OBJECTIVE:To examine whether outpatient post-stabilization therapy with montelukast produces more treatment failures than prednisolone.STUDY DESIGN:In this randomized, double-blind, double-dummy non-inferiority trial, 130 children 2 to 17 years of age with mild to moderate acute asthma stabilized with prednisolone in the emergency department received 5 daily treatments with either prednisolone or montelukast after discharge. The primary outcome was treatment failure within 8 days (ie, an asthma-related unscheduled visit, hospitalization, or additional systemic corticosteroids).RESULTS:The rates of treatment failure were 7.9% in the prednisolone group and 22.4% in the montelukast group (95% CI, 26.5%-2.4%). Treatment was more likely to fail in younger patients (odds ratio, 4.9). In the montelukast group, more patients received additional pharmacotherapy than in patients receiving prednisolone (23.9% versus 9.5%, P = .03). The differences in the daily salbutamol treatments, asymptomatic days, and changes in the Pediatric Respiratory Assessment Measure score were not significant (P = .85, .75, and .26, respectively).CONCLUSION:Montelukast does not represent an adequate alternative to corticosteroids after outpatient stabilization in mild to moderate acute asthma. This population should receive oral corticosteroids after discharge.

Objective: To quantify the effect of socioeconomic status (SES) on health outcomes during the first year after newborn discharge among infants with complex chronic conditions (CCCs) insured through a universal health plan.Design: Longitudinal, population-based cohort study.Setting: Ontario, Canada.Participants: Infants born in hospitals from April 1, 1996, through March 31, 2000. Infants with CCCs were identified from their newborn discharge records. Neighborhood income quintiles were obtained by linking participants' postal codes to census data.Main Outcome Measures: Mortality and hospital admissions in the first year after newborn discharge. Logistic and Poisson regression analyses were used to examine the relationship between neighborhood income quintiles and outcomes, adjusting for important covariates such as low birth weight and rural residence.Results: A total of 512 768 infants were included, of whom 2.3% had CCCs at newborn discharge. Infants with CCCs accounted for 37.8% of deaths and 11.0% of hospitalizations during the first year after the newborn discharge. Infants with CCCs living in the lowest-income neighborhoods had a 1.26-fold higher mortality risk (95% confidence interval, 0.83-1.90; P = .28) and a 1.24-fold higher hospitalization rate (1.09-1.40; P < .001) compared with those living in the highest-income neighborhoods. Although the income gradients associated with mortality and hospitalization were less pronounced among infants with CCCs compared with infants without CCCs, the absolute interquintile risk differences attributable to SES were higher among infants with CCCs.Conclusions: Despite universal health insurance, SES-related inequality affects hospitalization and, possibly, mortality rates among medically vulnerable infants.

PURPOSE:To perform a meta-analysis to evaluate the diagnostic performance of ultrasonography (US) and computed tomography (CT) for the diagnosis of appendicitis in pediatric and adult populations.MATERIALS AND METHODS:Medical literature (from 1986 to 2004) was searched for articles on studies that used US, CT, or both as diagnostic tests for appendicitis in children (26 studies, 9356 patients) or adults (31 studies, 4341 patients). Prospective and retrospective studies were included if they separately reported the rate of true-positive, true-negative, false-positive, and false-negative diagnoses of appendicitis from US and CT findings compared with the positive and negative rates of appendicitis at surgery or follow-up. Clinical variables, technical factors, and test performance were extracted. Three readers assessed the quality of studies.RESULTS:Pooled sensitivity and specificity for diagnosis of appendicitis in children were 88% (95% confidence interval [CI]: 86%, 90%) and 94% (95% CI: 92%, 95%), respectively, for US studies and 94% (95% CI: 92%, 97%) and 95% (95% CI: 94%, 97%), respectively, for CT studies. Pooled sensitivity and specificity for diagnosis in adults were 83% (95% CI: 78%, 87%) and 93% (95% CI: 90%, 96%), respectively, for US studies and 94% (95% CI: 92%, 95%) and 94% (95% CI: 94%, 96%), respectively, for CT studies.CONCLUSION:From the diagnostic performance perspective, CT had a significantly higher sensitivity than did US in studies of children and adults; from the safety perspective, however, one should consider the radiation associated with CT, especially in children.

Video-conferencing and remote vital signs monitors were used to provide Tele-HomeCare (THC) to children with complex healthcare needs. This paper reports the effects of THC on the health-related quality of life (QoL) of children and their parents, and the Impact on Families (IoF). A total of 63 children and their parents were enrolled in a THC trial in which they received traditional home care services and up to 6 weeks of THC. A reference group of 16 children and their parents was also recruited and received only traditional home care services. All parents completed QoL questionnaires for both their child and themselves, and the IoF scale. Complete data were available for 50 THC participants: 34 of these had no readmissions and 16 experienced multiple admissions. The reference group contained 10 participants who received standard community care. All three groups experienced similar improvements in quality of life at the time of their discharge to home after which their QoL remained stable. There were no significant differences in the IoF scores. THC is an effective clinical service that supports the transition from hospital to home at a time when the children continued to have complex care needs. Furthermore, improvements in QoL were observed for these families that were similar to those of families whose children had less intensive care needs. Moreover, the improvements were sustained beyond the termination of the THC service and were not associated with additional burden on families.

BACKGROUND. Inhaled corticosteroids are not as effective as oral corticosteroids in school-aged children with severe acute asthma. It is uncertain how inhaled corticosteroids compare with oral corticosteroids in mild to moderate exacerbations. PRIMARY OBJECTIVE. The purpose of this work was to determine whether there is a significant difference in the percentage of predicted forced expiratory volume in 1 second in children with mild to moderate acute asthma treated with either inhaled fluticasone or oral prednisolone. METHODS. This was a randomized, double-blind controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department. We studied a convenience sample of 69 previously healthy children 5 to 17 years of age with acute asthma and forced expiratory volume in 1 second at 50% to 79% predicted value; 41 families refused participation. Albuterol was given in the emergency department and salmeterol was given after discharge to all patients, as well as either 2 mg of fluticasone via metered dose inhaler and valved holding chamber in the emergency department plus 500 μg twice daily via Diskus for 10 doses after discharge (fluticasone group, N = 35) or 2 mg/kg of oral prednisolone in the emergency department plus 5 daily doses of 1 mg/kg of prednisolone after discharge (prednisolone group, N = 34). We measured a priori defined absolute change in percent predicted forced expiratory volume in 1 second from baseline to 4 and 48 hours in the 2 groups. RESULTS. At 240 minutes, the forced expiratory volume in 1 second increased by 19.1% ± 12.7% in the fluticasone group and 29.8% ± 15.5% in the prednisolone group. At 48 hours, this difference was no longer significant (estimated difference: 4.0 ± 3.4; P = .14). The relapse rates by 48 hours were 12.5% and 0% in the fluticasone group and prednisolone group, respectively. CONCLUSION. Airway obstruction in children with mild to moderate acute asthma in the emergency department improves faster on oral than inhaled corticosteroids.

Previous pediatric studies have failed to demonstrate a clear association between protease inhibitor (PI) therapy and abnormal glucose homeostasis in HIV-infected children. To define more precisely the impact of PI therapy on glucose homeostasis in this population, we performed the insulin-modified frequent-sampling iv glucose tolerance test on 33 PI-treated and 15 PI-naive HIV-infected children. Other investigations included fasting serum lipids; glucose, insulin, and C-peptide; single-slice abdominal computed tomography; and, in a subset of PI-treated children, an oral glucose tolerance test. There were no differences between the two groups with respect to fasting serum insulin or C-peptide, homeostatic model assessment insulin resistance, or quantitative insulin sensitivity check index. The mean insulin sensitivity index of PI-treated and PI-naive children was 6.93 +/- 6.37 and 10.58 +/- 12.93 x 10(-4)min(-1) [microU/ml](-1), respectively (P = 0.17). The mean disposition index for the two groups was 1840 +/- 1575 and 3708 +/- 3005 x 10(-4)min(-1) (P = 0.013), respectively. After adjusting for potential confounding variables using multiple regression analysis, the insulin sensitivity index and disposition index of PI-treated children were significantly lower than that of PI-naive children (P = 0.01 for both). In PI-treated but not PI-naive children, insulin sensitivity correlated inversely with visceral adipose tissue area (r = -0.43, P = 0.01) and visceral to sc adipose tissue ratio (r = -0.49, P = 0.004). Mildly impaired glucose tolerance was noted in four of 21 PI-treated subjects tested. Our results demonstrate not only that PI therapy reduces insulin sensitivity in HIV-infected children but also that it impairs the beta-cell response to this reduction in insulin sensitivity and, in a subset of children, leads to the development of impaired glucose tolerance. The presence of insulin resistance, dyslipidemia, and the significant correlation of reduced insulin sensitivity with increased visceral adipose tissue content suggest that PI-containing highly active antiretroviral therapy is associated with the emergence of early features of a metabolic syndrome-like phenotype.

Background: This study was undertaken to determine the association between poor developmental attainment (PDA) and biological, home environment and socio-demographic factors in a population-based sample of Canadian children.

Purpose: There is a need for a valid and reliable method to describe the severity of preseptal cellulitis.Methods: Items of a scoring system were derived by an expert group and evaluated using a retrospective chart review. The results were used to construct the final Severity Index. Validity and reliability of the Severity Index was evaluated by prospective assessment of 17 children. The Severity Index was compared with a Global Score, a score based on clinical impression.Results: The average Severity Index score was 2.0 for patients treated with oral antibiotics alone and 6.0 for patients treated with intravenous antibiotics. The Severity Index correlated well with the Global Score (Spearman rank correlation coefficient r(S) = 0.60, P = 0.01). Ranked clinical photographs of preseptal cellulitis correlated moderately to the Severity Index (r(S) = 0.66, P = 0.02). The Severity Index score after 24 hours of treatment was significantly lower than at presentation ( P = 0.004). The agreement between paired Severity Index scores [intraclass correlation coefficient (ICC) = 0.80, P = 0.001] was better than the agreement between paired Global Scores (ICC = 0.45, P = 0.03).Conclusions: The Severity Index is an objective clinical tool for evaluating severity of preseptal cellulitis in children. It correlates well with clinical constructs for severity and is sensitive to small changes in clinical status. It has better reliability than overall clinical impression. The Severity Index will also be valuable as an outcome measure for future therapeutic trials for preseptal cellulitis in children.

BACKGROUND Little is known about the determinants of parental response when children appear to have a respiratory tract infection (RTI). Our objective was to identify what factors predict that parents will seek medical consultation. METHODS In a prospective cohort study we consecutively recruited 400 children aged 2 months to 12 years from the urban, largely middle-class, primary-care practices of 7 pediatricians in Toronto. Baseline demographic data were collected and the children followed by telephone inquiry until an RTI developed or 6 months elapsed. Data about any medical consultation for the RTI were collected. The parents completed a questionnaire on clinical features and parental interpretations and concerns. Potential predictors of consultation were organized into 4 domains: family factors, principal complaints, functional burden of illness (determined with a validated measure, the Canadian Acute Respiratory Illness and Flu Scale [CARIFS]) and parental interpretation of the illness. Key variables for each domain were derived by endorsement, correlation and combination, and univariate association with the outcome (medical consultation). A model was created to identify independent predictors of consultation. RESULTS Of the 383 children (96%) for whom the study was completed, 275 (72%) had symptoms of an RTI within 6 months after recruitment. Medical consultation was sought for 140 (56%) of the 251 for whom further data were available. The questionnaire data and follow up were complete for 197 (78%) of the 251. Children with earaches compared to children without were more likely to be taken to a physician (odds ratio [OR] 10.2; 95% confidence interval [CI] 2.8-37.4), as were children with high fever (temperature > 40 degrees C) compared to children with no fever or fever < or = 40 degrees C (OR 3.2; 95% CI 1.2-8.6). Parents who rated their children as having a complaint that was severe or persisting for more than 24 hours were more likely to see a physician than parents who rated their children as having no complaints (OR 8.5; 95% CI 2.3-32.0). Parental concern that the illness had an unusual course, with prolonged duration or deterioration (OR 5.7; 95% CI 1.3-24.8), that the child had a specific illness (OR 2.9; 95% CI 1.1-7.7) or that specific treatment was needed (OR 5.0; 95% CI 1.1-23.1), compared to children with no illnesses or need for treatment, also predicted consultation with a physician. Parents' postsecondary education (OR 4.0; 95% CI 1.1-14.6), compared to parents with less than postsecondary education, was the only parental factor that independently predicted taking a child to see a physician. Child's age 48 months or less was the only child factor that independently predicted physician consultation (0-6 months, OR 9.2, 95% CI 1.4-58.1; 7-12 months, OR 17.3, 95% CI 2.0-147.2; 13-24 months, OR 9.2, 95% CI 1.3-63.6; 25-48 months, OR 5.2, 95% CI 0.8-34.4). Neither family demographics nor functional burden of illness predicted consultation. INTERPRETATION Generally, parents choose reasonable criteria for seeking physician advice. However, their perceptions and interpretations may be based in part on limited understanding of some factors. Further research is necessary to determine how these findings can be used to improve anticipatory guidance to parents and better address parental concerns.

tive use of high frequency oscillatory ventilation (HFOV) in very low birthweight infants reduces chronic lung disease (CLD) but is associated with higher rates of intracranial hemorrhage (ICH) or periventricular leukomalacia (PVL).OBJECTIVE: To compare the long-term survival and health effects of elective use of CV and HFOV strategies for preterm infants < 1500 grams using decision analysis approach.METHODS: The base case for the model was a 1500 gram preterm neonate requiring ventilation but with no other comorbidities.The model incorporated clinical events of early death, CLD, ICH, PVL, quality of life, and survival.We obtained model probabilities from the published literature and estimated baseline parameters and variances using formal meta-analytic techniques.We calculated health state quality of life weights using the Health Utility Index (Mark II), life expectancies by extrapolating observed survival into the future using exponential survival functions, and quality-adjusted survival by multiplying quality of life weights and survival.Model uncertainty was estimated with sensitivity analysis of all parameters and Monte-Carlo simulation.RESULTS: Survival with HFOV was 50.10 years and with CV was 49.83 years, for an incremental gain of 3.2 months, with a 95% confidence interval from Monte Carlo simulation of (-41 to 52 months).However, after applying quality adjustments, the incremental gain with CV was 1.3 months (95% CI -45.4 to 48.6 months) quality adjusted months.Sensitivity analysis indicated that the model was sensitive to many parameters.For example, if the relative risk of developing CLD with HFOV, compared to CV, was less than 0.4, HFOV was a preferred strategy.The model was also particularly sensitive to estimates of the probability of developing an ICH with HFOV and relative risk of ICH on CV.Monte Carlo simulation indicated that CV was preferred in 50.7% of simulations.CONCLUSIONS: Our model suggests that CV and HFOV are associated with similar long-term survival and quality adjusted survival.Sensitivity analysis suggests that future research should be particularly directed towards estimating long-term survival in this population.

OBJECTIVE To determine if, in the era after Haemophilus influenzae type b, the cerebrospinal fluid (CSF) white blood cell (WBC) count can be safely used to stratify children suspected of having bacterial meningitis into low- and high-risk groups. DESIGN Retrospective analysis of CSF samples. SETTING Tertiary care pediatric center in Toronto, Ontario, between January 1, 1992, and October 1, 1996. PATIENTS All CSF samples collected on children aged 2 months to 17 years were included. The final database consisted of 1617 atraumatic samples from children without prior neurologic or immunologic disease who underwent a lumbar puncture to assess the possibility of community-acquired bacterial meningitis. MAIN OUTCOME MEASURES The predictive values of CSF WBC count, differential, protein, and glucose. RESULTS There were 44 cases of bacterial meningitis. Five had 3 CSF WBCs per microliter or less, and 6 had 4 to 30 CSF WBCs per microliter. The negative predictive value of CSF specimens with 30 WBCs per microliter or less for bacterial meningitis was 99.3%. Cerebrospinal fluid samples with greater than 30 WBCs per microliter had a likelihood ratio for bacterial meningitis of 10.3 (95% confidence interval, 8.0-13.1) and a positive predictive value of 22.3%. Other significant predictors of bacterial meningitis included age, CSF glucose, protein, gram stain, CSF-serum glucose ratio, and peripheral blood band count. CONCLUSIONS Given the occurrence of bacterial meningitis in children in the absence of CSF pleocytosis, other factors should be considered when managing children with suspected bacterial meningitis. Children older than 6 months with 30 CSF WBCs per microliter or less are at low risk for bacterial meningitis. If clinically stable and without other laboratory markers of bacterial meningitis, hospital admission and empiric antibiotic therapy may be unwarranted.

Although acute respiratory infection (ARI) is the most frequent clinical syndrome in childhood, there is no validated measure of its severity. Therefore a parental questionnaire was developed: the Canadian Acute Respiratory Illness Flu Scale (CARIFS). A process of item generation, item reduction, and scale construction resulted in a scale composed of 18 items covering three domains; symptoms (e.g., cough); function (e.g., play), and parental impact (e.g., clinginess). The validity of the scale was evaluated in a study of 220 children with ARI. Construct validity was assessed by comparing the CARIFS score with physician, nurse, and parental assessment of the child's health. Data were available from 206 children (94%). The CARIFS correlated well with measures of the construct (Spearman's correlations between 0.36 and 0.52). Responsiveness was shown, with 90% of children having a CARIFS score less than a quarter of its initial value, by the tenth day.

IS BONE MARROW ASPIRATION NEEDED IN ACUTE CHILDHOOD IDIOPATHIC THROMBOCYTOPENIC PURPURA TO RULE OUT LEUKEMIA? † 906