip and pinch strength were measured between July, 1991, and June, 2003. RESULTS: Mean grip and pinch strengths were similar to those found in previous studies of children with meningomyelocele; 58 neurological events occurred in 39 (40%) individuals. These included 31 episodes of ventricular shunt failure and 22 symptomatic tethered cord occurrences. Specificity, sensitivity and likelihood ratios were calculated in multiple ways using different criteria for loss of grip or pinch strength and for interval to neurological event. Sensitivities were low (<0.35) and the highest positive likelihood ratio found, using fall in either lateral pinch with 6 months to neurological event, was 2.3. CONCLUSIONS: Despite previous recommendations, grip and pinch measurements were not helpful when used as a routine screening test for neurological dysfunction for children with meningomyelocele and hydrocephalus.     

Does assessment of pretest probability of disease improve the utility of echocardiography in suspected endocarditis in children?

OBJECTIVE: To compare the yield rate (YR) of echocardiography when evaluating children with suspected infectious endocarditis (IE) in both the actual clinical setting and in the hypothetic setting where strict clinical criteria are applied.Study design Medical records of 101 children undergoing echocardiography for suspected IE were reviewed. Echocardiograms with positive findings were identified and the actual diagnostic YR was calculated. With the use of clinical criteria proposed by von Reyn (VR), the probability of IE was retrospectively classified as (1) rejected, (2) possible, or (3) probable. Theoretic YR of echocardiography was calculated for each classification. RESULTS: The actual YR of echocardiography was 12% (12/101). The YR of echocardiography by VR class was 0% in rejected, 20% in possible, and 80% in probable cases (chi(2) = 55.1, P <.0001). Echocardiography did not change the probability of IE in any patient classified as rejected, but allowed reassignment of disease probability in a significant proportion of patients with possible or probable IE. CONCLUSIONS: The YR of echocardiography was significant when clinical probability of IE was intermediate-to-high, and low, with marginal clinical utility, when clinical probability was low. Strict pretest assessment of disease probability may lead to more effective utilization of echocardiography in this population.     

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.     

Should the lateral chest radiograph be routine in the diagnosis of pneumonia in children? A review of the literature

OBJECTIVE:

To assess the evidence of the additive diagnostic value of the lateral chest radiograph to the frontal chest radiograph in children (zero to 18 years) with suspected pneumonia in the emergency department.

METHODS:

The MEDLINE database (1966 to 2001) was searched to identify the highest level of evidence available in support of the lateral. The key words used included chest radiograph, pneumonia and chest x-ray.

RESULTS:

Only four controlled studies were identified that assessed the role of the lateral chest x-ray. Three of these studies were retrospective. In the first study, the addition of the lateral to the frontal chest x-ray in 414 children would have detected an additional nine patients (2.3%) with pneumonia. In the second study, involving 179 patients, a high level of agreement was found between the interpretations based on the frontal chest x-ray alone and those based on both views. A third study of 359 children assessed the criterion validity of a frontal chest x-ray alone. Based upon a radiologist’s interpretation of both views as the gold standard, the sensitivity of the frontal view alone was 86%. A fourth study of 158 children with suspected pneumonia revealed that the frontal view alone was diagnostic of pneumonia in 106 of 109 (97%) patients.

CONCLUSION:

There is no randomized controlled trial evidence to support the additive value of the lateral to the frontal chest x-ray in the diagnosis of children with pneumonia. Further prospective studies are required to determine if the addition of the lateral chest x-ray will modify therapy, prevent complications or whether it is cost-efficient.     

Are the symptoms and severity of head injury predictive of clinical findings three months later?

Aim: To describe symptoms and functional disabilities 3 mo after a minimal, mild or moderate head injury in children, and to analyse relationships between these and initial symptoms and management documented at the time of the injury. Methods: The sample consisted of all children (0-15 y) admitted to an emergency department during a 1-mo period with a history of head injury. Data were collected from the medical records at the time of the injury, and questionnaires about symptoms/change and functional problems 3 mo after the injury. Results: Symptoms and functional problems were reported in 35% of the children 3 mo after a head injury. Documented altered consciousness (in children less than 5 y) and disorientation (in children 5 y of age or older) at the emergency department were correlated with changes in behaviour at 3 mo. The initial duration of unconsciousness was not predictive of subsequent behaviour.

Conclusion: The difficulties in predicting outcomes in head-injured children, especially younger ones, indicate the need for a follow-up appointment in order to identify children with special needs. Further studies are needed regarding the early signs and symptoms in different age groups.     

Is it possible to predict the number of nebulizations and the use of intravenous corticosteroid in children with asthma attacks in the emergency room?

OBJECTIVE: To identify the number of nebulizations needed and the demand for intravenous corticosteroids in children with asthmatic attack, considering clinical and functional characteristics presented at the moment children were admitted to the emergency room. METHODS: We prospectively evaluated 130 children with asthmatic attack and from 1 to 13 years of age. At the moment children were admitted, they were evaluated according to clinical score, arterial oxygen saturation (pulse oximetry), and peak expiratory flow. Next, children received a standard treatment and were observed for the number of consecutive nebulizations required and the use of corticosteroid. Using regression analysis, we assessed the parameters evaluated for a correlation with the number of nebulizations and the use of intravenous corticosteroid. RESULTS: Eighty-eight children (67.7%) received from 1 to 3 nebulizations and 42 children (32.3%), 6 nebulizations. Sixty-eight children (52.3%) received corticosteroid. The initial values for clinical scores, arterial oxygen saturation, and peak expiratory flow showed a significant correlation with the number of nebulizations required and the need for corticosteroids. CONCLUSIONS: According to our results, it is possible to predict and anticipate, at the time chidren are admitted with asthmatic attack, the need for corticosteroid and more nebulizations, which can change the prognosis and the time of evolution of the attack.     

Adaptation of pain scales for parent observation: are pain scales and symptoms useful in detecting pain of young children with the suspicion of acute otitis media?

Background

The assessment of ear pain is challenging in young, mostly preverbal children. Our aim was to investigate whether pain scales are useful tools for parents to detect pain in their young children with the suspicion of acute otitis media (AOM), and to assess associations between 16 symptoms and the severity of pain.

Methods

This cross-sectional study included 426 children (6–35?months) with symptoms suggestive of AOM. We surveyed symptoms and pain via parental interview. As part of the interview, parents assessed their child’s pain by using two pain scales: The Faces Pain Scale-Revised (FPS-R) and the Face, Legs, Activity, Cry, Consolability (FLACC) Scale. The outcome of interest was moderate/severe pain. We used the χ² test or Fisher’s test as applicable to compare the severity of pain between three parental pain assessment methods (the parental interview, the FPS-R and the FLACC Scale). We also used multivariable logistic regression models to study the association between the severity of pain and AOM and to study the association between symptoms and the severity of pain.

Results

In children with AOM (n?=?201), pain was assessed by parents as moderate/severe in 65% via interview; 90% with the FPS-R; and 91% with the FLACC Scale (P?<?0.001). In children without AOM (n?=?225), the percentages were 56, 83 and 88%, respectively (P?<?0.001). Between children with and without AOM, the occurrence of moderate/severe pain did not differ with any of the pain evaluation methods. Of symptoms, ear pain reported by child and restless sleep were significantly associated with moderate/severe pain, regardless of the pain evaluation method.

Conclusions

It seems that nearly all the children with respiratory tract infection, either with or without AOM, might suffer from moderate/severe pain. Without pain scales, parents may underestimate their child’s pain. Of symptoms, ear pain reported by child and restless sleep might indicate pain in children with respiratory tract infection. We suggest that the adaptation of pain scales for parent observation is a possibility in children with respiratory tract infection which, however, requires further studies.

Trial registration

www.clinicaltrials.gov, identifier NCT00299455. Date of registration: March 3, 2006.

     

Do published guidelines predict pneumonia in children presenting to an urban ED?

OBJECTIVES: In 1997, a Canadian task force published evidence-based guidelines for diagnosing pediatric pneumonia, concluding that the absence of each of four signs (ie, respiratory distress, tachypnea, crackles, and decreased breath sounds) accurately excludes pneumonia. The study was performed to evaluate the accuracy of these guidelines in predicting pneumonia in young children. METHODS: This was an observational study conducted over a 4-month period at an urban emergency department with 80,000 annual visits, approximately 20% of which were children < or =5 years old. Consecutive children < or =5 years old who underwent chest radiography were enrolled. Prior to ordering radiographs, treating physicians were required to enter specific patient signs and symptoms into a computerized database. World Health Organization criteria were used to define tachypnea. Sensitivity, specificity, and predictive values of the task force guidelines in predicting pneumonia were calculated. RESULTS: Three hundred twenty-nine children, including 67 (20%) with pneumonia, were enrolled. Guidelines were 45% sensitive (95% confidence interval (CI) = 33-58) and 66% specific (95% CI = 60-72) for diagnosing pneumonia. Positive and negative predictive values were 25% (95% CI = 18-34) and 82% (95% CI = 77-87), respectively. CONCLUSION: Previously published evidence-based guidelines for excluding pediatric pneumonia were found unreliable in this study.