Letters and responses from readers
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Several readers contacted us about the photograph on the cover of the February 2003 issue, voicing three concerns: The needle is not a safety needle, the provider is not wearing gloves, and the child does not appear to be restrained.
The photograph, which showed an actual vaccination of a child, was selected from archives of stock photographs. The fact that the photo likely predates current US Occupational Safety and Health Administration guidelines does not excuse the fact that we missed an opportunity to reinforce important safety guidelines about vaccine administration.
New federal regulations regarding the use of safer injection devices (e.g., needle-shielding syringes or needle-free injectors) became effective April 2001. These rules require employers (including pediatric providers) to recognize technological improvements that reduce the risk of exposure to needlesticks, investigate those devices, and select and use those that 1) will not jeopardize employee or patient safety or be medically inadvisable, and 2) will make an exposure incident from a contaminated sharp device less likely to occur.1,2 Our cover photograph should have depicted one of the available needle-shielding devices.
Regarding the use of gloves, the General Recommendations on Immunization from the Advisory Committee on Immunization Practices (ACIP) states, "Hands should be washed with soap and water or cleansed with an alcohol-based waterless antiseptic hand rub between each patient contact. Gloves are not required when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands."1 It appears that the ungloved hands in the photograph are not in violation of federal standards, although a few readers who contacted us about this photo expressed the belief that providers should always be gloved when administering vaccinations. (We'll post an instant poll question on our Web site shortly to find out how our readers practice on this point.)
What constitutes appropriate patient restraint varies with the skill, experience, and, perhaps most important, the speed of the person administering the vaccine. Although the provider in the photograph on the cover of the February 2003 issue does not appear to be violating any rule, it can be reasonably argued that he (or she) used poor judgment.
We recognize that safety guidelines are promulgated only after considerable thought and consideration, and we apologize if this photograph appeared to undermine safe practice.
1. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP): MMWR 2002;51(RR-2), pp 1115
2. A Pediatrician's Guide to Understanding OSHA Needlestick Prevention Regulations, www.aap.org/moc/indexmoc2.cfm
We are concerned about the recommendation for irrigating the nose with a saline solution in the otherwise excellent article, "Why won't this child's nose stop running?" (December 2002). First, directions are vague (2 to 3 tsp of pickling salt or "sea water" once or twice a day). Have any studies of this irrigating hypertonic solution been done by the authors or anyone else? None is mentioned in the article's references. Second, neither the duration of therapy nor the age group for which irrigation is recommended is specified, although the age can be assumed to be 2 to 5 years. Third, use of a Waterpik, mentioned in the Guide for Patients and Parents, is of particular concern because doing so requires adjustments to the device.
There are numerous reports of hypertonic solutions causing hypernatremia and nasal obstruction.13 Errors in the treatment of gastroenteritis with home-prepared salt solutions have resulted in tragic cases of hypernatremia.1,49 Instructions were frequently misunderstood or forgotten by anxious parents. Use of a commercially prepared solution is necessary to prevent this pitfall.
Improper preparation of "saline" solution nose drops for infants has occurred when parents misunderstood the provider or received inadequate instructions and used more than 1/4 tsp of salt in up to 8 oz of water.3 Hypertonic nasal salt solutions can result in irritation of the nasal mucosa, edema, inflammation, complete nasal obstruction, and respiratory distress in infants and small children.3 There is no way to predict whether the solution will act as theorized and alleviate nasal edema.
Because 1 tsp of sodium chloride is approximately 5,000 mg of NaCl2 or 86 mEq of sodium, 2 to 3 tsp of salt would have 10,000 to 15,000 mg of NaCl2 or 172 to 259 mEq of sodium.10 If one were to utilize sea water as advised, which contains 350 to 400 mg/dL of sodium or a 152 to 173 mEq/L concentration,4 it would have the potential to raise the serum sodium level an additional 21 to 24 mEq/L above the normal baseline of 135 to 145 mEq/L.
Based on our clinical experience with cases of hypernatremia from salt poisoning and on those cases reported in the literature, we believe the use of homemade salt solutions for irrigation and other purposes should not be encouraged.
1. Fuchs S, Listernick R: Hypernatremia and metabolic alkalosis as a consequence of the therapeutic misuse of baking soda. Pediatr Emerg Care 1987;3:242
2. Puczynski MS, Cunningham DG, Mortimer JC: Sodium intoxication caused by the use of baking soda as a home remedy. CMAJ 1983;128:821
3. Utin LS, Bartlett GL: Iatrogenic acute nasal obstruction in an obligate nasal breather. JAMA 1980;243:1657
4. Porath A, Mosseri M, Harman I, et al: Dead sea water poisoning. Ann Emerg Med 1989;18:187
5. Hansted C: Alimentary salt poisoning. Arch Pediatr 1960;77:457
6. Calvin ME, Knepper R, Robertson WO: Hazards to health: Salt poisoning. N Engl J Med 1964;270:625
7. Saunders N, Balfe JW, Laski B: Severe salt poisoning in an infant. J Pediatr 1976;88:268
8. Nomura FM: Broth edema in infants. N Engl J Med 1966;274:1077
9. Fujiwara P, Berry M, Hauger P, et al: Chicken-soup hypernatremia (letter) N Engl J Med 1985;313:1161
10. Sodium chloride monograph. Micromedex Healthcare Series Vol. 115 expires 3/2003
Author reply: We thank Drs. Mofenson and Caraccio for their thoughtful letter. However, we believe their concern about the method and use of hypertonic saline nasal irrigation is unwarranted. The reports of hypernatremia they cite are cases in which children have ingested hypertonic saline solution, which is then absorbed through the alimentary tract. Hypertonic nasal saline solutions are applied topically, and patients are instructed that it is not intended for ingestion.
Concern over the potential for aggressive overuse or misuse of any management recommendation is always valid, but current clinical reports in the specialty of otolaryngology indicate nasal saline irrigation is safe and effective.13 Papsin and Mctavish, for example, conclude that "nasal irrigation is a simple, inexpensive treatment that relieves the symptoms of a variety of sinus and nasal conditions, reduces use of medical resources, and could help minimize antibiotic resistance."4 Rabago and colleagues conclude that "daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis. Primary care physicians can feel comfortable recommending this therapy."5 In other articles, authors advocate the use of hypertonic saline to the nasal cavity, finding that the hypertonicity of the solution significantly improves mucociliary clearance.6,7
We prescribe hypertonic saline for our patients, infants and older. In our combined experience over the past 10 years, no significant deleterious effects have been identified.
Mechanical delivery devices such as the Waterpik with a nasal tip adapter have been well studied and are available from Hydro Med. Murray Grossan, MD, who has made major contributions to otolaryngology by advocating the use of pulsatile nasal irrigation to improve mucociliary clearance and sinonasal disease, has found it to be safe and effective in adult and pediatric patients.8,9
We maintain that the key component to sustaining normal intranasal hygiene is to maintain natural mucociliary flow by mechanically relieving obstruction and by promoting hydration. The current literature and our experience bear out that the homemade hypertonic saline solution with the use of the Waterpik and nasal adaptor, or a bulb syringe, is safe and effective in pediatric patients with sinonasal disease.
1. Heatley DG, McConnell KE, Kille TL, et al: Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg 2001:125:44
2. Tamooka LT, Murphy C, Davidson TM: Clinical study and literature review of nasal irrigation. Laryngoscope 2000:110;1189
3. Shoseyov D, Bibi H, Shai P, et al: Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol 1998; 101:602
4. Papsin B, Mctavish A: Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician 2003;49:168
5. Rabago D, Zgierska A, Mundt M, et al: Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: A randomized controlled trial. J Fam Pract 2002:51;1049
6. Homer JJ, England RJ, Wilde AD, et al: The effect of pH of douching solutions on mucociliary clearance. Clin Otolaryngol 1999:24:312
7. Talbot AR, Herr TM, Parsons DS: Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope 1997:107:500
8. Grossan M: Irrigation of the child's nose. Successful application of a Dental Pulsating irrigation device. Clinical Ped 1974:13:229
Thank you for the excellent article by Drs. Pichichero and Casey, "Defining and dealing with carriers of group A streptococci" (January 2003). As usual, Dr. Pichichero provides productive and, at times, provocative information.
One treatment option for recurrent strep that has worked well for me over many years is the standard antibiotic regimen (for the usual 10 days), followed by a month of bedtime penicillin. In my experience, this treatment is well tolerated and recurrence is extremely uncommon. The potential threat of a tonsillectomy and adenoidectomy sometimes improves parental and patient adherence.
As a pediatrician and the mother of a beautiful girl with Down syndrome, I take exception to the generalization made by Dr. Pector in "Coping with your own child's illness" (March 2003). Dr. Pector says, "Parents will always grieve for what they think they should have had . . . We adjust to our child's disabilities, but we never totally accept them or stop thinking about what might have been." I do not think that I am alone among parents of children with a disability in saying that I would not change my child's "disability" even if I could. I accept her completely just the way she is, and I love everything about her. I honestly do not "grieve" for "what might have been." I enjoy every day with my precious girl.
We are both pediatricians, celebrating the 14th anniversary of our oldest son's diagnosis of acute lymphocytic leukemia. "Coping with your own child's illness" conjured up the sadness, angst, and uncertainty we felt during the early years of therapy, and afterward when chemotherapy ended and our son began "flying solo." We sweated every fever, illness, ache, and pain. Nevertheless, his illness helped put our priorities in order. We began working less and spending more time with our family.
We would not, of course, recommend this experience to physicians, but it has, in truth, made both of us much better doctors and people. The best news is that our son has been off therapy for 11 years now. He has graduated from college, is attending law school, and is happily married.
In the January 2003 Pediatric Puzzler ("Frustration over unremitting fever in a 3-year-old girl: Why, oh why?"), which I wrote, I neglected to acknowledge Dori Lamphere, MD, for her assistance with the case report on which the article was based and with the case itself. Dr. Lamphere was a resident at the time the patient was ill, and it was, in fact, she who made the diagnosis by specifying "Yersinia" on the order for a stool culture. Dr. Lamphere also helped me considerably by gathering information to turn this interesting case into a report. I am grateful for her assistance, and regret my oversight.
Readers' Forum. Contemporary Pediatrics May 2003;20:134.