Paediatric drugs
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Regional anesthesia has become a routine part of the practice of anesthesiology in infants and children. Local anesthetic toxicity is extremely rare in infants and children; however, seizures, dysrhythmias, cardiovascular collapse, and transient neuropathic symptoms have been reported. Infants and children may be at increased risk from local anesthetics compared with adults. ⋯ Two new enantiomerically pure local anesthetics, ropivacaine and levobupivacaine, offer clinical profiles comparable to that of bupivacaine but without its lower toxic threshold. The extreme rarity of major toxicity from local anesthetics suggests that widespread replacement of bupivacaine with ropivacaine or levobupivacaine is probably not necessary. However, there are clinical situations, including prolonged local anesthetic infusions, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring a large mass of local anesthetic, where replacement of bupivacaine with ropivacaine, levobupivacaine or (for continuous techniques) chloroprocaine appears prudent.
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Nosocomial pneumonia is a common hospital-acquired infection in children, and is often fatal. Risk factors for nosocomial pneumonia include admission to an intensive care unit, intubation, burns, surgery, and underlying chronic illness. Viruses, predominantly respiratory syncytial virus (RSV), are the most common cause of pediatric nosocomial respiratory tract infections. ⋯ Therapy should be modified when a specific pathogen and its antimicrobial susceptibility are identified. Effective prevention of nosocomial pneumonia requires infection control measures that affect the environment, personnel, and patients. Of these, hand hygiene, appropriate infection control policies, and judicious use of antibacterials are essential.
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Behavioral interventions, particularly biofeedback and relaxation therapy, have demonstrated their effectiveness in the treatment of both adults and older children with migraine in controlled trials. The physiological basis for their effectiveness is unclear, but data from one trial suggest that levels of plasma beta-endorphin can be altered by relaxation and biofeedback therapies. The data supporting the effectiveness of behavioral therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. ⋯ People who experience migraines can also experience episodic headaches throughout life. An important consideration is preparing children to deal with future headaches, allowing them to feel in control of their health. Behavioral therapies have the potential to do this, giving the child access to a technique that can be easily resumed without a medical visit or prescription.
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In diabetes insipidus, the amount of water ingested and the quantity and concentration of urine produced needs to be carefully regulated if fluid volume and osmolality are to be maintained within the normal range. One of the principal mechanisms controlling urine output is vasopressin which is released from the posterior pituitary gland and enhances water reabsorption from the renal collecting duct. In diabetes insipidus, the excessive production of dilute urine, and the causes of this clinical picture can be divided into three main groups: the first is primary polydipsia where the amount of fluid ingested is inappropriately large; the second group is cranial diabetes insipidus where the production of vasopressin is abnormally low; and, the third group is nephrogenic diabetes insipidus where the kidney response to vasopressin is impaired. ⋯ The treatment of these patients is difficult and typically involves therapy with a diuretic such as chlorothiazide, as well as indomethacin. These agents enhance urine osmolality by their effect on circulating volume and renal solute and water handling. The fluid intake of most young children with primary polydipsia can be safely reduced to a more appropriate level.
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There is evidence to suggest that, in children, episodic abdominal pain occurring in the absence of headache may be a migrainous phenomenon. There are four separate strands of evidence for this: the common co-existence of abdominal pain and migraine headaches; the similarity between children with episodic abdominal pain and children with migraine headaches, with respect to social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurological and vasomotor features; the effectiveness of nonanalgesic migraine therapy (such as pizotifen, propanolol, cyproheptadine and the triptans) in abdominal migraine; and the finding of similar neurophysiological features in both migraine headache and abdominal migraine. Abdominal migraine is rare, but not unknown, in adults. ⋯ There is scant evidence on which to base recommendations for the drug management of abdominal migraine. What little literature exists suggests that the antimigraine drugs pizotifen, propanolol and cyproheptadine are effective prophylactics. Nasal sumatriptan (although not licensed for pediatric use) may be effective in relieving abdominal migraine attacks.