Steiner wheezing

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					Preclinic Conference
Updates and Reminders: Winter Seasonal Illnesses-2010
November 22, 2010

  • Review the clinical presentations of common winter illnesses
  • Review the standard therapies for those illnesses
  • Introduce new trends in the diagnosis and management of these conditions

    • Key evaluation points:
           o Rule out other diseases (Isolated vomiting? Hematochezia? Rash?)
           o Assess severity
                  • In most ED studies, less than 10% of patients have significant
                     dehydration (>5%)
    • Supportive care is the mainstay of therapy in almost all patients
    • Oral rehydration if dehydration present
    • Medication to improve outcomes
           o Can consider trial of ondansetron (Zofran) if you feel that IVF and/or
              admission might be necessary after failed oral rehydration
    • Medications for symptomatic treatment, frequently not used
           o Anti-diarrheals OK in older children
           o Ondansetron?
    • Remember early return to food!

Updates from 2009 and 2010:
   • NICE guidelines,
           o No major outpatient changes in recommendations (inpatient—recommends
             isotonic fluid use for bolus and maintenance).
   • Increasing use of ondansetron---still no studies in clinics or with less ill patients

UNC Pediatrics guidelines at
    • This is one area where you will see variation in practice in clinic, “trial of benefit”
        for albuterol
    • No role for standard use of bronchodilators, steroids, antibiotics, or extensive
        diagnostic evaluation
    • Bronchodilators
            o No one suggests that it changes length of illness, data suggests that
                 questionable efficacy in groups for acute use also
            o Only potential benefit is acute---therefore I would only try if there is a need
                 for acute benefit (may get hospitalized, etc…).
    • Anecdotes/Some evidence:
            o Workup: Urinalysis/culture if high fever or unusual presentation

                                                                          Steiner, 11/24/2010
Update for 2009 and 2010:
   • NEJM,
           o 1st time wheezing infants, epi plus dex for 5 days ‘may’ reduce risk of
              hospital admission
   • Hypertonic saline in ED and inpatient
           o Multiple studies now, most mild positive, 1 published study no difference
           o Multiple strengths of hypertonic solution studied
           o No risk identified

Recurrent Wheezing in Young Infants (0-4 year olds):
   • Usually comes up in the second year of life
   • Recommend initiating maintenance therapy if:
          1. >=4 episodes of wheezing in past year lasting more than 1 day and
             affecting sleep
          2. Severe episodes
                 • atopic dermatitis, aeroallergens, or parental asthma
                 • 2 among food sensitization, >4% blood eosinophils, or wheezing
                     apart from URIs/LRIs

                                                                      Steiner, 11/24/2010

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