Scenario

A mother brings her 2 week old baby to your clinic. The child has a small umbilical granuloma but is otherwise well. Should you use silver nitrate to cauterise the granuloma?

Structured clinical question

In a well, 2 week old neonate with an umbilical granuloma [patient], is silver nitrate cauterisation preferable to conservative treatment [intervention] in order to facilitate safe resolution of the granuloma [outcome]?

Search strategy and outcome

Secondary searches—Cochrane, Clinical evidence—none.

Medline 1966–2001, using the OVID interface.

1.

Silver nitrate.tw

2.

Clinical trial limit, 1+2 found: 36 papers, of which none were relevant.

3.

Umbilic$.tw, , 1+3 found: 10 papers, 1 highlighting complications, 1 was a comment on this paper, 1 discussing the use of salt; 7 were irrelevant.

Summary

See table 1-1.

Commentary

The above papers suggest umbilical granulomas may be self limiting and resolve with conservative management such as the application of salt. They also suggest that application of silver nitrate is not without risk.

Anecdotal evidence suggests that cleaning with Steret alcoholic wipes may be as effective as salt. If they are used, they should be applied at each nappy change. It may also be beneficial to fold the front of the nappy to expose the umbilicus.

No randomised controlled trials have been performed to investigate whether conservative management is as effective as silver nitrate. A randomised controlled trial to investigate this is being planned.

Scenario

A 9 year old girl attended her general practitioner with a moderate to severe exacerbation of asthma. Initial treatment included nebulised salbutamol (albuterol) and oral steroids. She was admitted to hospital, and treated with salbutamol, ipratropium, and oxygen. In the morning, a consultant comments “Ipratropium? I've always found that doesn't work.”

Structured clinical question

In a 9 year old child with moderate to severe exacerbation of asthma [patient], does ipratropium and salbutamol (albuterol) [intervention] compared with salbutamol alone [comparison] improve clinical outcomes (admission rates, relapse, etc) [outcome]?

Search strategy and outcome

Secondary sources—Cochrane review—1 relevant.

SumSearch—“asthma” AND “ipratropium” AND filter “therapy” AND “child”.

Search results—36 original articles, 1 relevant and not in Cochrane review.

Summary

See table 2-2.

Commentary

Pooling of studies in the systematic review has shown a significant reduction in hospitalisation rates for children with severe acute asthma treated with ipratropium added to β₂agonists in a protocol of multiple fixed doses. Insufficient data exists on the effects of ipratropium in more flexible multiple dose regimes, which may more closely resemble the actual treatment of children with acute asthma.

The recent study by Craven et al confirms this trend of shorter hospitalisation, but with insufficient numbers of severe asthma sufferers to show statistical significance. Importantly only 43% of eligible children entered this study, creating a possible selection bias.

In mild and moderate acute asthma, ipratropium has not been shown to significantly improve outcome in terms of hospitalisation rates or length of stay, or clinical care path progression rate.

Scenario

A 5 month old boy attends the emergency department with a history of fever given by his mother. His temperature as taken with a tympanic thermometer is 37.5°C. His mother says he is hot to the touch. He has no focus for his fever on examination. The departmental protocol recommends a full septic screen in this age group if the temperature is above 38°C. You would like to know how accurate temperatures taken by this method are, and whether you should check the temperature using another method.

Structured clinical question

In a 5 month old boy with a fever [patient], how accurate is tympanic thermometry [diagnosis] as a measure of core body temperature [outcome]?

Search strategy and outcome

Secondary sources—0. Systematic reviews—1. Original research—SumSearch “temperature measurement”, “child”, “fever” AND filter “diagnosis”—57 individual articles, 2 directly relevant.

Summary

See table 3-3.

Commentary

The systematic review reported 44 studies addressing the use of different methods oftemperature measurement including, axillary, sublingual, tympanic, and rectal. Two further studies directly addressed the question of how representative tympanic measurements are of core temperature measurement. Both studies showed a correlation between tympanic and rectal methods of temperature measurement, although it was not strong enough to use as a basis to make decisions regarding clinical management.