ers forPediatricsask authors presenting information about new therapies to include analyses as suggested by Guyatt et al2?
Douglas Dransfield, MD*
Dale Kessler, Jr, MD, PhD*
Carol McCarthy, MD‡
Department of Pediatrics, Divisions of *Neonatology and ‡Infectious Disease
Maine Medical Center Portland, ME 04102
REFERENCES
1. The PREVENT Study Group. Reduction of respiratory syncytial virus hospitalization among premature infants and infants with bronchopul-monary dysplasia using respiratory syncytial virus immune globulin prophylaxis.Pediatrics.1997;99:93–99
2. Guyatt GH, Sackett DL, Cook DJ. User’s guides to the medical literature: II. How to use an article about therapy or prevention: B. What were the results and will they help me in caring for my patients?JAMA.1994; 271:59 – 63
3. Sackett DL, Haynes RB, Guyatt GH, Tugwell P.Clinical Epidemiology: A Basic Science for Clinical Medicine.2nd ed. Boston, MA: Little Brown & Co Inc; 1991:218
In Reply.—
The issue common to the aforementioned letters concerning the PREVENT study article is that it did not provide an analysis of the cost benefit of prophylaxis of RespiGam, specifically analysis of the number of children needed to be on prophylaxis to prevent an RSV hospitalization or of the cost of possible adverse effects related to the drug. The PREVENT trial1 was designed as the pivotal study for licensure of RespiGam and thus had safety and efficacy as its specific and primary objectives. Important elements in this pivotal study were enrollment of a large number of children sufficient to show a treatment effect if it occurred, a simple study design amenable to uniform conduct over the many centers re-quired, and precise and prospectively defined primary and sec-ondary endpoints. These clinical endpoints were selected to be similar to those used in previous RespiGam prophylaxis studies2,3 to accommodate comparisons among the studies (ie, the incidence of respiratory syncytial virus (RSV) hospitalization, intensive care unit care, and mechanical ventilation, as well as RSV hospital days and RSV hospital days with an oxygen requirement). The analysis presented in the article was in the same format as the product license application to the Food and Drug Administration. It was consistent with what was prospectively defined in the study pro-tocol and analysis plan as required for a pivotal study.
Although we agree that cost issues are important in the deci-sion regarding how to use an effective drug, we also believe that valid studies of cost must be designed, conducted, and analyzed in a comprehensive and rigorous manner, analogous to the safety and efficacy data. The PREVENT trial was not designed to capture actual medical costs of RSV disease, all respiratory disease, all hospitalizations, infusions, or complications of drug infusions. Because of the nature and size of the PREVENT trial, the collection of comprehensive cost data was not possible without significantly impacting collection of data for the primary objective of the study. Using the PREVENT outcome data to construct cost analysis ret-rospectively requires making key assumptions and thus is prob-lematic. The choice of assumptions clearly influences the outcome. For example, the authors of the above letters use only RSV hos-pitalizations as the measure of benefit. Nevertheless, it is clear from the data that the overall rate of respiratory hospitalizations was substantially reduced. Because respiratory hospitalizations represented the primary reason for admission for the study pop-ulation, this benefit probably should not be ignored. If a number needed to treat analysis is performed for all respiratory hospital-izations, the result is 6.5 children. A second issue is the assump-tion of the rate of RSV hospitalizaassump-tion. The rate of RSV hospital-izations seen in the study setting is likely to be lower than that seen in the clinical care setting. Another example is raised by Dr Moler. Should one expense the three reported cases with mild cerebrospinal fluid pleocytosis as related to RespiGam or not expense them because the clinical pattern or timing in relationship to infusion did not suggest to us that the reports were consistent
with the aseptic meningitis syndrome reported after IGIV infu-sion.4We did attempt to display the data so that readers could use them for additional analysis of interest and it appears to us from the spirited commentary in the letters that we have largely, but not completely, succeeded in this objective. However, it is clear that the accurate assessment of cost is a complex issue that will require formal, comprehensive, and peer-reviewed analysis.
In response to specific queries by Dr Moler, the incidence of hospitalization for any cause in the PREVENT study was 92/260 (35%) in the placebo group and 73/250 (29%) in the RespiGam group (P5 0.14), and the total days of hospitalization for any cause was 412/100 children in the placebo group and 263/100 children in the RespiGam group (P50.07). Also, the fatality rates in all RespiGam prophylaxis studies are as follows: RespiGam 750 mg/kg dose 21/601 (3.5%); RespiGam 150 mg/kg dose 3/79 (3.8%); controls 15/563 (2.7%).
Although we share Dr Moler’s belief that education should be a powerful tool to reduce the incidence of severe RSV disease by lowering infection rates, in fact this hypothesis has not been tested. Although the modes of RSV transmission have been known for many years, regular outbreaks of RSV still occur in both the community and hospital setting. We believe that for high-risk infants and children both education of parents regarding reducing RSV exposure and prophylaxis with RespiGam are indicated.
Edward M. Connor, MD David A. Carlin, PhD Franklin H. Top, Jr
MedImmune, Inc Gaithersburg, MD 20878
REFERENCES
1. The PREVENT Study Group. Reduction of respiratory syncytial virus hospitalization among premature infants and infants with bronchopul-monary dysplasia using respiratory syncytial virus immune globulin prophylaxis.Pediatrics.1997;99:93–99
2. Groothuis JR, Simoes EAF, Levin AJ, et al. Prophylactic administration of respiratory syncytial virus immunoglobulin to high-risk infants and young children.N Engl J Med.1993;329:1524 –1530
3. Simoes EAF, Sondheimer H, Meissner HC, et al. Respiratory syncytial virus immunoglobulin as prophylaxis against respiratory syncytial vi-rus in children with congenital heart disease.Pediatr Res.1996;39:113A. Abstract
4. Scribner C, Kapit R, Phillips E, et al. Aseptic meningitis associated with high-dose intravenous immunoglobulin therapy.Ann Int Med.1994;121: 305–306
Sedation for Procedures
To the Editor.—
doses recommended in this article, they are in fact using amounts associated with general anesthesia. Because of this, it is not ade-quate to have a second individual trained only in “bag/mask ventilation,” but this person should be experienced with endotra-cheal intubation as well. The authors also need to be more em-phatic that this technique is not (not “may not” be) suitable for patients at increased risk of developing problems with ketamine. In addition, we would like to comment on the use of an anti-sialagogue with ketamine. Ketamine can produce copious secre-tions, particularly in children who have (or are recovering from) a mild upper respiratory tract infection. The authors did observe that “all patients developed some degree of increased oral secre-tions with some patients requiring oral suctioning during or after the procedure.” It has been our experience that if a drying agent is not administered, there is an increased incidence of laryngospasm and airway obstruction. Although the authors did not see these problems in their series of patients, one should be cautious when administering ketamine without an antisialagogue because with enough patients, difficulties secondary to oral secretions are likely to be encountered.
Finally, the authors only required abstinence from solid food for 4 hours and clear liquids for 1 hour before “sedation.” This does not conform to the fasting guidelines recommended by the American Academy of Pediatrics2(AAP) or the American Society of Anesthesiologists.3 Although ketamine anesthesia tends to maintain protective airway reflexes better than many other anes-thetic agents, aspiration of gastric contents can still occur.
In summary, it is important to be aware that deep sedation/ general anesthesia can be induced by ketamine and a variety of other drugs, not merely with potent volatile agents delivered by inhalation. In fact, drugs can induce deep sedation/general anes-thesia when administered intravenously, intramuscularly, trans-mucosally, rectally, or even orally. Each of the authors of this letter has been intimately involved in creating and enforcing sedation policies for his institution. Each policy emphasizes the AAP guide-lines, which stress the differences between conscious and deep sedation and appropriate monitoring, personnel, equipment, and NPO guidelines. We recommend that all sedation policies closely follow AAP guidelines and emphasize these issues.
Mark Rockoff, MD
Department of Anesthesia (Pediatrics)
Children’s Hospital of Boston and Harvard Medical School
Boston, MA 02115
Charles Cote´, MD
Departments of Anesthesiology and Pediatrics Northwestern University Medical School Children’s Memorial Hospital
Chicago, IL 60614
Richard Kaplan, MD
Departments of Anesthesiology and Pediatrics George Washington University Medical Center Children’s National Medical Center
Washington, DC 20010
REFERENCES
1. Parker RI, Mahan RA, Giugliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children.Pediatrics.1997;99:427– 431 2. Committee on Drugs, American Academy of Pediatrics. Guidelines for
monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures.Pediatrics.1992;89: 1110 –1114
3. A Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 1996;84:459 – 471
To the Editor.—
We do not agree with the old notion that “children don’t feel pain,” and we support the study performed by Parker et al1that provides a different point of view to the management of pain
during invasive procedures in pediatric patients. They used the combination of ketamine and midazolam to provide sedation in 350 invasive procedures such as lumbar puncture, bone marrow aspiration, and radiotherapy sessions, and concluded that this sedation regimen was safe and effective.
Invasive procedures, required for diagnosis or treatment of several diseases in pediatric patients, can be a source of anxiety and pain.2Children commonly undergo procedures such as intra-venous cannulation, tissue biopsy, bone marrow aspiration, and lumbar puncture without the benefit of analgesia in many centers. Previous experience of a painful procedure such as a repeated bone marrow aspiration in a cancer patient makes the child and his parents more anxious and fearful. The major reason for avoid-ance in terms of confronting the issue of pain might be the sim-plicity of the procedures, which might lead to the belief that small amounts of pain are not so harmful to children. Another important reason might be that sedating a child before an invasive procedure requires additional skillful personnel and monitoring device(s), and cost. Additionally, the sedation itself may cause some com-plications.
In pediatric gastroenterology several diagnostic and therapeu-tic invasive procedures such liver biopsy, upper gastrointestinal endoscopy, and colonoscopy are performed. The primary aim of sedation is not only to ensure patients’ safety and to complete the procedure successfully but also to keep the patients’ and their parents’ confidence in the physician. Benzodiazepines, especially midazolam, are commonly used for their sedative, anxiolytic, and anterograde amnestic effects.3They can be used alone or in com-bination with an opioid (eg, meperidine or fentanyl) for short outpatient procedures. The doses are titrated to use the minimal dose needed to sedate the patient and to cause a minimal number of side effects. Recently, we conducted a prospective study to investigate the efficacy and safety of the deep intravenous seda-tion accomplished by meperidine and midazolam in pediatric patients, and also to reveal the complication rate of the intrave-nous sedation during various endoscopic procedures.4A total of 120 procedures (68 upper gastrointestinal endoscopies, 52 colonos-copies) were performed in children ranging in age from 21⁄2 months to 17 years. It was found that the most common compli-cation was allergic skin reactions (eg, facial flushing, urticaria, phlebitis) and observed in 15.8% of patients. Transient hypoxemia and stridor were observed in 2.4%; agitation was observed in only 0.8% of patients. The recovery time was between 30 to 60 minutes in more than 50% of patients. The endoscopic procedures were completed successfully in all patients, and although available the pharmacologic antagonists were not needed during the proce-dures. We concluded that the intravenous deep sedation by this drug regimen, when administered by an experienced person and monitored closely, is a safe and effective way of sedation for even more painful and complicated procedures such as colonoscopy and upper gastrointestinal endoscopy.
In the study performed by Parker et al, no mention was made about the use of meperidine in the sedation of children. Meperi-dine is a safe narcotic analgesic when the doses are titrated to achieve a satisfactory level of sedation, and when combined with midazolam the doses can be kept at a minimum to avoid cardio-respiratory side effects. Another advantage of choosing this drug for sedation is the availability of a pharmacologic antagonist.
Our experience in pediatric gastroenterology demonstrated to us that sedating a child properly and safely is not so difficult, and there are different alternative drug regimens and techniques for sedation. The important point is that the physicians who perform invasive procedures routinely in children should be aware that “children feel pain,” and sedating a child satisfactorily and safely is as important as the diagnostic or therapeutic procedure itself.
Deniz Ertem, MD Yesim Acar, MD Evin Ozguven, MD Ender Pehlivanoglu, MD
Pediatrics/Pediatric Gastroenterology and Nutrition Marmara University School of Medicine
Tophanelioglu cd.13-15 81190 Altunizade Istanbul, Turkey
REFERENCES
1. Parker RI, Mahan RA, Giugliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children.Pediatrics.1997;99:427– 431 2. Bauchner H. Procedure, pain, and parents.Pediatrics.1991;87:563–565 3. Ament ME, Brill JE. Pediatric endoscopy, deep sedation, conscious
sedation, general anesthesia—what is best?Gastrointest Endosc.1995;41: 173–175
4. Ertem D, Acar Y, Ozguven E, Pehlivanoglu E. Complications of intra-venous deep sedation in pediatric endoscopy. 5th Congress of the Asian Pan Pacific Society of Pediatric Gastroenterology and Nutrition Abstract Book PO228:174;April 10 –13, 1997; Taipei
To the Editor.—
It is with great concern that I read the article by Parker et al1 regarding the efficacy and safety of intravenous midazolam and ketamine as procedural sedation for children. First of all, as the authors clearly state in their introduction, ketamine is a dissocia-tiveanesthetic,not a sedative or anxiolytic. Second, the technique of combining intravenous ketamine with a benzodiazepine to produce general anesthesia has been well-used and well-described in the anesthesiology literature for decades.2The development in the last 5 to 10 years of safer and more efficacious pharmacology for procedural sedation has largely replaced this old technique.3,4
Specifically, several points in this study merit discussion: 1. A 4-hour fast after solid food is not usually sufficient to ensure
gastric emptying for elective procedures, especially if airway protection is not planned. A 1-hour fast after liquids is not recommended as sufficient for gastric emptying even in elective patients, and no amount of fasting may be sufficient to neglect securing the trachea in urgent patients or those with increased risk for emesis (some oncology patients).5
2. The standard intravenous dose of ketamine required for induc-tion of general anesthesiais 1.0 to 2.0 mg/kg, the same dose advised by the authors for sedation. The use of midazolam before giving ketamine (as advocated in this study) willreduce the amount of ketamine necessary to produce anesthesia. 3. Because ketamine produces dysphoria and hallucinations, it is
a poor anxiolytic/sedative. It is, however, occasionally used as an analgesic adjuvant in very small doses (0.1– 0.3 mg/kg) because of its effect on spinal cord receptors.
4. Although flumazenil may reverse the sedative effects of mida-zolam, its effectiveness at reversing central respiratory depres-sion is at best inconsistent and short-lived.6
5. The authors state that “(n)o patient developed urticaria or wheezing or any other sign of laryngospasm.” Laryngospasm is often seen with ketamine administration because of the pres-ence of copious oral secretions with intact airway reflexes. Sudden glottic closure may precipitate rapid desaturation or even negative pressure pulmonary edema. Concurrent emesis, particularly in the unfasted patient, may occur. These airway complications are common with the doses of ketamine reported in this study. The small number of patients studied should not give the unskilled practitioner assurance that these potentially devastating events will not occur. Furthermore, laryngospasm, unlike bronchospasm, is not related to histamine release and therefore urticaria and wheezing are not related signs. Rather, ketamine is a bronchodilator and is recommended for the asth-matic patient.
6. I appreciate that the authors are concerned with avoiding the stress and behavioral changes that are seen with anesthesia and surgery. Quantitating and treating perioperative anxiety are important aspects of pediatric anesthesiology.7Unfortunately, many older children and adults have reported that a ketamine anesthetic is an extremely unpleasant experience because of profound dysphoria and emergence phenomena. Although the authors report (unquantified) satisfaction by the procedural practitioners and the parents, this satisfaction is not compared with other more pleasant techniques. Patient satisfaction is also not reported.
7. The authors informally attempt to illustrate cost-effectiveness for ketamine/midazolam versus other techniques of sedation and anesthesia that may or may not be comparable. The low efficacy and high morbidity and mortality from the lytic cock-tail (meperidine, promethazine, chlorpromazine) have
pre-cluded the use of this technique in most institutions and caused at least one author to conclude 15 years ago that “no dose may be safe for sedation.”8A more accurate cost analysis of contem-porary sedation techniques outside of the operating room may be found in other sources.9
8. The authors state that anesthesia support is required for propo-fol use in nonintubated patients (patients in whom the trachea is not intubated), making the use of this drug undesirable. The scientifically documented safety and efficacy of propofol in children has allowed us to nearly completely replace the use of ketamine with a drug that offers improved hemodynamic sta-bility, reduction in nausea and vomiting, lowered intracranial and intraocular pressure, spontaneous ventilation without in-creased airway irritability, and rapid, pleasant emergence (propofol half-life: 9 minutes versus ketamine half-life: 2 hours). Both ketamine and propofol are classified as intrave-nous anesthetics, and both should demand consultation and participation from trained, experienced, board-certified anes-thesiologists. It is surprising that these authors were granted institutional approval and privilege to administer an intrave-nous anesthetic without the presence of anesthesia-trained per-sonnel.
Anesthetic drugs are not selected merely according to proce-dure. The choice of anesthesia is determined by the child’s phys-iology or pathophysphys-iology, medical history, age, stress, and anx-iety as related to different drugs’ route of delivery, time of onset and duration, and pharmacologic effects. Although it takes no special training to administer intravenous ketamine, our specialty standards and boards dictate that 4 years of postgraduate training (with an additional 1 to 2 years for pediatric fellowship) are required to develop the skill and judgment to select and admin-ister anesthetics while anticipating, monitoring, and treating the effects of these agents. I hesitate to think that an outmoded anes-thetic technique will be adopted by nonanesthesiologists in an effort to avoid consulting those physicians with the most training, education, and clinical experience in sedation pharmacology.
Charlotte Bell, MD
Department of Anesthesiology Section of Pediatric Anesthesia Yale University School of Medicine New Haven, CT 06520-8051
REFERENCES
1. Parker RI, Mahan RA, Giugliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children.Pediatrics.1997;99:427– 431 2. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years
of clinical experience.Can J Anaesth.1989;36:186 –197
3. Bell C. Outpatient anesthesia in nonoperating room settings. In: McGoldrick K, ed. Ambulatory anesthesiology: A Problem-Oriented Ap-proach.Baltimore, MD: William & Wilkins; 1995
4. Bell C, Kain Z, Hughes C. Anesthesia and sedation away from the operating room. In:The Pediatric Anesthesia Handbook.2nd ed. St. Louis, MO: Mosby-Year Book; 1997
5. Kallar SK, Everett LL. Potential risks and preventive measures for pulmonary aspiration: new concepts in preoperative fasting guidelines. Anesth Analg.1993;77:171–182
6. Shalansky SJ, Naumann TL, Englander FA. Effect of flumazenil on benzodiazepine-induced respiratory depression. Clin Pharm.1993;12: 483– 487
7. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children.Arch Pediatr Adolesc Med.1996;150:1238 –1245
8. Mitchell AA, Louik C, Lacouture P, Slone D, Goldman P, Shapiro S. Risks to children from computed tomographic scan premedication. JAMA.1982;247:2385–2388
9. Kain ZN, Gaal DJ, Kain TS, Jaeger DD, Rimar SR. A first-pass cost analysis of propofol versus barbiturates for children undergoing mag-netic resonance imaging.Anesth Analg.1994;79:1102–1106
In Reply.—
pediatric anesthesiology. We reported on our experience with this sedative/analgesic regimen as we felt that it would be both of interest and instructive to those clinicians performing procedures on children that may require some degree of sedation. We recog-nized that this was a “work-in-progress” and reported changes in our regimen that occurred over time.1Indeed, the initial doses of ketamine and midazolam used were higher than those we now use and did result in a degree of sedation deeper than desired. We recognized that fact and titrated our drug doses downward. We elected to report the initial drug doses used rather than the more recent lower doses as we felt the reader deserved the full benefit of our experience. In retrospect, we should have emphasized more the fact that the doses used in the most recent patients are signif-icantly lower than those used in the earliest patients. The main concerns with our report raised by the anesthesiologists who chose to write to the Editor (and I am sure there are many others who hold the same concerns) appear to center around four issues. The first of these is the drug doses used by us. As stated in the article, we did decrease our drug doses over time and presently most patients are effectively sedated using an initial midazolam dose of 0.05 mg/kg (2 mg maximum single dose, 4 mg maximum total dose) followed by 0.2 to 0.5 mg/kg of ketamine. As Dr Bell so correctly points out, ketamine has been known to cause unpleas-ant hallucinations when used alone, which was why we elected to administer the midazolam first. With this regimen, only one pa-tient has reported any unpleasant hallucinations that did not recur when ketamine was given at a lower dose (0.05 mg/kg31).
The second concern involves our choice not to use an antisiala-gogue along with ketamine. Although many of our patients ex-hibited oral secretions resulting in a need for suctioning, and virtually all our patients exhibited an increase in oral secretions, in no case did these secretions compromise airway management. We do recognize that in some patients an increase in oral secretions may create problems in maintaining a patent airway and we had considered the routine use of an antisialagogue. However, we elected not to routinely use one in an attempt to keep the drug regimen as simple as possible. Antisialagogues are commonly used with ketamine in the context of general anesthesia induction, and their use in conjunction with ketamine administered in an ambulatory setting may add to the safety of sedation. However, our experience would suggest that routine use of these agents may not be necessary.
An additional concern raised by several anesthesiologists, in-cluding Drs Rockoff, Cote´, Kaplan, and Dr. Bell, is our “NPO” policy for this sedative/analgesic regimen. The 1992 AAP guide-lines quoted by many of these physicians suggest a 6-hour fast before the induction of sedation.2 However, more recently, the AAP Section on Anesthesiology has written that clear liquids up to 2 to 3 hours before anesthesia does not increase the risk of aspiration.3The AAP Section on Anesthesia recognizes local vari-ability of the NPO policies as long as a policy falls within the broad outlines provided. We agree with this approach to NPO policies in regard to conscious sedation and believe that our practice of allowing clear liquids up to 4 hours before the sedation meets these criteria. At times, we did provide sedation to children who had taken clear liquids more recently than 4 hours before the sedation if they had been NPO for at least 1 to 2 hours and if the procedure (generally a radiologic study) was urgently needed. The decision to do so was always on a case-by-case basis, taking into account the clinical condition of the child, the quantity and type of ingestion, and the need for the procedure. We did not, and do not, recommend that NPO restrictions routinely be shortened to 2 hours.
Lastly, several writers have raised concerns with our recom-mendation that support personnel be able to provide bag/mask ventilation without a recommendation that they also be trained in endotracheal intubation. In a child with an otherwise normal airway, bag/mask ventilation is the initial maneuver recom-mended in Pediatric Life Support (PALS) training to support ventilation.4When properly administered, bag/mask ventilation is quite effective. In our institution, individuals trained in endo-tracheal intubation are always readily available so we do not need to require that someone trained in this procedure be at the pa-tient’s side throughout the procedure. As the duration of action of these drugs is relatively short, particularly at the lower doses that we now use, it is likely that any patient who experiences respira-tory depression as a consequence of the medication can be sup-ported by bag/mask ventilation for the period of time it takes for
spontaneous recovery or until personnel trained in endotracheal intubation can arrive.
Although any sedation regimen presents some risks to the patient, we believe that intravenous sedation can be safely administered outside of the operating room as long as appro-priate precautions to address the safety of the patient are taken. The wider utility of conscious sedation for patients other than oncology patients is pointed out by Dr Ertem and colleagues. The involvement of our anesthesia colleagues in providing the sedation is appreciated and desirable but may not always be practical outside of large, tertiary care pediatric centers. Con-sequently, we believe pediatricians and anesthesiologists need to work together to create institutional guidelines and systems that maximize patient safety and meet patient, physician, and institutional needs.
Robert I. Parker, MD
Rosemary A. Mahan, RN, CPNP Gebra Giugliano, RN
Margaret M. Parker, MD
Children’s Medical Center at Stony Brook Department of Pediatrics
School of Medicine
State University of New York at Stony Brook Stony Brook, NY 11794-8111
REFERENCES
1. Parker RI, Mahan RA, Giugliano D, Parker MM. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children.Pediatrics.1997;99:427– 431 2. American Academy of Pediatrics, Committee on Drugs. Guidelines for
monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures.Pediatrics.1992;89: 1110 –1114
3. American Academy of Pediatrics, Section on Anesthesiology. Evalua-tion and preparaEvalua-tion of pediatric patients undergoing anesthesia. Pedi-atrics.1996;98:502–508
4. Chameides L, Hazinski MF.Textbook of Pediatric Advanced Life Support. Dallas, TX: American Heart Association; chap 4
Childhood Lead Poisoning From Apple Cider
To the Editor.—
We report an unusual case of childhood lead poisoning. The Vermont Department of Health received a report of an asymp-tomatic 7-year-old child with a blood lead level of 33 mg/dL (repeat venous sampling showed 36mg/dL). The family lived and worked on a vegetable farm in a rural area. The child’s environ-ment showed the presence of lead paint in the home; however, paint was intact, without chipping, peeling, or flaking. The home, built before 1900, was clean and well-maintained, with no visible dust. Soil testing was negative for lead. The family was drinking bottled water that met state water quality requirements including standards for lead. No other source of water was used for drinking or cooking.
Follow-up blood testing 1 month later showed a blood lead level of 40mg/dL. A detailed history was negative for parental occupation, hobby, or attendance at day care. The child’s mother, however, noted that the family produced and consumed their own apple cider and that the child had consumed just under a liter of cider daily for the past 4 years.
Further inquiry revealed that cider was made in a maple syrup evaporator, heated to 180 degrees and poured into glass canning jars. Two samples collected from different batches were analyzed by the Vermont Department of Health for lead using Environmen-tal Protection Agency methods, and showed 533 and 143 parts per billion lead, respectively. Chemical spot testing (LeadCheck, Hy-brivet Systems Inc) of the solder joining interior seams of the evaporator was positive for lead.
The remaining cider was discarded and the child’s cider con-sumption stopped. Periodic retesting of the child’s blood lead level showed a gradual decline, with a level of 18 mg/dL 22 months later.
Despite the presence of intact lead paint in the home, consump-tion of lead-contaminated cider was felt to be the major
DOI: 10.1542/peds.100.6.1045
1997;100;1045
Pediatrics
Mark Rockoff, Charles Coté and Richard Kaplan
Sedation for Procedures
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