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Physician Blog : Pediatric Perspectives
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This blog for physicians will provide you with practical information you can use in your office while highlighting new techniques and programs available at Helen DeVos Children's Hospital.

 

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photo Dominic Sanfilippo, MD
photo James Fahner, MD
photo William Stratbucker, MD
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Tuesday, March 29, 2011
Stop Fever Phobia in its Tracks
by Pediatric Perspectives at 09:17 AM

Dan McGee, MD, Pediatric Hospitalist
Helen DeVos Children's Hospital
Grand Rapids, Michigan

By now you've no doubt heard about the American Academy of Pediatrics' (AAP) new clinical report on fever and the Dan McGee, MDuse of antipyretics in children. Put simply, too many parents have "fever phobia," racing for the ibuprofen or acetaminophen at the slightest uptick on the thermometer. While the report doesn't come out and list a temperature at which such an approach is warranted, it does note that there is no evidence that fever negatively affects the course of a disease or causes long-term complications. Plus, up to 85% of parents wake up their children to take the medication at a time when the children need their rest most, and up to half administer the wrong dose.

When my kids were young, we didn't even keep a thermometer in the house. Instead, I focused on how they were acting. If they were in pain or uncomfortable, I gave them something; if they weren't, I didn't. And if they were acting listless and lethargic, I became concerned. Parents should follow the same guidelines. Or, as the AAP statement notes, focus on improving a child's comfort rather than bringing down the fever. Treat the child, not the thermometer.  Often, doing the former results in the latter. 

If you're getting questions from parents about the AAP statement, which received significant media attention, remind them that fever is the body's way of fighting off infection, in part by creating a more hostile environment for bacteria and viruses while at the same time providing a more hospitable environment for the immune response to the infection.

And, of course, remind parents that excessive use of acetaminophen may lead to liver problems, while excessive use of ibuprofen, or using it while the child is dehydrated, could lead to kidney damage. 

Dan McGee, MD, is a pediatric hospitalist at Helen DeVos Children's Hospital in Grand Rapids, Michigan

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Monday, March 14, 2011
Pediatric Kidney Stone Incidence Increasing
by Pediatric Perspectives at 01:28 PM

Theodore D. Barber, MD, Pediatric Urologist 

To diabetes, high blood pressure, and an increased risk of cardiovascular disease, add a growing prevalence of Theodore Barber, MDurolithiasis (kidney stones) to the consequences of the obesity epidemic in our children. It's a new phenomenon; just two papers and an abstract have been published or presented on the topic. Both papers report kidney stone incidence in the emergency department, while the abstract presented at the 2009 American Urological Association meeting reported inpatient admissions. Still, if what we see in our practice is reflective of what's happening in pediatric urological practices across the country, then the increase is real. 

The study of inpatient admissions from 2002 to 2007 at 44 children's hospitals not only found an increase, but also that, unlike in adults where males are more likely to be hospitalized with stones, in a pediatric population females were more likely to be hospitalized (odds ratio = 1.37, confidence interval = 1.31-1.45). In addition, most hospitalized children were between 8 and 13 years of age and most were white. Another difference between adults and children seen in this study is that more patients came from the north central region of the country, not the South.

Meanwhile, VanDervoot et al, reported on a fivefold increase in the number of children seen with urolithiasis in their New York state ED over the past decade, while Sas et al reported a 234% increase in the incidence of pediatric stones in children seen in the ED in South Carolina between 1996 and 2007.2,3 During that period, the overall incidence in the South Carolina study increased from 7.9 per 100,000 children in 1996 to 18.5 per 100,000 in 2007 (P<0.0001).

The message for pediatricians? If you see a child with flank pain, consider kidney stones in your differential diagnosis. You can diagnose stones with an ultrasound followed by a simple x-ray; CT scan-with its attendant increased radiation-is not routinely necessary.

The good news is that the rate of spontaneous stone passage tends to be higher in children than adults. First-line treatment for children diagnosed with a stone should be ketorolac (Toradol) for analgesia as well as an alpha blocker such as tamsulosin (Flomax) to facilitate ureteral dilation. If children don't pass the stone within about four weeks, shockwave lithotripsy or endoscopic removal are the next step. 

Are you seeing more patients with pediatric kidney stones? Click "Add Comment" below to join the conversation.

Theodore D. Barber, MD is a is a urologic consultant at Helen DeVos Children's Hospital in Grand Rapids, Michigan. 

References

1Bush NC, Holzer MS, Brown B, et al. US Hospitalizations For Pediatric Stone Disease: Contemporary Incidence And Demographics. Paper presented at: American Urological Association Annual Meeting, 2009.

2VanDervoort K, Wiesen J, Frank R, et al. Urolithiasis in Pediatric Patients: A Single Center Study of Incidence, Clinical Presentation and Outcome. J Urology. 2007;177: 2300-2305.

3Sas DJ, Hulsey TC, Shatat IF, et al. Increasing Incidence of Kidney Stones in Children Evaluated in the Emergency Department. J Pediatrics. 2010;157:132-7.

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