Current Treatment Options in Pediatrics

Quality improvement work in healthcare requires an understanding of not only the methodology and science of improvement but also a mastery of the concepts of change management. These “softer skills” include leadership, team building, culture, context, and patient and family engagement. Capable leaders and teams facilitate improvement by fostering a culture of improvement. By engaging patients and families, interventions and innovations can be appropriately tailored to suit individual contexts. Without the incorporation of these change management concepts, successful, sustainable quality improvement cannot be achieved.

The treatment of pediatric inflammatory neck masses depends upon the underlying etiology and may include both medical and surgical interventions. The most common causes of bacterial cervical lymphadenitis include Staphylococcus aureus (increasingly methicillin-resistant S. aureus), and Streptococcus pyogenes. A contrast-enhanced computed tomography (CT) scan can provide an accurate means of diagnosing whether an abscess is present which might need surgical drainage. Recent studies, however, have focused on the ability to diagnose abscesses using imaging studies that limit the patient exposure to radiation, including the use of ultrasound, magnetic resonance imaging (MRI) and low-voltage CT scanning. Recent database studies have demonstrated trends in the incidence and management of deep neck abscesses from 2000 to 2009. The incidence of retropharyngeal abscesses has increased while the incidence of peritonsillar abscesses, parapharyngeal abscesses or combined space deep neck infections has remained the same. Rates of incision and drainage for retropharyngeal abscesses have decreased, while for peritonsillar abscesses rates of incision and drainage have increased with a corresponding decrease in tonsillectomy rates. Fusobacterial infections have been associated with peritonsillar abscesses and deep neck space infections in association with Lemierre syndrome. These infections are treated with culture-directed antibiotics and surgical drainage when indicated and the prognosis is generally good when identified early. Kawasaki disease (KD) is a potential non-infectious/idiopathic cause of inflammatory pediatric neck mass. In addition to cervical lymphadenopathy, patients with Kawasaki disease may present with retropharyngeal cellulitits or abscess. It is critical that the patient with KD be identified within 10 days of illness onset so the child can be treated with intravenous immunoglobulin which has unequivocally been shown to decrease the incidence of potentially life-threatening cardiac aneurysms.

This paper will review common etiologies of stridor for primary care specialists with an emphasis on recent literature. New international consensus recommendations for laryngomalacia provide management algorithms per symptom severity with acid suppression therapy being considered prior to surgery for moderate laryngomalacia. CT imaging has been proposed over diagnostic bronchoscopy for patients with suspected foreign body aspiration. Endoscopic balloon dilation is successful in 50–100% of subglottic stenosis cases dependent on the severity. Vocal fold immobility resolution occurs in up to 40% of idiopathic cases versus only a quarter of neurologic and cardiac etiologies. Speech therapy is first-line treatment of vocal cord dysfunction. A thorough history and physical with special consideration of presenting age and stridor characteristics is imperative for accurate diagnosis. Flexible laryngoscopy, direct laryngoscopy and bronchoscopy, and/or imaging are utilized in many cases for diagnosis and/or management.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have significant morbidity and mortality in pediatrics. Although, MRSA frequently causes skin and soft tissue infections (SSTI), invasive infections due to MRSA have become increasingly common. This review aims to provide clinicians with the current treatment options available for invasive and non-invasive MRSA infections in pediatrics. MRSA resistance is increasing and antibiotics, such as clindamycin and TMP-SMX, may not be as effective. Ceftaroline is a newer agent that has been approved in the USA and Canada for the management of acute bacterial SSTI and community acquired pneumonias caused by MRSA. Vancomycin remains the mainstay of therapy for most invasive MRSA infections. However, the choice of antibiotic used in the clinical setting can depend on many factors: resistance patterns, site of infection, age and geographical location of the patient, side effects and availability of antibiotics. In pediatrics, future clinical studies are required to determine the efficacy and safety of novel antibiotics such as ceftaroline.

Nephrotic syndrome (NS) is among the most common pediatric kidney diseases with a high risk of morbidity and mortality due to infection and thrombosis. Goals of treatment are to reduce proteinuria to normal levels thereby reducing symptoms and risk of complications. Children with NS should initially be treated with prednisone or prednisolone at a dose of 60 mg/m2/day daily for 6 weeks followed by 40 mg/m2/day given every other day for an additional 6 weeks. While most children are steroid responsive, approximately 20 % of children with NS do not go into remission with steroids and should be treated with a calcineurin inhibitor such as cyclosporine or tacrolimus. Some children with NS who respond to steroids eventually have a frequently relapsing or steroid-dependent course and may have significant side effects from cumulative corticosteroid therapy. For these children, steroid-sparing medications are required. Treatment with mycophenolate mofetil is recommended as first-line therapy for treatment of frequently relapsing or steroid-dependent NS with steroid toxicity due to its favorable side effect profile compared to alternatives. If this is not effective, alternate agents such as cyclophosphamide, calcineurin inhibitors, or rituximab could be considered after careful review of the pros and cons of each medication with the child’s family. Further randomized controlled trials are necessary to determine which agents are most effective and to determine methods to predict medication response in individual children.

Our goal is to review a number of methodologies which have been used to improve safety in healthcare since the release of the Institute of Medicine report in 1998 which documented that error was a significant cause of mortality in the USA. Multifaceted approaches have each led to reduction in error. Methods for error reduction included in this review are “Just Culture,” increased transparency and accountability, error reporting and investigation, second-victim programs, training in quality and safety methods, standardization and bundles, electronic health records, computerized order entry, barcode scanning, clinical decision support, predictive analytics, and situational awareness. Newer fields with the potential to improve patient safety include human factors engineering, indication-based prescribing, and Safety II. While each intervention has led to incremental improvement, continued expansion of these programs is necessary to eliminate medical error.

Given the lack of randomized controlled trials or robust literature in children, we are left with recommended bundles, adult-based literature, and common sense. The quality improvement approach to studying prevention of hospital-acquired infections through the use of bundles has generally been studied en masse, rather than by individual bundle elements. Due to the mortality risk, indirect and direct attributable costs, and the inevitable penalties associated with these largely preventable harms, we must reliably implement bundles to avoid these hospital-acquired infections. ”Implementation is the most difficult but most essential aspect of harm prevention”. The journey to zero harm, whether infectious or not, will ultimately require a robust safety culture, incorporation of high reliability principles, and patient and family engagement.

This review explores the role of diet in the pathogenesis and treatment of inflammatory bowel disease and highlights various contemporary dietary options in the treatment of adult and pediatric inflammatory bowel disease. The role of diet in inflammatory bowel disease has become clearer through epidemiologic, basic science, and interventional studies. Multiple dietary treatment strategies are used as primary or adjunctive therapy in inflammatory bowel disease to varying degrees of success. While the field of nutrition and nutritional therapy in inflammatory bowel disease has evolved with supporting evidence from basic science and clinical research, further studies are necessary to fully understand the impact and potential of diet and dietary therapy in the management of IBD.

Elements based on specific literature to assist in the elaboration of an early mobilization (EM) protocol for severely ill children in a pediatric intensive care unit or in an inpatient care unit. Recent findings have shown that immobility during critical periods of the disease may cause physical, neuromusculoskeletal, metabolic, cognitive, and psychological sequelae that may extend throughout life. Prolonged bed rest is associated with thromboembolic events, decreased protein synthesis and muscle mass, and increased risk of death. Children surviving from serious illnesses have an increased risk of delay in overall recovery, resulting in poor quality of life and increased costs of post-discharge health services in the short, medium, and long term. Further research is needed to delineate protocols for specific populations in PICU as well as to find associations between interventions in PICU with EM, and with outcome times spent in PICU and hospital, need for care after hospital discharge, death and quality of life, among others.