Friday, December 21, 2012

Articles worth keeping - Child Presenting With Recurrent Cutaneous Abscesses

What is the most specific and practical work-up for a child (12 years old) who has recurrent cutaneous abscesses? The last one cultured out methicillin-resistant Staphylococcus aureus (MRSA). 
Recurrent cutaneous abscesses can be caused by particularly virulent pathogens, immune deficiencies, or primary dermatologic conditions. If MRSA has been cultured from the abscess, it suggests that the former may be the most likely explanation. This type of organism is, by definition, resistant to treatment with many of the standard antibiotics, and sensitivities should be performed to direct therapy. Especially in a child, it is important to treat until multiple cultures are negative to establish that the infection has indeed resolved. It is also important to search for a reservoir where the bacteria may be "hiding" between infections. The nasopharynx is the most common reservoir (and this area should be cultured), although occasionally a pet or another family member or playmate can carry the bacteria.
Immune deficiency should also be considered, since neutrophil-killing disorders such as chronic granulomatous disease (CGD) are typically associated with recurrent abscesses of the skin. Clues for an immune deficiency would be a history of abscesses in other closed spaces (lung, sinuses, etc), or periodontal disease. If CGD is suspected, a complete blood count should be obtained, along with a differential to calculate the absolute neutrophil count. The bloodsmear should be evaluated to assess neutrophil morphology, which is abnormal with some immune deficiencies. Finally, superoxide production, which is an important tool for killing bacteria and fungi, can be screened with the nitroblue tetrazolium (NBT) test. This test involves incubating fresh peripheral blood cells with a colorless dye (formazan), which turns blue when cells are activated in the test tube.
Dermatologic diseases can also present with either abscesses or pustules that closely resemble abscesses. In addition, some dermatologic diseases, such as atopic dermatitis, are associated with an enhanced susceptibility to infections, particularly with Staphylococcus and Streptococcus. Finally, hidradenitis suppurativa can be recognized by a typical distribution of cutaneous abscesses corresponding with apocrine sweat glands. It is uncommon before puberty, and is sometimes associated with inflammatory bowel disease.
Comments: A common problem seen in OPD practice. Now all I need is a lab in Chandigarh (in the private sector) that can do an NBT test with accuracy.

Thursday, December 13, 2012

Bouncy-House Injuries Skyrocket !

Yael Waknine
  Nov 27, 2012
The number of bouncy-house injuries has skyrocketed in the last 10 years, reaching the point where an American child is injured every 46 minutes, according to research published online November 26 in Pediatrics.
Meghan C. Thompson, BA, from the Center for Injury Research and Policy, Research Institute at Nationwide Children's Hospital, Columbus, Ohio, and colleagues analyzed injury records for almost 65,000 children, finding that the rate and number of bouncy-house-related injuries increased 15-fold from 1990 to 2010, more than doubling in the last 2 years alone.
"Bouncer-related injury patterns identified in this study were similar to those described for trampolines," the authors write. For both trampolines and inflatable bouncers, with increasing age the frequency of upper-extremity injuries and fractures decreased and lower-extremity injuries increased.
Children aged 6 to 12 years were most often hurt compared with those aged 0 to 5 years and 13 to 17 years (54.0% vs 35.8% and 10.2%, respectively).
Boys were more likely to sustain injuries than girls (54.6% vs 45.4%), including concussions/closed head injuries and lacerations (relative risk [RR], 2.49 [95% confidence interval (CI), 1.46 - 4.25] and 2.41 [95% CI, 1.55 - 3.73], respectively), or injure their head/neck or face (RR, 1.37 [95% CI, 1.09 - 1.73] and 1.76 [95% CI, 1.35 - 2.30], respectively). In contrast, girls were more likely than boys to sustain lower-extremity injury (RR, 1.39; 95% CI, 1.17 - 1.64).
Of the 65.2% of cases for which a venue was reported, 43.7% of injuries occurred at a sports or recreational facility and 37.5% occurred at home.
The vast majority of children treated in the emergency were released or left against medical advice (96.6%); only 3.4% of injuries required hospitalization or 24-hour observation, primarily for fractures (81.7%).
"Policy makers must consider whether the similarities observed in bouncer-related injuries warrant a similar response" to the recommendations given for trampolines, the authors write, noting that although pediatric bouncer-related injury rates are currently lower than trampoline-related rates (5.28 vs 31.9 per 100,000 in 2009), they are rising rapidly. "[P]olicy makers should, at minimum, formulate recommendations for safer bouncer usage and design," they emphasize.
65,000 Injuries Over the Course of 20 Years
For the study, researchers analyzed the National Electronic Injury Surveillance System records for an estimated 64,657 children younger than 18 years who had been treated in US emergency departments for inflatable bouncer-related injuries from 1990 to 2010.
Results revealed that the rate and number of bouncy-house related injuries increased 15-fold during the period from 1995 to 2010, from 1.01 per 100,000 children (95% confidence interval [CI], 0.70 - 1.32 injuries/100,000 children) in 1995 to 15.2 per 100,000 children (95% CI, 9.93 - 20.56 injuries/100,000 children) in 2010. There were 702 (95% CI, 284 - 1120) injuries in 1995 compared with 11,311 (95% CI, 7115 - 15,506) injuries in 2010. ( P < .001 for both). In 2010 the average number of injuries in the United States was 31 per day, corresponding to an injury report every 46 minutes.
Fractures were the most common type of injury (27.5%) and most frequently occurred in children aged 5 years and younger (relative risk [RR], 1.31; 95% CI, 1.12 - 1.54); strains and sprains were also common (27.3%) and were reported most frequently among teenagers aged 13 to 17 years (RR, 1.45; 95% CI, 1.12 - 1.88). Teenagers were also more likely to experience lower-extremity injuries (RR, 1.37; 95% CI, 1.13 - 1.66).
As with trampoline-related accidents, the majority of injuries occurred to the extremities (lower, 32.9%; upper, 29.7%). An additional 18.5% of injuries involved the head and neck, 9.3% affected the face, and 9.0% were trunk injuries.
Lacerations were 14.3 times (95% CI, 10.46 - 19.53 times) more likely to occur in the face than any other body region, and fractures were 3.31 times (95% CI, 2.58 - 4.24 times) more likely to occur in the upper extremity than any other body region, particularly among children aged 12 years and younger (RR, 1.89; 95% CI, 1.05 - 3.41).
Stunts and Collisions
As with trampoline-related accidents, falling was the major source of injury, accounting for 43.3% of cases. More children were injured falling in or on the bouncer than getting on or off (26.1% vs 17.2%), which may be a matter of design, the authors note.
Other sources of injury included other children (16.2%), with 9.9% of cases attributable to colliding with or being pushed/pulled by another person and 6.3% the result of another child's fall.
"Stunts and collisions were common injury mechanisms in this study and in previous bouncer and trampoline studies," the authors write, noting that as with trampolines, the presence of several children on a single bouncer is a risk factor for injury.
According to the authors, the similar nature and mechanism of trampoline- and bouncer-associated injuries suggests that prevention methods for one may be extrapolated to the other, but this concept has not been adequately explored.
As previously reported by Medscape Medical News, recommendations from the American Academy of Pediatrics in 2012 addressed trampolines and recommended their use only as part of a structured training program that includes appropriate safety measures. These recommendations made no mention of bouncy houses because they do not fall into the training category. Other organizations such as ASTM International and the US Consumer Product Safety Commission have attempted to address bouncer safety issues. In the end, the standards are set by individual manufacturers, the authors write.
"To date, the medical and public health community has not provided safety recommendations regarding pediatric use of inflatable bouncers," the authors assert, noting that the recent increase in injuries also underscores the need for guidelines to improve bouncer use and design.
The authors have disclosed no relevant financial relationships.
Pediatrics. Published online November 26, 2012. Full text
Comments:  We have an increasing number of bouncy houses that are now available in various play areas and fairs in India. A large number of children are invariable found in these at any given point of time. Given the fact that most injuries seem to occur to children while they are on the bouncy house and due to collisions./ stunts I am fairly certain that we too need to be careful to prevent such injuries in our children. My daughter loves playing on these bouncy houses, and I for one, would now approach these with more care

Monday, December 03, 2012

A beautiful infographic regarding baby developmental milestones

For many parents, regularly worrying about their baby's development is the norm.
The following lovingly created infographic tells about the common milestones for children from 0-24 months (2 years) old. Please remember to ask your pediatrician if you have persistent concerns regarding your child's development though !

Click to Enlarge Image

The FamilyCord Baby Milestones Guide - Brought To You By FamilyCord