No abstract

Objectives: Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions.Methods: This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 μg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05. Results:Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group.Conclusions: Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.

Objectives: Compliance with recommended follow-up from the pediatric emergency department (PED) has been shown to be poor. This study evaluated whether a text message reminder to the caregivers after discharge from the PED improved compliance with recommended primary care follow-up.Methods: This was a blinded randomized control trial conducted at a level 1 pediatric trauma center. The intervention was a text message sent to the caregiver within 24 hours of discharge from the PED reminding them to follow up with their primary care doctor. Patients were eligible if the caregiver had text message capability on their cellular phones, they were currently established patients of the organization's Pediatric Faculty Practice, they were discharged home from the PED, and they were referred for follow-up within 1 week of discharge by the pediatric emergency physician. After informed consent, pediatric patients were randomized to either an intervention group (text message appointment reminder) or a control group (standard scheduling with no reminder). The patient, treating physician, and primary care outpatient center were blinded to the group assignment. Enrollment occurred 24 hours per day and 7 days per week.Results: There were 123 patients enrolled in the study, 62 patients randomized to the control group (standard scheduling) and 61 randomized to the intervention group (text message appointment reminder). Of the patients, 58% were male and 42% were female, with the average age of the patients being 2.2 years (SD, 2.8). The majority of patients were seen in the PED on a weekday, with 24% presenting on a weekend. Only 28% of patients completed the recommended follow-up, and the average time from PED discharge to follow-up was 6 days (SD, 4.2; range, 0-17 days). There was no significant difference in follow-up in the standard treatment group (19/62, 31%) versus the text message intervention group (16/61, 26%) (P = 0.69; rate ratio, 0.94; 95% confidence interval, 0.75-1.18). When we assessed other variables, we found that parents of younger children were more likely to follow up as recommended by the pediatric ED physician. Of those who were compliant with follow-up, we found a mean age of 1.3 years (SD, 2.0; range, 0.8-9.1) versus 2.6 years (SD, 3.0; range, 0.08-15.3) for those who were not compliant with follow-up (P = 0.02). Conclusions:In this randomized controlled study, a text message reminder to caregivers did not improve compliance for PED patients. However, caregivers of younger children were more likely to complete follow-up as recommended by the PED physician compared with caregivers of older children.