Community-based case-control study of childhood chronic abdominal pain: role of selected laboratory investigations

OBJECTIVE

To compare laboratory investigation results in children with chronic abdominal pain and in healthy control children. Our hypothesis was that parasitic infection was not a causal factor for chronic abdominal pain and that there would be no difference in leukocyte count, hemoglobin level, or erythrocyte sedimentation rate (ESR) between the 2 groups.

PATIENTS AND METHODS

Children with chronic abdominal pain and healthy control children (5-15 years) were recruited from the practices of 6 primary care pediatricians in Toronto, Canada. Stool samples were analyzed for ova and parasites, and serum samples were used to estimate leukocyte count, hemoglobin, and ESR. A standardized questionnaire was used to gather social, demographic, and clinical information.

RESULTS

A total of 157/200 children (79%) provided samples. Children with chronic abdominal pain were more likely to be female than were control children. Stool samples were positive for parasitic infection in 15 children, with no difference in prevalence between children with chronic abdominal pain (6/87; 7%) and healthy control children (9/70; 13%); P = 0.28). The mean (standard deviation) leukocyte count in children with chronic abdominal pain was 7.4 x 10(9)/L (2.03), compared with 8.3 x 10(9)/L (1.82) in healthy control children. No child had a leukocyte count above 20 x 10(9)/L. The mean (SD) hemoglobin in children with chronic abdominal pain was 131 g/L (8.4), compared with 130 g/L (9.2) in healthy control children. Last, the median ESR in children with chronic abdominal pain was 5 mm/hour, compared with 3 mm/hour in control children.

CONCLUSIONS

The study findings suggest that in the absence of alarming symptoms and signs, parasitic infection is not a causal factor for chronic abdominal pain and that routine screening tests (leukocyte count, hemoglobin, ESR) are not useful.

Pain response to M-M-R vaccination in 4-6 year old children

BACKGROUND

Differences in pain response to two different M-M-R products have previously been demonstrated in 12-month old infants and in 4 â 6 year old children. Objective To determine if the acute and immediate pain response to two licensed M-M-R vaccine products (using a self-report measure) in children 4-6 years of age was similar to that demonstrated in younger infants.

METHODS

Randomized, double blind, study. Subjects were randomly allocated to PriorixA (SmithKline Beecham) or M-M-R IIA (Merck Frosst). The primary outcome measure was pain response to vaccination quantified using a self-report OUCHER pain scale. Secondary outcome measures included pain measurement by proxy (physician and parent) using a visual analog scale (VAS) and measurement of cry and cry duration immediately post-vaccination.

RESULTS

Of the 60 subjects enrolled, 30 received PriorixA and 30 received M-M-R IIA. There were no significant differences between the two groups on age, sex, or previous painful procedure. Post-vaccination, children in the M-M-R IIA group had higher median pain scores compared with children in the PriorixA group for VAS (12.5 vs. 2.0, respectively by paediatricians, p=0.017; 18.5 vs. 5.0, respectively by parents, p=0.235), OUCHER (20 vs. 0.00, respectively, p=0.047). The median duration of crying post M-M-R IIA was higher compared with PriorixA (6 vs. 0 seconds, respectively, p=0.020). Conclusion PriorixA was associated with significantly less pain compared with M-M-R IIA, at the time of injection.

Topical 4% amethocaine gel reduces the pain of subcutaneous measles-mumps-rubella vaccination

OBJECTIVES

Ametop gel (4% amethocaine) is a relatively new topical anesthetic that produces anesthesia within 30 to 45 minutes and therefore may be appropriate for use in busy outpatient settings. The objective of this study was to assess the efficacy and safety of 4% amethocaine in reducing the pain of subcutaneous measles-mumps-rubella vaccination in 1-year-old infants.

METHODS

A double-blind, randomized, placebo-controlled trial was conducted in pediatric outpatient clinics.

RESULTS

A total of 120 infants participated in the study; 60 were followed up for assessment of antibody titers after 1 month. Either 1 g of amethocaine or placebo was applied for 30 minutes before vaccination. The Modified Behavioral Pain Scale was used to assess pain; the mean (standard deviation) pain scores for the amethocaine group (n = 61) was 1.5 (1.6) versus 2.3 (2.2) for the placebo group (n = 59). The rate of vaccination success (88% and 87%) was not different between treatment groups.

CONCLUSIONS

4% Amethocaine significantly reduces the pain of measles-mumps-rubella vaccination in infants when compared with placebo and does not seem to interfere with subsequent development of protective antibody levels. Because of its relatively short application time (30 minutes), 4% amethocaine may be suitable for busy clinics and emergency departments.

Effect of Choice of Measles-Mumps-Rubella Vaccine on Immediate Vaccination Pain in Infants

OBJECTIVE

To compare acute pain response to 2 measles-mumps-rubella vaccines.

DESIGN

Double-blind clinical trial.

SETTING

Hospital for Sick Children, Toronto, Ontario. Patients Forty-nine infants 12 months of age receiving their first measles-mumps-rubella vaccination.

INTERVENTIONS

Random allocation to receive Priorix or M-M-R II.

MAIN OUTCOME MEASURES

Pain responses before (baseline) and after (within 15 seconds) vaccination were quantified by visual analog scale (VAS; range, 0-100), completed by the parent and independently by the pediatrician, and the Modified Behavioral Pain Scale (range, 0-10), scored by a coder blinded to the vaccine allocation. Crying (yes or no) and latency to the first cry after injection were also measured.

RESULTS

Twenty-six infants received Priorix and 23 received M-M-R II. There were no differences between the 2 groups in baseline characteristics or prevaccination baseline pain scores. Median pain scores after vaccination (Priorix vs M-M-R II) were as follows: pediatrician VAS, 15 vs 58 (P =.001); parent VAS, 22 vs 53 (P =.007); and Modified Behavioral Pain Scale, 6 vs 8 (P =.02). Median difference in pain scores (after minus before) for Priorix vs M-M-R II were as follows: pediatrician VAS, 15 vs 53 (P =.003); parent VAS, 22 vs 47 (P =.008); and Modified Behavioral Pain Scale, 3 vs 5 (P =.03). The median latency to first cry was 1.5 seconds in the Priorix group compared with 1 second in the M-M-R II group (P =.26).

CONCLUSIONS

Priorix vaccine causes significantly less pain than M-M-R II at the time of injection for 12-month-old infants receiving their first measles-mumps-rubella vaccination.

Effects of age, gender and holding on pain response during infant immunization

Determinants of infant pain responses are important when assessing the efficacy of analgesics. In a randomized controlled trial, 106 infants aged 2 to 6 months were positioned either supine (SUP) on the examination table or held (HLD) by a parent during routine immunization in a community pediatric office. There was no difference between the SUP and HLD infants in duration of crying, facial grimacing or visual analogue scale (VAS) pain scores. Similarly gender did not affect pain response. In contrast, 2-month-old infants displayed more pain during immunization than did 4 or 6-month-old infants.

Hospitalization of children with acute immune thrombocytopenic purpura - is it necessary?

OBJECTIVE

To identify a target group of children with acute immune thrombocytopenic purpura (ITP) that may not require hospitalization for management.

METHODS

A retrospective chart review was conducted of all children admitted over a two-year period to a tertiary care paediatric hospital with the diagnosis of acute ITP. Patients were classified according to typical and atypical presentations. Typical patients were defined as those aged between one and 10 years, with no hepatomegaly or significant splenomegaly and who had typical laboratory features for ITP. Patients who did not meet these criteria were categorized as atypical. Outcome measures included length of stay (LOS) in hospital; frequency of bone marrow aspiration (BMA); type of treatment; incidence of intracranial hemorrhage (ICH) or severe bleeding; and admission and discharge platelet counts.

RESULTS

There were 74 patients hospitalized for a mean of 3.6 days. No patients suffered an ICH or bleeding requiring transfusion. Patients with typical presentations (42) were compared with patients with atypical presentations (32) and were not significantly different for clinically important outcomes such as admission and discharge platelet counts, serious complications or type of therapy. Typical patients had significantly fewer BMAs than did atypical patients - 22 of 42 (52%) versus 25 of 32 (78%) (P=0.02), and a shorter LOS - 3.1 (+/-0.9) days versus 4.2 (+/-1.8) days (P=0.01).

CONCLUSIONS

Children presenting with ITP have a low incidence of bleeding complications and many of these patients can be managed as outpatients. A multicentre study is needed to properly delineate a low risk group suited for outpatient medical management.

Rapid painless diagnosis of viral respiratory infection

The concordance of nasal compared with nasopharyngeal swabs was assessed for the diagnosis of respiratory viral infections, and the degree of discomfort associated with each procedure was compared. The use of nasal swabs was shown to be as accurate but significantly less painful than nasopharyngeal swabs for virus diagnosis.

Screening for celiac disease in children with recurrent abdominal pain

BACKGROUND

The clinical presentation of celiac disease--a life-long gluten intolerance--may be characterized by chronic abdominal pain. The objective of this study was to determine if children with recurrent abdominal pain had a higher prevalence of antiendomysial antibodies (a serologic marker of celiac disease) compared with healthy children.

METHODS

Children with recurrent abdominal pain and healthy control participants were recruited from the offices of community pediatricians. Serum samples were drawn and antiendomysial antibodies were measured in both groups. Demographic data included age, gender, height, and weight.

RESULTS

A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for antiendomysial antibody. The frequency of antiendomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants.

CONCLUSIONS

This community-based case-control study found no association between recurrent abdominal pain and the prevalence of antiendomysial antibody. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.

Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians

AIM

To determine the diagnostic accuracy of physical examination by office based (general practice) paediatricians in the evaluation of heart murmurs.

DESIGN

Each of 30 office based paediatricians blindly examined a random sample of children with murmurs (43% of which were pathological). Sensitivity and specificity were calculated and were related to paediatricians' characteristics.

RESULTS

Mean (SD) sensitivity was 82 (24)% with a mean specificity of 72 (24)% in differentiating pathological from innocent murmurs, with further investigations requested for 54% of assessments. The addition of a referral strategy would have increased mean sensitivity to 87 (20)% and specificity to 98 (8)%. Diagnostic accuracy was not significantly related to the paediatricians' age, education or practice characteristics, but was related to referral practices and confidence in assessment.

CONCLUSIONS

Diagnostic accuracy of clinical assessment of heart murmurs by office based paediatricians is suboptimal, and educational strategies are needed to improve accuracy and reduce unnecessary referrals and misdiagnosis.

Influenza vaccination of high-risk children: a survey of three physician groups

OBJECTIVE

To determine the variability in physician knowledge, attitudes, and behaviours in relation to influenza vaccination of children.

METHOD

A 17-item cross-sectional questionnaire, with follow-up mailings to non-responders, was mailed to a random sample of 100 family physicians and 100 community pediatricians within Metropolitan Toronto and all 130 subspecialists at The Hospital for Sick Children, Toronto.

RESULTS

Of 315 eligible physicians, 243 (77%) responded. Of the three groups, community pediatricians were more likely than either family physicians or subspecialists, to recommend vaccination for all but one of the high-risk conditions. Pediatricians (54%) were also the most likely to use active strategies to contact families of high-risk children compared with family physicians and subspecialists (both 23%). Only 44% of all physicians were themselves vaccinated against influenza.

CONCLUSIONS

Influenza vaccination is recommended by most physicians; however, the responsibility for vaccination appears to fall to those in the community. Physician education plus further research and a review of provincial strategies for improving vaccination are needed.

Influenza vaccination of high-risk children: a survey of three physician groups

OBJECTIVE

To determine the variability in physician knowledge, attitudes, and behaviours in relation to influenza vaccination of children.

METHOD

A 17-item cross-sectional questionnaire, with follow-up mailings to non-responders, was mailed to a random sample of 100 family physicians and 100 community pediatricians within Metropolitan Toronto and all 130 subspecialists at The Hospital for Sick Children, Toronto.

RESULTS

Of 315 eligible physicians, 243 (77%) responded. Of the three groups, community pediatricians were more likely than either family physicians or subspecialists, to recommend vaccination for all but one of the high-risk conditions. Pediatricians (54%) were also the most likely to use active strategies to contact families of high-risk children compared with family physicians and subspecialists (both 23%). Only 44% of all physicians were themselves vaccinated against influenza.

CONCLUSIONS

Influenza vaccination is recommended by most physicians; however, the responsibility for vaccination appears to fall to those in the community. Physician education plus further research and a review of provincial strategies for improving vaccination are needed.

Evaluation of short-course therapy with cefixime or rifampin for eradication of pharyngeally carried group A streptococci. The Ontario GAS Study Group

Therapy to eradicate pharyngeally carried group A streptococci (GAS) has increasingly been used in the management of institutional outbreaks and is now recommended for household contacts of patients with streptococcal toxic shock syndrome. In this randomized, controlled trial, contacts of patients with GAS infections were screened for pharyngeal GAS colonization. Those whose cultures were positive were randomized to receive either cefixime (8 mg/[kg.d]; maximum 400 mg) or rifampin (20 mg/kg; maximum, 600 mg) once a day for 4 days. Two to five days following completion of therapy, repeated cultures were negative for 13 (38%) of 34 rifampin recipients and 71 (77%; 95% CI, 69%-85%) of 97 cefixime recipients. At 10-14 days after treatment, only 53% of cefixime recipients remained culture-negative. Rates of successful clearance improved with increasing age (P < .01); among 17 adults who received cefixime, the success rate was 94%. Four days of therapy with rifampin is not effective for eradication of pharyngeally carried GAS. Four days of therapy with cefixime may be effective for adults, but further studies are needed.

Effect of neonatal circumcision on pain responses during vaccination in boys

Using data from one of our randomised trials, we investigated post-hoc whether male neonatal circumcision is associated with a greater pain response to routine vaccination at 4 or 6 months. Pain response during routine vaccination with diphtheria-pertussis-tetanus (DPT) alone or DPT followed by Haemophilus influenzae type b conjugate (HIB) was scored blind. 42 boys received DPT and 18 also received HIB. After DPT, median visual analogue scores by an observer were higher in the circumcised group (40 vs 26 mm, p = 0.03). After HIB, circumcised infants had higher behavioural pain scores (8 vs 6, p = 0.01) and cried longer (53 vs 19 s, p = 0.02). Thus neonatal circumcision may affect pain response several months after the event.

Use of lidocaine-prilocaine cream for vaccination pain in infants

PURPOSE

To determine whether use of lidocaine-prilocaine 5% cream (EMLA) decreases pain associated with diphtheria-pertussis-tetanus (DPT) vaccination in infants.

METHODS

Randomize, double-blind, controlled trial in outpatient pediatric practice, Toronto, Ontario, Canada. Before vaccination, parents applied 2.5 gm of EMLA or placebo to the infant's leg and covered it with an occlusive dressing for at least 60 minutes. The infant received a 0.5 ml intramuscular injection of DPT at 2 degree to 8 degree C with a 1.6 cm 25-gauge needle; the infant was videotaped. The Modified Behavioral Pain Scale (MBPS) was used to assess baseline and postvaccination pain scores. Latency and duration of infant cry were also measured.

RESULTS

A total of 49 evaluable infants received EMLA, and 47 infants received placebo. There were no significant differences in demographic data; mean age was 5 months; and 50% of the subjects were male. The median difference in pre-vaccination and postvaccination MBPS scores was lower for EMLA than for placebo (p = 0.001). The latency to the first cry was longer for subjects who were treated with EMLA (p = 0.0004)), but the total crying time was shorter (10.3 seconds vs 25.2 seconds; p = 0.027). Of the study group, 90% (45/50) of subjects treated with EMLA and 12% (6/49) of subjects treated with placebo had local skin reactions (p < 0.0001), mainly skin blanching.

CONCLUSIONS

Pretreatment with EMLA decreases infant pain from DPT vaccinations. Application of these data is limited to healthy infants receiving DPT vaccinations.

Physicians' attitudes toward the diagnosis and management of fever in children 3 months to 2 years of age

Ninety-seven primary-care physicians, including 73 family physicians and 24 pediatricians, were surveyed in order to ascertain their knowledge and attitudes regarding fever in children 3 months to 2 years of age. A rectal temperature between 37.0 degrees C and 37.9 degrees C was considered to indicate fever by 35% of physicians. Only 17% believed there was no danger from fever, while 12% believed that fever could cause brain damage. Seizures were considered a principal danger of fever by 49% of physicians, and 22% believed that brain damage could result from typical febrile seizures. While 70% chose relief of discomfort as the main purpose of antipyretic treatment, 30% would use temperature alone as an indication for antipyretics. It is concluded that although many physicians have an acceptable attitude toward the diagnosis and management of fever, a significant number still have exaggerated concerns.