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Bronchiolitis: progress at last?
The majority of infants with bronchiolitis do well. I suspect that few parents of infants with bronchiolitis seek care and of those that do, the majority are reassured and sent home. However, for the infant who makes it to the emergency department or is actually hospitalised, few therapies are effective. Virtually all guidelines indicate that neither bronchodilators nor steroids are helpful. However four recent studies address new approaches to treatment. In a well done multi-site Canadian study, 800 infants with bronchiolitis who were seen in a paediatric emergency department were randomized to one of four groups: two treatments of nebulized epinephrine and six oral doses of dexamethasone; nebulized epinephrine and oral placebo; nebulized placebo and oral dexamethasone; and nebulized and oral placebos.1 They found that infants who received both epinephrine and steroids were significantly less likely to be admitted (17.1%) within seven days of being seen than any of the other three groups. The number needed to treat is approximately 12. The one concern in this study was that the admission rate in the three comparison groups ranged between 23.7% and 26.4%. This seems high to me. A recent Cochrane review of three randomised clinical trials in which 3% normal saline (and in most cases bronchodilators) was used found that it significantly shortened hospital length of stay by about 25%.2 In two home oxygen therapy trials, one published in ADC this month, and commented upon by Steve Cunningham, it appears that home oxygen therapy can be used to prevent hospitalisation3 and shorten length of stay following admission. The total number of patients treated in these two studies is small, so it is difficult to assess safety, although I suspect significant adverse events would be rare. Where do these studies leave us? For most infants with bronchiolitis, no treatment is necessary. The combination of steroids and epinephrine appears to be helpful in preventing hospitalisation, and given its relatively low cost and safety profile, appears worth trying. Finally, when infants are admitted to the hospital, once they are stable, home oxygen therapy may be a reasonable option. See page 565
Predicting which children will do poorly when hospitalised
Rapid response teams are increasingly popular in adult services. Preventing the need for cardiopulmonary resuscitation is a far better approach to care, than treating patients after they have either cardiac or pulmonary arrest. Will such services work on paediatric wards? The study by Edwards et al from Cardiff suggest that efficiently identifying children who will have cardiac or respiratory arrest may not be possible. In a study of a 1000 patients, their scoring system had a sensitivity of 89% and a specificity of 64%. The scoring system included eight physiologic measures. Too many children would need to be assessed by a rapid response team to potentially prevent a single case of cardiopulmonary arrest or intensive care unit admission. Why is predicting adverse outcome so difficult in children? First, these outcomes are much more rare in children than adults and second, the scoring systems are complex since they include respiratory rate, heart rate and systolic blood pressure, all measures which vary with age. See page 602
Short course treatment for bacterial meningitis
Over the past 20 years the length of treatment with antimicrobial agents for many infectious diseases has declined. In a meta-analysis Karageorgopoulos et al determined whether short course treatment (seven days or less) for bacterial meningitis was as effective as long-course therapy (at least two days longer than the corresponding short-course treatment). Five RCTS involving 426 children (3 weeks to 16 years) were included in the study. They did not find any difference between groups in end of treatment clinical success, neurological complications, or hearing impairment. Although it may be difficult to shorten the course of treatment in resource rich countries, particularly since the prevalence of bacterial meningitis has declined so dramatically over the past five years, these results may have important implications in countries with limited health care resources. See page 607
Our information seeking-behaviour
As a journal editor and clinician, I am fascinated by changes in the way we learn, keep up with advances in medicine, and search for answers to clinical questions. We have tried to respond to these changes by giving our readers different options in accessing information from ADC. In this issue, Prendiville et al, report the information seeking behaviour of all paediatric registrars and consultants in Ireland. The majority use the internet as the “first port of call,” to answer clinical questions every 1-3 days. They access the internet in their office to conduct literature searches and find guidelines. Pubmed appears more popular than search engines. None of these findings are surprising except the use of Pubmed. They reinforce the requirement that every modern healthcare system provide high speed internet connection for their clinicians. I was surprised by the popularity of Pubmed since 70% of our hits come through a search engine rather than Pubmed and I find search engines much quicker than Pubmed, particularly if I can recall the author and journal of an article I am searching for. See page 633
This month in E&P:
Maria Atkinson, our new guidelines columnist describes the new NICE recommendations for the surgical management of otitis media with effusion
Drs. Tse and Rylance review the emergency management of anaphylaxis
Our learning and teaching section under the direction of Drs. Diwakar and Murdoch-Easton continues with two additional papers