Download The present investigation has highlighted that under

RESEARCH LETTERS
The present investigation has highlighted that
under-nutrition (thinness) in early adolescents girl is
a major health problem at rural sectors of West
Bengal, India.
It is well documented that thinness is an indicator
of acute under-nutrition which is the results of more
recent food deprivation [4]. It also indicates that
intensive and comprehensive approaches are required
immediately at rural sectors to combat undernutrition among adolescent girls. This result is
important to public health policy makers, planners
and social organizers.
SOUMYAJIT MAITI,1 DEBIDAS GHOSH,1,2 and
SHYAMAPADA PAUL2,3
1
Department of Bio-Medical Laboratory Science and
Management (U.G.C Innovative Department),
Vidyasagar University, Midnapore 721 102, West
Bengal, India, 2Department of Nutrition & Dietetics,
Vidyasagar University, Midnapore 721 102,
West Bengal, India and 3Rural Research Institute of
Physiology & Applied Nutrition (RRIPAN),
Midnapore 721 101, West Bengal, India
doi:10.1093/tropej/fmr005
Advance Access Published on 25 January 2011
Acknowledgements
The authors gratefully acknowledge to the authorities of Indian Red Cross Society (Paschim
Medinipur District branch) for their help and
cooperation. We owe our thanks to the girls who
participated in this study.
References
1. Alam N, Roy SK, Ahmed T, et al. Nutritional status,
dietary intake and relevant knowledge of adolescent
girls in rural Bangladesh. J Health Popul Nutr
2010;28:86–94.
2. Malhotra A, Jain P. A diet quality and nutritional
status of rural adolescent girl beneficiaries of ICDS in
north
India.
Asia
Pac
J
Clin
Nutr
2007;16(Suppl. 1):8–16.
3. Pelletier DL, Frongillo EA. Changes in child survival
are strongly associated with changes in malnutrition in
developing countries. J Nutr 2003;133:107–19.
4. World Health Organization. Physical status: the use
and interpretation of anthropometry. Technical Report
Series No. 854. Geneva: World Health Organization,
1995.
5. Lohman TG, Roche AF, Martorell R. Anthropometric
Standardization Reference Manual. Chicago, IL:
Human Kinetics Books, 1988.
6. Cole TJ, Flegal KM, Nicholls D, et al. Body mass index
cut-offs to define thinness in children and adolescents:
international survey. Br Med J 2007;355:194–198.
7. Mandal G, Bose K, Bisai S. Thinnes among rural
children in Bengal. Indian J Pediatr 2009;76:817–19.
Journal of Tropical Pediatrics
Vol. 57, No. 6
8. Mondal N, Sen J. Thinness is a major underlying
problem among Indian children. J Trop Pediatr
2010;56:456–7.
Correspondence: Prof. Debidas Ghosh, U.G.C Innovative
Department, Bio-Medical Laboratory Science
and Management, Vidyasagar University,
Midnapore 721 102, West Bengal, India.
E-mail: <[email protected]>.
Life-threatening Cardiac Arrhythmia after a
Single Dose of Nebulized Epinephrine in
Pediatric Emergency Department
Summary
Cardiac adverse effects are not commonly
reported complications of nebulized epinephrine
therapy. We present a case of critical cardiac
arrhythmia developed at the Pediatric
Emergency Department in an otherwise healthy
infant after receiving 3 mg of L-epinephrine
(1:1000) nebulization over a 90 min period for
a diagnosis of bronchiolitis. Unstable ventricular
tachycardia was found after the nebulization
therapy that required chemical cardioversion.
Frequent premature ventricular contractions
(PVCs) were found initially following the cardiac insult that was controlled with oral
amiodarone, and disappeared during follow-up.
Although epinephrine inhalation is generally
safe, adverse life-threatening events could be
unpredictable and may evolve even after a single
dose of nebulized epinephrine.
Key words: Nebulized epinephrine, bronchiolitis,
cardiac arrhythmia, croup.
Background
Nebulized epinephrine is a commonly used treatment
in the emergency department for relieve of respiratory distress in children presenting with bronchiolitis
and croup syndromes [1–3]. It is considered as a safe
treatment modality with potential minor cardiovascular adverse effects related to its sympathomimetic
activity [4]. We report a case of unstable ventricular
tachycardia after an initial first dose of epinephrine
nebulization in a young infant presented with
bronchiolitis.
Case Presentation
A previously healthy 33-day-old male infant, presented to our Pediatric Emergency Department with
cough and difficulty of breathing of 2 days duration.
The initial assessment of the patient revealed
497
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FIG. 1. Wide complex tachycardia noticed after the third dose of nebulized epinephrine.
moderate respiratory distress in the form of tachypnea, subcostal retractions and wheezing and had the
following vital signs: heart rate 168 min1, respiratory rate 62 min1, blood pressure 106/62 mmHg,
temperature 37.4 C and oxygen saturation of 93%
on room air. A diagnosis of bronchiolits was made,
and treatment of L-epinephrine (adrenaline) nebulization 3 mg (1:1000) divided into three equal doses,
diluted in 2 ml of 0.9% saline each, and given one
after the other was ordered. The three doses were
administered over a period of 90 min. After the third
dose of nebulized epinephrine, the patient suddenly
deteriorated and became lethargic, pale, cyanosed
and had the following vital signs: oxygen saturation
was 80% on room air, heart rate 200 min1, respiratory rate 60 min1, blood pressure 60/50 mmHg and
temperature 36.8 C. Oxygen treatment was started
using a non re-breathing mask. Cardiac monitor, and
a 12-lead electrocardiogram showed ventricular
498
tachycardia with palpable peripheral pulses (Fig. 1).
Intravenous access was started and the patient
received 10 ml kg1 bolus of 0.9% normal saline,
and then 5 mg intravenous lidocaine was given. Five
minutes later, the ventricular arrhythmia converted
to a sinus rhythm, with stable vital signs. Complete
blood count, serum electrolytes, renal function test
and thyroid function tests were all normal. Chest
X-ray was red with bilateral hyperinflation of both
lung fields, atelectatic opacities at the right upper
lobe. The patient was then monitored in the pediatric
intensive care unit for 3 days where frequent runs of
premature ventricular contractions (PVCs) and one
brief attack of ventricular tachycardia for few
seconds that resolved spontaneously were recorded.
Oral amiodarone 25 mg twice per day was started
and the patient was continued on 3% hypertonic
saline nebulization. Echocardiography done on the
day of admission showed normal results apart from a
Journal of Tropical Pediatrics
Vol. 57, No. 6
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patent foramen ovale with left to right shunt. The
patient went home after 2 weeks of hospital admission during which he was hemodynamically stable all
through, discharged on oral amiodarone 25 mg twice
per day to complete a 4 weeks course. One month
later during follow-up, the patient remained asymptomatic and 48 h Holter recordings showed sinus
rhythm with occasional ectopic ventricular beats.
Eight months later, the patient was still asymptomatic, repeated 48 h Holter recordings showed normal
sinus rhythm with no ectopic beats. Eighteen months
after the cardiac incident, the patient was doing well
and had a normal electrocardiogram.
Discussion
Although nebulized epinephrine in the recommended
doses was labeled as a safe treatment in infants and
children [5], it does not lack complications. Cardiac
arrhythmia with elevated cardiac enzymes was previously reported after repeated doses of nebulized
racemic epinephrine, which resolved spontaneously
on discontinuation of the nebulization, and the
authors recommended cardiac monitoring for patients requiring administration of nebulized epinephrine more frequently than every 1 to 2 h [6]. Racemic
epinephrine 2.25% (an equal mixture of l- and
d-isomers) is ideally used for nebulization therapy
in children, and L-epinephrine in equivalent doses can
be as effective as racemic epinephrine [7]. Our patient
received the recommended dose of nebulized
L-epinephrine which was 0.5 mg/kg [8]. The potent
sympathetic system stimulation induced by nebulized
epinephrine seems to be the likely contributing factor
for this patient’s arrhythmia. In addition to the
epinephrine effects on an already stressed heart, in
the presence of severe respiratory distress and possible hypercarbia leading to increased myocardial
excitability. An underlying heart problem such as
myocarditis or cardiomyopathy that could be
induced by the viral cause of bronchiolitis itself
might have propagated the toxicity of epinephrine,
but we believe that the normal EKG, the resolution
of arrhythmia after treatment and the 1.5 years
normal follow-up makes this unlikely. Our reported
case raises the concern of possible serious adverse
effects, even after the first recommended treatment,
of nebulized epinephrine. Cardiac monitoring is
recommended for patients requiring frequent or
even a single dose of nebulized epinephrine.
FATIHI HASSAN TOAIMAH,1 and KHALID AL-ANSARI1,2
1
Division of Pediatric Emergency Medicine,
Department of Pediatrics, Hamad Medical
Corporation, Doha, Qatar and 2Weill Cornell Medical
College, Doha, Qatar
doi:10.1093/tropej/fmq123
Advance Access Published on 21 January 2011
Journal of Tropical Pediatrics
Vol. 57, No. 6
References
1. Bertrand P, AranõÂbar H, Castro E, SaÂnchez I.
Efficacy of nebulized epinephrine versus salbutamol in
hospitalized infants with bronchiolitis. Pediatr
Pulmonol 2001;31:284–8.
2. Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitis: Can we
identify children for outpatient therapy? Am J Emerg
Med 1994;12:613–16.
3. Ledwith C, Shea L, Mauro R. Safety and efficacy of
nebulized racemic epinephrine in conjunction with
dexamethasone and mist in the outpatient treatment
of croup. Ann Emerg Med 1995;25:331–5.
4. Zhang L, Sanguebsche LS. The safety of nebulization
with 3 to 5 ml of adrenaline (1:1000) in children: an
evidence based review. J Pediatr 2005;81:193–7.
5. Babbitt CJ, Tse GC, Ramos P. Continuous nebulized
racemic epinephrine for bronchiolitis. Clin Inten Care
2004;15:149–52.
6. Butte MJ, Nguyen BX, Hutchison TJ, Wiggins JW,
et al. Pediatric myocardial infarction after racemic
epinephrine administration. Pediatrics 1999;104:e9.
7. Waisman Y, Klein BL, Boenning DA, et al. Prospective
randomized
double-blind
study
comparing
l-epinephrine and racemic epinephrine aerosols in the
treatment of laryngotracheitis (Croup). Pediatrics
1992;89:302–6.
8. American Academy of Pediatrics, Hegenbarth MA, the
Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008;121:433–43.
Correspondence: Dr Khalid Alansari, MD, FRCPC, FAAP
(PEM); Hamad Medical Corporation, Department of
Pediatrics, Pediatric Emergency Center Al-Sadd, PO Box:
3050, Doha, Qatar. Tel.: 00974 44396006; Fax: 00974
44392677.
E-mail: <[email protected]>
No Difference in Prevalence of Anal Fissure
among Infants who are Breast-Fed, Formula-Fed
and Mixed-Fed
Anal fissure in infants is widely known as a consequence of chronic constipation. Both chronic constipation and anal fissure are troublesome in children
who consume excessive cow’s milk [1]. Recently,
cow’s milk protein allergy (CMA) has been shown as
a cause of constipation, anal fistula and anal fissure
[2–6]. Thus, the objective of our study was to look
into the prevalence of anal fissure in infants who are
breast-fed, formula-fed and mixed-fed.
Healthy 404 infants of both sexes aged between
0 and 4 months from the Well-Baby Clinic of
Department of Pediatrics, Faculty of Medicine,
Siriraj Hospital, Mahidol University, Thailand,
were recruited into this study. Infants were divided
into three groups according to their patterns of
feeding. Group I was exclusively breast-fed; Group II
was solely cow infant formula-fed while Group III
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