Unintentional exposure of young children to camphor and eucalyptus oils

BACKGROUND:

Essential oils, such as camphorated and eucalyptus oils, are volatile oils that can be absorbed by mouth and through the skin; if ingested orally by children, they can be harmful, even life-threatening.

OBJECTIVE:

To determine the frequency of essential oil ingestion among children in Toronto, Ontario.

METHODS:

Charts from December 1995 through March 1997 at the Ontario Regional Poison Information Centre, The Hospital for Sick Children, Toronto were reviewed to collect information on calls about essential oil ingestion, and a search of MEDLINE articles from 1966 to 1998 was conducted using the key words: ‘camphor’, ‘eucalyptus’, ‘paediatric’, and ‘poisoning’.

RESULTS:

Callers to the Poison Information Centre reported that 251 children had ingested an essential oil or product: eucalyptus oil 50 children; camphorated oil 18 children; VapAir (Drug Trading, Canada) vaporizing liquid 93 children; and Vicks VaporRub (Procter & Gamble, Canada) 90 children. The most common symptoms were cough, vomiting and cough associated with vomiting. Two children had seizures but recovered. The MEDLINE search found 18 reports of paediatric ingestion of the oils or oil products. The main symptoms were vomiting, lethargy, coma and seizures. One child died.

CONCLUSION:

Although widely used by health care consumers, essential oils and the products that contain them can be harmful when ingested by children. Further education for parents and other caregivers about the risks involved in exposure to these products is required.     

Cytomegalovirus as an occupational risk in daycare educators

BACKGROUND

Cytomegalovirus (CMV) infection continues to be an important occupational risk in the daycare setting. A comprehensive update of scientific evidence is timely to inform and promote appropriate preventive measures.

METHODS

A review of the literature was conducted to examine the evidence for an occupational risk of CMV infection in daycare educators. Sources included Medline, government documents and additional references from published bibliographies. The key words used for searches were ‘child day care centres’ or ‘nurseries’ and ‘cytomegalovirus’ or ‘cytomegalovirus infection’.

RESULTS

Eight CMV seroprevalence studies on daycare educators in industrialized countries were found: four in the United States, three in Canada and one in Italy. Risk factors for seropositivity were older age, nonwhite race, foreign birth, birth in a low- or middle-income country, diaper changing, having children at home, and a child to educator ratio greater than 6:1 in children 18 to 35 months of age. Risk factors for seroconversion were younger age and working with young children. These studies suggest that daycare centres may be a high-risk setting for CMV infection.

DISCUSSION

Recommendations to prevent CMV infection in this setting include handwashing, selective serological screening, avoiding work with younger children if pregnant and, in some cases, preventive leave from work. Evaluation and expert opinion of the effectiveness of various preventive options for CMV acquisition are needed to ensure that recommendations are evidence-based.     

Active surveillance for tuberculosis in Wales: 1996-2003

Aims

To estimate the incidence of active tuberculosis (TB) and study the use of chemoprophylaxis for latent TB in children in Wales, and to identify potential areas for improving prevention and management.

Methods

Active surveillance for TB in children aged 0–15 years from July 1996 to December 2003, using the Welsh Paediatric Surveillance Scheme.

Results

A total of 232 children, 102 with active TB (2.3 per 100 000) and 130 with latent TB (2.9 per 100 000), were identified. Nearly half (45%) belonged to ethnic minorities (19% were of black African origin), a much higher proportion than the base population. Pulmonary disease was the most common presentation (47%), including six (9%) children who were sputum smear positive. There were 10 cases of disseminated TB, nearly all in white children under 10 years of age. Less than two thirds of eligible children (27/46, 59%) were known to have received BCG immunisation. The source of infection was an adult household contact in most cases, but was not known in 44 cases, particularly among teenagers. Four community outbreaks occurred during the surveillance period, including three in high schools.

Conclusion

TB incidence in children in Wales remains low, but the epidemiology is changing with an increasing proportion of cases in black African children. The high proportion of patients with disseminated TB is of particular concern. TB in teenagers was often associated with school outbreaks. Many eligible children do not receive BCG immunisation, indicating further scope for prevention.     

Severe injury mechanisms in two paediatric trauma centres: Determination of prevention priorities

BACKGROUND

To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.

METHODS

The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.

RESULTS

A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.

CONCLUSION

The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.     

Influenza vaccination options to prevent hospitalization

BACKGROUND:

Vaccination of children against influenza remains a controversial topic despite the substantial morbidity caused by this infection.

OBJECTIVE:

To estimate the effect of three different vaccination strategies on preventing hospitalization due to influenza.

METHODS:

A retrospective chart review was conducted of all children admitted to a tertiary health care centre who tested positive for influenza during three consecutive influenza seasons.

RESULTS:

The final analysis included 208 cases with an age range of five days to 16.1 years. Seventy-six children were considered ‘high-risk’ and 132 were considered ‘previously healthy’. Length of stay (LOS) ranged from one day to 46 days with a mean of 6.3 days. The mean LOS was 8.6 days for children with risk factors and 4.9 days for those without risk factors. The number of preventable influenza admissions was determined over three years and averaged over one year for the three vaccination strategies. A universal strategy of vaccinating all previously healthy and high-risk children over six months of age would have prevented 118 admissions. Using a selective strategy of vaccinating only children over six months of age with risk factors and a third strategy of vaccinating only two- to six-month-old infants would have prevented 58 and 55 admissions, respectively.

CLINICAL IMPLICATION:

Use of the universal vaccination strategy would have prevented over one-half of the influenza admissions, which was over twice that of targeted vaccination. Until the challenges of implementing universal vaccination are fully understood, targeted vaccination remains an acceptable alternative.     

Childhood overweight and obesity management: A national perspective of primary health care providers' views, practices, perceived barriers and needs

BACKGROUND:

Obesity and overweight in children are an escalating problem in Canada and worldwide. Currently, little is known about the manner in which primary health care providers are responding to Canada’s obesity epidemic.

OBJECTIVE:

To determine the views, practices, challenges/barriers, and needs of a national sample of family physicians (FPs) and community paediatricians (CPs) with respect to paediatric obesity identification and management.

METHODS:

A self-administered questionnaire was mailed to a random sample of 1200 FPs and 1200 CPs across Canada between 2005 and 2006.

RESULTS:

A total of 464 FPs and 396 CPs participated. The majority of practitioners viewed paediatric obesity as an ‘important’/‘very important’ issue. Although the majority reported providing dietary (more than 85%) and exercise (98%) advice to their overweight/obese patients, practitioners’ perceived success rate in treating paediatric obesity was limited (less than 22%). Approximately 30% of FPs and 60% of CPs (P<0.05) used the recommended method to identify paediatric obesity. At least 50% of practitioners indicated that too few government-funded dietitians, a lack of success in controlling paediatric patients’ weight, time constraints and limited training were key barriers to their success. To support efforts to identify or manage paediatric obesity, practitioners identified the need for office tools, patient educational materials and system-level changes.

DISCUSSION:

Canadian primary health care providers are not adequately equipped to deal with the paediatric obesity epidemic. Effective assessment tools and treatment resources, dissemination of clinical practice guidelines, enhanced undergraduate medical education and postgraduate continuing medical education, and system-level changes are urgently needed to address this health problem.     

Perinatal brachial plexus palsy

BACKGROUND

Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births.

OBJECTIVES

To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions.

METHODS

A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included ‘brachial plexus’, ‘brachial plexus neuropathy’, ‘brachial plexus injury’, ‘birth injury’ and ‘paralysis, obstetric’.

RESULTS

There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments.

CONCLUSIONS

It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.     

Demographic characteristics and needs of families at an urban,low-income,multicultural paediatric clinic

OBJECTIVES:

To describe the demographic characteristics and identify the needs of a population attending an urban, low-income area, multicultural paediatric clinic.

METHODS:

Surveys were distributed to caregivers of children zero to 16 years of age (n=299).

RESULTS:

Of the children attending appointments, 55% were female and 51% were five years of age or younger. Of the caregivers, 29.5% were born outside of Canada and 25% reported that their primary spoken language was not English. Sixty-six per cent of families had been living in Edmonton for more than three years, with two-thirds of respondents living in Edmonton’s second-lowest average household income region. Seventy-six per cent of respondents lived in households with four or more persons.

CONCLUSIONS:

Challenges facing individuals attending an urban, low-income area, paediatric clinic include language barriers, lower household income and larger family size. Immigrants living outside of major Canadian cities are under-represented and may have different needs compared with their counterparts in ‘gateway’ cities. More studies are needed to determine their needs, and will ultimately lead to the provision of culturally competent care.     

Determining the benefits and objectives of a child health residency program for Canadian rural family physicians: An international qualitative research study

OBJECTIVES:

To clarify the need for an advanced child health training program for Canadian rural family physicians, and to determine the key learning objectives to enable graduates to become community leaders in child and youth health care.

DESIGN:

Qualitative educational research study.

Setting:

Canada and Australia.

METHODS:

To gather data, the authors carried out semistructured interviews and focus groups with child care consultants, Canadian rural family physicians, child patients and parents, family medicine residents and Australian rural family physicians. Standards of qualitative methodology were applied to identify themes and subthemes.

RESULTS:

It was determined that a family medicine child health program would provide the following benefits: enhanced care by family physicians, improved access to child care, increased attractiveness of family medicine as a career and reduced ‘specialty burden’.Five key learning objectives for graduates were identified: the ability to provide child-centred care, to care for acutely or critically ill children, to care for children with complex needs, to recognize and act on ‘red flags’, and to provide behavioural and mental health care.The Australian general practitioners confirmed that their training provided most of these benefits, and enabled them to achieve the objectives identified.

CONCLUSION:

The present study showed that multiple stakeholders believed that advanced training in child health for rural family physicians would provide better care for children. The study also identified key learning objectives for the program. The present research led to the establishment of a Family Medicine Child Health Residency Program (www.familymedicineuwo.ca/PostGrad/PGY3/ChildHealth.aspx) at The University of Western Ontario (London, Ontario).     

The spectrum of seat belt syndrome among Canadian children: Results of a two-year population surveillance study

BACKGROUND

Seat belts have been proven to save lives. However, if they are not properly fitted, ‘seat belt syndrome’ can occur. The aim of the present study was to describe injuries encountered in Canadian children with seat belt-associated injuries.

METHODS

Canadian paediatricians and paediatric subspecialists were surveyed monthly through the Canadian Paediatric Surveillance Program. Children younger than 18 years of age who were restrained in motor vehicles at the time of a collision, with abdominal or thoracolumbar spine injuries, were included. The children may have been restrained in child safety seats, booster seats, or two- or three-point seat belts.

RESULTS

Twenty-eight children, between two and 16 years of age, with injuries compatible with seat belt syndrome were reported in Canada between September 2003 and August 2005. Although 12 children were younger than eight years of age, only one was restrained in a booster seat and only four of the older children were properly restrained with a three-point seat belt. Twenty-four children had abdominal injuries. Of these, 18 had stomach and/or intestinal injuries and 11 had solid organ injuries. Twelve patients had a spinal fracture, including only five Chance-type fractures. Seven patients presented with paraplegia, and none of them recovered.

CONCLUSION

In Canada, over a two-year period, 28 children were reported to have sustained injuries consistent with seat belt syndrome; seven of these children remained paraplegic. These results emphasize the necessity to review restraints in motor vehicles to adequately protect children.     

The Montreal Children's Hospital Feeding Scale: A brief bilingual screening tool for identifying feeding problems

OBJECTIVE:

To establish the psychometric characteristics of a newly developed, brief bilingual 14-item parent report tool (The Montreal Children’s Hospital Feeding Scale [MCH-Feeding Scale]) designed to identify feeding problems in children six months to six years of age.

METHODS:

To establish construct validity, 198 mothers of children visiting community paediatrician’s offices (normative sample) and 174 mothers of children referred to a feeding clinic (clinical sample) completed the scale. Test-retest reliability was obtained by the re-administration of the MCH-Feeding Scale to 25 children in each sample.

RESULTS:

Excellent construct validity was confirmed when the mean [± SD] scores of the normative and clinical samples were compared (32.65±12.73 versus 60.48±13.04, respectively; P<0.01). Test-retest reliabilities were high for both groups (normative r=0.845, clinical r=0.92).

CONCLUSION:

The MCH-Feeding Scale can be used by paediatricians and other health care professionals for quick identification of feeding problems.     

Retinopathy of prematurity: A systematic review of the literature

OBJECTIVE:

To assist in the diagnosis of retinopathy of prematurity (ROP) to facilitate treatment in a timely manner to help prevent blindness.

DATA SOURCES:

Systematic review using MEDLINE including the following key words, “retinopathy of prematurity”, “retrolental fibroplasia”, “blind”, “blindness”, “vision screening”, “cryotherapy”, “cryosurgery”, “laser” and “ablative therapy”. The bibliographies of the references found using the above techniques were scanned for references missed in the primary search.

DATA SELECTION:

Eight population-based studies examining the incidence and severity of ROP were identified. Other studies of ROP were included because they contributed to an understanding of the natural history, treatment or long term outcome of ROP.

DATA EXTRACTION:

Data was analyzed cumulatively from the population-based studies to determine the incidence of ROP. For the natural history, treatment and schedule of eye examinations, data was reported from individual studies.

DATA SYNTHESIS:

Infants at greatest risk of ROP were 1500 g or less at birth, or 30 weeks gestational age or younger. An inverse relationship existed between the incidence and severity of ROP and birth weight or gestational age. The age of onset of ROP was four to six weeks; however, a few newborns presented with an aggressive form of ROP called ’rush disease’ as early as three weeks of age. For those requiring treatment for ROP, the maximum severity was about 11 weeks of age. Long term follow-up for refractive errors was more effective between six and 12 months and again at four years.

CONCLUSION:

Very premature or very low birth weight infants are at highest risk of ROP. Based upon published information, an optimal screening schedule is recommended and a long term follow-up strategy is provided.     

Interobserver variability of croup scoring in clinical practice

BACKGROUND:

Viral laryngotracheobronchitis croup is the most common cause of acute upper airway obstruction in young children. Clinical assessment of children with croup is often performed using ‘croup scores’; however, these scores have not been validated outside of the research setting.

OBJECTIVE:

To determine the reliability of clinical observation items in croup scores in a paediatric emergency department (ED) setting.

DESIGN:

Literature review identified 12 observation items (level of consciousness or mental status, inspiratory breath sounds, air entry, stridor, cough, cyanosis or colour, anxiety or air hunger, retractions and/or flaring, respiratory rate and heart rate, oxygen saturation and respiratory distress); overlapping items were combined, yielding 10 variables. In a prospective cohort study over 13 months, patients presenting with croup were observed independently, and croup scores were assigned by the triage nurse, ED nurse and the ED physician before treatment. Agreement among observers for clinical observations was analysed using Cohen’s quadratic weighted kappa.

SETTING:

University-affiliated, paediatric hospital ED providing primary care to an urban area (population 330,000).

PATIENTS:

Children aged three months to five years presenting with viral croup (preceding history of at least one day of upper respiratory tract symptoms associated with barking cough and/or hoarseness and/or stridor).

RESULTS:

One hundred fifty-eight children meeting inclusion criteria for croup were assessed by three observers within 1 h of each other’s assesments and before treatment. Interobserver agreement among the three observers using weighted kappa was greater than chance for all clinical observation items and ranged from fair to moderate (0.2 to 0.4 and 0.4 to 0.6, respectively).

CONCLUSIONS:

In the busy practice setting of a paediatric ED, substantial interobserver variability exists among health care providers in the measurement of respiratory signs associated with croup in young children. Based on the present study in a practice setting and two research studies, the most reliable items of all of the published items included in croup scoring systems were stridor and retractions.     

Risk compensation in children��s activities: A pilot study

BACKGROUND:

The intent of protective equipment (PE) in sports and leisure activities is to reduce injuries. However, some postulate that any safety measure prompts riskier behaviour, a phenomenon known as ‘risk homeostasis’ or ‘risk compensation.’ This study explores one approach to examining this in children. The rationale for this pilot study was to establish if children between six and 16 years old could answer questions about risk-taking sensibly and which questions, if any, could be eliminated; to establish the reliability of response; and to determine the numbers needed for a definitive study.

METHODS:

Sixty-three children with nonsevere injuries, ages six to 16 years, were interviewed while waiting to be seen at the Montreal Children’s Hospital emergency department. An interviewer administered a questionnaire comprising three sections. The first part only applied to those who were injured in an activity for which some form of PE was available (n=19). The second part examined customary risk-taking behaviour using the thrill and adventure seeking scales of a standardized questionnaire (Zuckerman) (n=63). The third section posed hypothetical questions about likely risk-taking when using PE to those who had engaged in such activities (n=58).

RESULTS:

The approach and questionnaire proved feasible with this age group. The responses suggest that children wearing PE were more likely to report increased risk-taking than those who did not wear PE. For most of the hypothetical questions, the majority also reported changes toward riskier behaviour when using PE. However, those wearing PE scored lower on the thrill and adventure seeking scale, suggesting that they are, by nature, less venturesome.

CONCLUSION:

The results indicate that risk compensation may modify the effectiveness of PE for children engaged in sports and leisure activities. Conversely, the findings also suggest that those wearing PE may be a cautious subgroup.     

Parents may know best! A pilot study suggests that children of parents who do not have contact with health care professionals before attending the emergency department are triaged as more urgent

OBJECTIVE

To assess the influence of prehospital health care contact on triage acuity.

METHODS

One hundred fifteen families were assigned Canadian Triage and Acuity Scale scores by a paediatric emergency department (ED) physician. Scores of children who had or had not seen a health care professional before attending the ED were compared.

RESULTS

Sixty-two of 72 (86.1%) children without previous health care professional contact, and 30 of 43 (69.8%) children with contact were triaged as ‘urgent’ (P=0.034). Parents with first aid knowledge (29 of 43 [67.4%]) were more likely to have had contact with a health care professional before visiting the ED compared with those with no such knowledge (27 of 72 [37.5%]; P=0.003).

CONCLUSION

Patients without previous health care professional contact were assigned more acute triage categories. Health care professionals may advise families to visit the ED more frequently than necessary, which could contribute to ED congestion. Incorporating a parental estimate of the degree of urgency of their child’s complaint into triage procedures represents an intriguing and challenging possibility.     

Does the use of primary continuous positive airway pressure reduce the need for intubation and mechanical ventilation in infants ≤32 weeks’ gestation?

BACKGROUND:

Ventilator-induced lung injury is a recognized risk factor for bronchopulmonary dysplasia.

OBJECTIVE:

To determine whether primary continuous positive airway pressure (CPAP), defined as CPAP without previous endotracheal intubation for any indication, can reduce the need for intubation and mechanical ventilation in infants born at ≤32 weeks’ gestational age.

METHODS:

The literature was reviewed using the methodology for systematic reviews for the Consensus on Resuscitation Science adapted from the American Heart Association’s International Liaison Committee on Resuscitation.

RESULTS:

Fourteen studies were reviewed. Eleven studies provided varying degrees of supportive evidence (level of evidence 3 to 4) that the use of primary CPAP can reduce the need for intubation and mechanical ventilation.

CONCLUSION:

The use of CPAP as a primary intervention and mode of respiratory support is an option for infants ≤32 weeks’ gestation, but avoidance of intubation and mechanical ventilation is more likely in mature infants >27 weeks’ gestation.     

Does primary surgical closure of the patent ductus arteriosus in infants <1500 g or ≤32 weeks’ gestation reduce the incidence of necrotizing enterocolitis?

BACKGROUND:

The hemodynamic perturbation related to patent ductus arteriosus (PDA) is associated with a higher risk of necrotizing enterocolitis (NEC).

OBJECTIVE:

To determine whether primary surgical closure, as compared with treatment with indomethacin or exposure to prophylactic indomethacin, reduces the incidence of NEC in preterm infants <1500 g and/or ≤32 weeks’ gestation with clinically and echocardiogram-identified PDA.

METHODS:

The literature was reviewed using the methodology for systematic reviews for the Consensus of Science adapted from the American Heart Association’s International Liaison Committee on Resuscitation.

RESULTS:

Ten studies were reviewed. The incidence of NEC was not lower in infants who underwent primary surgery for closure of the PDA compared with infants treated with indomethacin or infants exposed to prophylactic indomethacin (level of evidence 2).

CONCLUSION:

Primary surgical closure of the PDA cannot be recommended as an intervention to decrease the incidence of NEC in infants <1500 g and/or ≤32 weeks’ gestation.     

The evolution of freestanding children��s hospitals in Canada

OBJECTIVE

The purpose of the present article is to examine the evolution of freestanding children’s hospitals in Canada over the past century. The results include documentation of the number of freestanding children’s hospitals in Canada that have since closed, merged with other institutions or remained freestanding. Similar data are presented for the United States (US). Also included is an analysis of factors in the internal and external environment that contributed to the changing structure of children’s hospitals.

METHODS

Sources of information included a review of the literature, publicly available data and statistics on children’s hospitals in Canada and the US.

RESULTS

Nine of the 16 children’s hospitals in Canada were freestanding at one time. Today, only two remain freestanding. Three formerly freestanding children’s hospitals have merged with maternal health facilities and four formerly freestanding children’s hospitals have merged with adult institutions. Similar trends are seen in the US.

CONCLUSIONS

The structure of children’s hospitals in North America has changed significantly over the past century. This can be attributed to a number of factors, including the evolution of the health status of children due to medical advances, as well as external forces such as demographics and the rising cost of health care. The impact on the health of children and the mission of children’s hospitals in terms of patient care, teaching and research remains to be seen.