"How Will I Ever Remember the Dose for Tylenol®?"

Patient Presentation
An 18-month-old female came to clinic with upper respiratory tract symptoms and a fever to 101° F for two days. She was drinking well and playing but since she had a history of several ear infections her parents wanted her examined. She was otherwise well. The pertinent physical exam showed an alert female in no distress with normal vital signs and a temperature to 99.8° F temperature. She had rhinorrhea but her ears and the rest of her examination were normal. The diagnosis of an upper respiratory tract infection was made. As the new intern physician was counseling the family, the father asked what the proper dose of Tylenol® was. The intern consulted her pocket handbook and gave the parents the proper dosage for the acetaminophen. After the patient encounter, the intern was discussing how this dosing question was such a common parent question and that she felt she would never be able to remember the proper dosing especially with all the different forms of the medication available. Her attending physician said, “You need to learn the Rules of 10s – 80s and 100s and then you will always remember.” He then sat down and explained the general rule to her and the other interns and medical students in the room.

Discussion
Parents always have a number of common questions that any pediatric healthcare provider should be able to answer easily because they are so common. The proper dosing of antipyretics/analgesics is one of those questions. Parents often have this particular question because the labeling directions may tell the parent to contact a physician or they are concerned that they may be giving too much of the medication. Parents are often surprised to know that they are actually underdosing the medication because the child often has gained weight and therefore needs more medication for it to be effective.

In an emergency room study, parents were asked to state the antipyretic dosage they would use for their child and then were asked to draw up the correct dosage using real medication and syringes/teaspoons etc. Overall, 40% of parents could accurately state the correct dosage, and only 30% could accurately state and then demonstrate drawing up the correct antipyretic dosage for their child. In another emergency room study, only 49% of children who received a known amount of antipyretic medication received a correct dosage. Infants less than 1 year of age were much more likely to receive an inaccurate dosage. This study also found that medication dosage based upon parental weight estimation was more likely to have an accurate dosage.

Pediatric health care providers often cannot show a parent how to draw up the correct dosage in the office or emergency room setting. However, they can be familiar with common forms of the medication and common ways they are dispensed. Questioning the parents about what form of medication they have, and how they give it gives the health care provider the chance determine an accurate dosage and then verbally tell and write down how much the parent should give using what is available in the home. This also models for the parent using weight to obtain an accurate dose.

Learning Point
One method to remember common forms of antipyretic medication is the Rule of 10s, 80s and 100s.
Abbreviations used below are: mg = milligrams, ml = milliliters, and kg = kilogram

Dosing – The Rule of 10s

Multiply the weight of the child in kilograms x 10 to give an estimated dose in milligrams (kg x 10 = dose in mg). Then adjust the dose up or down to a convenient amount of the medication for the parent to give the child based upon what form of medication and method to deliver it is available such as a syringe, cup, medication spoon, etc.

		Acetaminophen		Ibuprofen
Dosing 		10-15 mg/kg/dose	5-10 mg/kg/dose
Dosing interval	every 4-6 hours		every 6-8 hours

For example, a child weighs 15 kilograms and the parent has infant drop acetaminophen at home.
15 kg x 10 = 150 mg/dose
Because the dosing range for acetaminophen is 10-15 mg/kg/dose. The 150 mg/dose can be rounded up to 160 mg/dose which is 1.6 ml or 2 droppers of acetaminophen.
If on the other hand the parent had chewable ibuprofen tablets available at home, the dose would be 150 mg which is 1.5 tablets/dose.

Whole amounts are easier to accurately give than 1/2 amounts. Quarter and 3/4 amounts are often difficult to give. For example, give a whole or 1/2 tablet if possible as giving 1/4 or 3/4 of a tablet is more difficult.

Acetaminophen – the Rule of 80s

Acetaminophen concentrations are usually in some variant of 80 milligrams, the exceptions are dosages of 325 mg (close to 4 x 80 mg), 500 mg and 650 mg (close to 8 x 80 mg) in the tablet forms. Maximum dose is 4 grams/24 hours or 5 doses/24 hours.

Drug form	Common Parent Names	Concentration

Suspension/syrup/elixir "syringe-kind" 	160 mg/5 mls
		"cup-kind"
		"teaspoon-kind"
		"syrup"
		"suspension"
		"elixir"
Chewable tablets"chewables" 		80 or 160 mg/tablet
		"chew-tabs"
		"meltaways"
Tablets/capsules			160, 325, 500, or 650 mg/tablet
/caplets/geltabs "tablet"
		"capsule"
		"caplet"
		"geltab"
Suppositories	"rectal"	 	80, 160, 325, or 650 mg/suppository

*Note bene: In the fall of 2011 all liquid brands of acetaminophen changed to a single concentration of 160 mg/5 ml. Previously there were two different concentrations.

Ibuprofen – the Rule of 100s

Ibuprofen concentrations are usually in some variant of 100 milligrams. Droppers for the administration of ibuprofen are usually marked .625 mls (= 25 mg), 1.25 mls (= 50 mg) and 1.875 ml (= 150 mg) to assist in dosing. Common parent names are the same and so are omitted here. Maximum dose is 40 mg/kg/24 hours.

Drug form		Concentration
Infant drops		50 mg/1.25 mls
Suspension/syrup/ 	100 mg/5 mls
elixir
Chewable tablets 	50 or 100 mg/tablet
Tablets/capsules	100, 200, 400, 600, or 800 mg/tablet
/caplets/geltabs

Questions for Further Discussion
1. What other names do parents have for the different forms of acetaminophen and ibuprofen?
2. What are other common medication questions that parents have?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Pain Relievers and Over-the-Counter Medicines
and at Pediatric Common Questions, Quick Answers for this topic: Pain Management

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Simon HK, Weinkle DA. Over-the-counter medications. Do parents give what they intend to give? Arch Pediatr Adolesc Med. 1997 Jul;151(7):654-6.

Li SF, Lacher B, Crain EF.
Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care. 2000 Dec;16(6):394-7.

Robertson J, Shilkofski N. The Harriet Lane Handbook. 17th. Edit. Mosby Publications: St. Louis. 2005:688-689,839-840.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

  • How Can I Help One of My Moms Develop a Safety Plan?

    Patient Presentation
    An 8 month-old male came to clinic with upper respiratory tract infection symptoms for 2 days.
    The physician had seen the mother, infant and 2 other siblings for health supervision visits and several acute care visits for this infant and 2 other siblings who also came along.
    The children appeared well taken care of, but the mother seemed more disheveled in appearance than normal and withdrawn during the interview. When the physician asked her about how things were going at home, the mother burst into tears.
    Once she was calmer, the mother said she wanted to talk but not with the children around.
    While the children were watched by the nursing and office staff the mother revealed that her husband was becoming more and more angry with her especially since the birth of the third child.
    The “explosions” as she called them, came after the children went to bed and he would start to scream at her. The reasons for the episodes were various including money, household cleanliness, children’s behavior, etc. The episodes were worse if he had been drinking and occurred several times per week.
    He showed little remorse per the mother, and said that otherwise he spoke very little to her.
    She said that he never touched or hit her physically, nor would force her to perform sexual acts but that he would not allow her to go out of the house without him unless it was to the doctor’s office, the grocery store or her part-time job as a cashier at a gas station.
    She wasn’t allowed to have visitors over including her family that lived in the same town and she wasn’t allowed to talk with friends or family by the telephone.
    She was given money by him for groceries and for the doctor’s visits but only at the time of those errands.
    She gave him her paycheck as soon as she arrived home from work and he did not allow her any other money.
    She said that she never felt like he was going to hurt her physically so that she had never called the police but that the explosions were occurring more and he was drinking more.
    Overall she said he did help to take care of children physically, but that he preferred to work around the house or watch TV, and didn’t spend much time with the children.
    She said he talked “roughly” to them and occasionally would yell at them, but that he never had “exploded” at them or hurt them physically.
    The past medical history for the child was unremarkable.
    The social history revealed that the father worked in a manufacturing plant. Both parents were high school graduates.
    Both extended families lived in the area. The mother denied any domestic violence in the extended families or any problems with alcohol, drugs or law enforcement.
    The pertinent physical exam showed an infant with normal growth parameters and development. He had no obvious bruising, scratches or other skin changes. He had clear rhinorrhea and the rest of his examination was negative.
    The diagnosis of an infant with an upper respiratory infection and a mother who is being emotionally abused was made.
    The mother was afraid and unwilling to talk with a social worker or a counselor.
    She was very afraid of what her husband may do if he found out that she had told the physician about the episodes.
    The physician tried to talk about developing a safety plan for her and the children if the problems became worse and she needed to leave the home quickly, but the mother did not want to discuss it. She was willing to come back to have the child re-checked later in the week though.
    The patient’s clinical course showed that the infection was improving. There had been 1 explosive episode since the previous visit, and the mother said she had thought about the safety plan.
    She said that she was willing to take a paper with the local domestic violence intervention program telephone number on it as she knew a safe place that she could hide the paper. However she was unwilling to try to gather other items such as clothing and documents because she was afraid of her husband.
    Over the next few weeks, she brought the children to the clinic for rashes, upper respiratory infections and other minor illnesses. Each time she confided that she was slowly gathering items and had surreptitiously gotten some help from her family.
    She said that she was going to call the domestic violence intervention program soon. Unfortunately, she did not come back to the clinic after this visit.

    Discussion
    According to the National Domestic Violence Hotline, “Domestic violence can be defined as a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner.
    Abuse is physical, sexual, emotional, economic or psychological actions or threats of actions that influence another person. This includes any behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure or wound someone.”

    It is a national and international problem mainly for women but men can also be abused. It affects the entire family including the children even if they are not directly abused as they may be a witness to the violence or suffer from neglect because of it.
    About half of men who abuse their female partners abuse their children also.

    Many professional organizations recommend screening for domestic violence. The American College of Obstetrics and Gynecology recommends asking all women the following 3 questions:

    • Within the past year — or since you have been pregnant — have you been hit, slapped, kicked or otherwise physically hurt by someone?

    • Are you in a relationship with a person who threatens or physically hurts you?
    • Has anyone forced you to have sexual activities that made you feel uncomfortable?

    The National Domestic Violence Hotline has a more extensive but short list of self-asked questions (see To Learn More below).

    Physical abuse that may trigger the healthcare provider to consider domestic violence as a cause. There are also behavioral and emotional symptoms can also represent domestic violence.

    • Anxiety
    • Aggression towards self or others
    • Apathy
    • Attention seeking, often for minor problems
    • Depression
    • Eating disorders
    • Emotional lability
    • Withdrawing from social interactions
    • Learning problems and declining school or work performance, especially in children
    • Malnutrition
    • Neglect of self or others
    • Sexual dysfunction including early initiation of sexual activity and compulsive sexual behaviors
    • Sleep disturbance
    • Somatization disorders
    • Substance abuse including alcohol, drugs and tobacco
    • Suicide attempt
    • Poor adherence to medical recommendations
    • Problems with authorities including lying, stealing, truancy and running away, particularly in children

    Resources are available to healthcare providers to assist their patients and families.
    The National Domestic Violence Hotline is available 24 hours per day at: 1-800-799-SAFE (7233), 1-800-787-3224 (TTY).

    Guidelines are also available from the Victorian Government Department of Justice in Australia, which are applicable internationally (see To Learn More below).

    Learning Point
    Victims of domestic violence should be offered help to develop a safety plan to get out of a violent situation quickly, even if they are not willing or able to leave their current environment. The plan needs to be thought out with the idea that the victim and/or children may never be able to return to that location again.
    The plan should include:

    • Try to avoid fighting in a kitchen or bathroom where the abuser may have access to weapons or where there is no escape.
    • Know exactly where you will go. Regardless of the time of day or night, know a friend’s or a relative’s home or a shelter for battered women where you can go. Also think of another alternative if for some reason you couldn’t go to this place. Remember that you may not be able to return ever!
    • Pack a suitcase and keep it in a safe place. Keep a change of clothing for you and your children, bathroom items, and an extra set of keys to the house and car with a friend or neighbor.
    • Keep special items in a safe place. Keep important items handy so you can take them with you on short notice, or pack duplicates. These may include prescription medicines, identification, extra cash, checkbook, credit cards, and address book and telephone numbers. Also include medical and financial records, such as mortgage or rent receipts. Consider taking a special toy or book for each child.
    • Talk to your children. Let them know that it is not their job to try to stop the fighting. Tell them to call the police or get help from a family member, friend, or neighbor if they need to.
    • If you are hurt call your doctor or go to the emergency room. Give your doctor complete information about how you were injured. Ask for a social worker or a domestic violence intervention worker to help you and the children with finding safe housing, medical treatment and filing charges with police officers if you wish
    • Call the police. Domestic violence is a crime. Give the police complete information about what happened. Be sure to get the officer’s badge number and a copy of the report in case you want to file charges later.

    Questions for Further Discussion
    1. What is PTSD and how does it relate to domestic violence?
    2. What days of the week or year are especially high risk for domestic violence?
    3. What is the telephone number to the local domestic violence intervention program?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Domestic Violence and Child Abuse
    and at Pediatric Common Questions, Quick Answers for this topic: Child Abuse

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Committee on Child Abuse and Neglect.
    The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women.
    Pediatrics 1998 101: 1091-1092. Available from the Internet at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/6/1091 (rev. 10/2004, cited 5/23/07).

    American College of Emergency Physicians. Policy Statement. Guidelines for the Role of EMS Personnel in Domestic Violence. Available from the Internet at http://www.acep.org/webportal/PracticeResources/issues/pubhlth/violence/GuidelinesRoleEMSPersonnelDomesticViolence.htm (rev. 2000, cited 5/23/07).

    American College of Obstetrics and Gynecology. Domestic Violence. Available from the Internet at http://www.acog.org/publications/patient_education/bp083.cfm (rev. 2002, cited 5/23/07)

    American Academy of Family Physicians. Policy Statement. Family and Intimate Partner Violence and Abuse. Available from the Internet at http://www.aafp.org/online/en/home/policy/policies/f/familyandintimatepartner-violenceandabuse.html (rev. 2004, cited 5/23/07).

    Victorian Government Department of Justice. Management of the whole family when intimate partner violence is present: guidelines for primary care physicians. Melbourne, Australia, 2006. Available from the Internet at http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/
    Familywomenviolence/Intimatepartnerabuse/20060507intimatepartnerviolence.pdf
    (rev. 10/2006, cited 5/23/2007).

    American Bar Association. Safety Tips for You and Your Family.Available from the Internet at http://www.abanet.org/domviol/safety_tips.html (cited 5/31/2007).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 16, 2007

  • Do Antibacterial Products Really Work?

    Patient Presentation
    A resident physician was discussing a premature female infant’s health supervision visit with his attending physician.
    The resident felt that he had adequately answered all of the mother’s questions except for one that was “do those antibacterial cleaning wipes actually work?”The attending physician said that although he didn’t have any research studies to point the resident to, he thought that they did not work because of all the variabilities of which product, surface type, drying times, etc.. They then went on to discuss whether or not alcohol-based handrubbing products worked.
    The attending physician said that again he couldn’t point to the literature, but knew that there were several studies that supported the use of alcohol-based handrubbing products.
    The attending physician also pointed out that the hospital was now providing and promoting the handrubbing products. He said, “Someone who looks at this all the time, must think that they work or they wouldn’t have us use them.”Later in the week, the resident did a PUBMED search and found a research article which compared various antibacterial cleaning wipes for food surface decontamination.
    The resident and the attending discussed the article at their next continuity clinic and both agreed that they could improve upon their own cleaning procedures at home and would be better able to talk to parents about the issue.

    Discussion
    Hand hygiene, and food and other surface decontamination procedures are some of the most important ways to decrease infection transmission.
    Over the past several years, new consumer and professional products have been developed to help improve these procedures.

    Bacteria survival and transfer between surfaces including hands is influenced by temperature, nature of the surface, moisture level, bacteria type, inoculum, and time since bacterial inoculation.

    Learning Point
    According to the Hand Hygiene Resource Center, “Two million people each year become ill as a result of a hospital-acquired infection. Proper hand hygiene is critical to the prevention of these infections – which contribute to the death of nearly 90,000 hospital patients per year and $4.5 billion in medical expenses.”The Centers for Disease Control recommended alcohol-based handrubbing products in healthcare settings in 2002.
    These recommendations include using these products when hands are not visibly soiled and:

    • Before and after having direct contact with patients
    • Before putting on and after taking off sterile and non-sterile gloves
    • If during patient care, one moves from a contaminated-body site to a clean-body site
    • After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings
    • After contact with inanimate objects, including medical equipment, in the immediate area of the patient

    These recommendations include using plain soap and water or an antibacterial soap and water when:

    • Hands are visibly soiled
    • Before eating
    • After using the restroom
    • Exposure to Bacillus anthracis is suspected or proven

    One study of the effectiveness of antibacterial products on decontaminating food surfaces inoculated food preparation surfaces with Escherichia coli and Staphylococcus aureus. Four different antibacterial products were evaluated none of which was household bleach. The study found that survival of the bacteria depended on:

    • Surface type – with glass > plastic >> wood surfaces, with glass having the highest bacterial survival and wood having the least survival.

    • Antibacterial product – wipes > sprays, with wipes having highest bacterial survival

    The products ability to decontaminate the surfaces was wood > glass >> plastic with wood having the best decontamination rate and plastic the least
    This was presumably because of the uneven surface of the plastic. Wood apparently has some intrinsic antibacterial properties and also the porous nature allows the bacteria to penetrate the wood and not be recoverable on the surface thereby decreasing contamination.
    The study also found that the one antibacterial product that did not perform as well as the other products had confusing consumer instructions and the authors felt that this could contribute to an even higher rate of continued contamination when using these products.

    Childcare centers and other settings often use bleach as a disinfectant because it is inexpensive and easy to use. The recommendation is to mix 1/4 cup (2 ounces) household bleach in 1 gallon (128 ounces) of water and dispense by a spray bottle. For smaller amounts 1 tablespoon (15 ml) in 1 quart (32 ounces) of water can be used. The solution must be mixed fresh everyday because the chlorine evaporates.
    The bleach solution should contact the surface for 2 minutes or longer to provide disinfection.

    Questions for Further Discussion
    1. Does using alcohol-based handrubbing product increase or decrease the skin condition (i.e. irritation) of health care providers?
    2. How can household sponges be appropriately cleaned?
    3. How long should hands be washed or rubbed for?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Germs and Hygiene
    and Food Contamination and Poisoning

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Wilson E. Child Care Home: Disease Prevention. National Network for Child Care. Available from the Internet at http://www.nncc.org/Health/cch.disease.html (rev. 1996, cited 5/14/2007).

    Boyce JM, Pettet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR. October 25, 2002 / 51(RR16);1-44. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm (cited 5/14/2007).

    Hand Hygiene Resource Center. Available from the Internet at http://www.handhygiene.org/ (rev. 2/2/2007, cited 5/14/2007).

    Girou E,
    Loyeau S,
    Legrand P,
    Oppein F,
    Brun-Buisson C.
    Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial.
    BMJ. 2002:17; 325(7360):362.

    Larson EL,
    Cimiotti J,
    Haas J,
    Parides M,
    Nesin M,
    Della-Latta P,
    Saiman L.
    Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.
    Arch Pediatr Adolesc Med. 2005;159(4):377-83.

    Devere E,
    Purchase D.
    Effectiveness of domestic antibacterial products in decontaminating food contact surfaces.
    Food Microbiol. 2007;24(4):425-30.

    ACGME Competencies Highlighted by Case

  • Patient Care

    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 25, 2007

  • Does She Still Need Antibiotics for Her Heart?

    Patient Presentation
    A 9-year-old female came to clinic for her health maintenance examination. She was doing well.
    She had a history of atrial septal defect that she had repaired by a prosthetic device placed by an interventional cardiology procedure 2 years ago.
    She had taken prophylactic antibiotics in the past for dental procedures, but her mother heard on the news that there were new guidelines and wanted to know if her daughter needed to continue to take the antibiotics.
    The past medical history was otherwise normal.
    The pertinent physical exam showed a thin female with growth percentiles in the 10-25%. Her cardiac examination showed a regular rate and rhythm without murmurs. Her upper extremity pulses were equal to her lower extremity pulses.
    The diagnosis of a healthy female with stable, repaired, atrial septal defect was made. The physician was not aware of the new recommendations. He went to the American Dental Association’s website which gave him an overview of the recommendations and then he also accessed the new guidelines from the American Heart Association.
    Since she was more than 2 years out from her procedure, she was not deemed to be at highest risk and therefore prophylactic antibiotics were not recommended for dental procedures or other procedures.

    Discussion
    The American Heart Association updated their prophylactic antibiotics guidelines for infective endocarditis (IE) prevention in May 2007. The guidelines are aimed at patients with the greatest risks, and eliminate patients with fewer risks who previously had prophylactic antibiotics recommended.
    The Committee recommended changes after a literature evaluation. The changes were recommended based upon the risk/benefit balance of potential adverse side effects to the antibiotics verses risk of developing IE.
    The main reasons for the new recommendations are that : 1. IE is more likely to be caused by activities of daily living (such as toothbrushing) than by various medical procedures (e.g. dental, gastrointestinal or genitourinary), 2. prophylaxis if given may prevent a very small number of IE cases and the risks of prophylactic antibiotic therapy outweigh the benefits,
    and, 3. “maintenance of oral health and hygiene may decrease the incidence of bacteremia and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.”

    Infective endocarditis is a serious, potentially life-threatening but uncommon condition.
    It is thought to be caused by a series of events where there is endothelial damage on the cardiac valve or elsewhere, production of nonbacterial thrombosis at the site of the endothelial damage, bacteria from a bacteremia in the bloodstream that then adheres to the thrombosis and finally proliferation of the bacteria within the thrombosis forming a vegetation.

    Learning Point
    The cardiac conditions associated with the highest risk of adverse outcome from IE for which antibiotic prophylaxis for dental procedures is recommended are:

    • Previous IE
    • Prosthetic cardiac valve
    • Congenital heart disease (CHD)
      • Unrepaired cyanotic CHD including palliative shunts and conduits
      • Completely repaired CHD defect with prosthetic material or device, whether placed by catheter intervention or surgery, during the first 6 months after the procedure. (Endothelialization of the prosthetic material occurs during the first 6 months after the procedure so that prophylaxis is needed during this time period only.)
      • Repaired CHD that has residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
    • Cardiac transplantation recipients who develop cardiac valvulopathy

    Note: except for the CHD conditions noted above, antibiotic prophylaxis is NOT RECOMMENDED for any other CHD conditions.

    Dental procedures for which antibiotic prophylaxis is recommended are:

    • All dental procedures that involve manipulation of the gingival tissue or the periapical region of the teeth or perforation of the oral mucosa in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE listed above.

    Dental procedures for which antibiotic prophylaxis is not recommended are:

    • Anesthesia (routine) through non-infected tissue
    • Dental radiographs, taking of
    • Appliances, placement of removable prosthodontic or orthodontic
    • Appliances, adjustment of orthodontic
    • Brackets, placement of orthodontic
    • Deciduous teeth shedding
    • Bleeding from trauma to the lips or oral mucosa

    Recommendations for respiratory tract, skin, musculoskeletal procedures

    • Prophylactic antibiotics are recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE listed above.

    Recommendations for gastrointestinal or genitourinary procedures

    • Prophylactic antibiotics solely to prevent IE is not recommended during gastrointestinal or genitourinary procedures.
    • For patient with patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE previously listed above who are being treated with antibiotics for other reasons, may have antibiotics that prevent IE considered in the overall antibiotic treatment plan.

    Questions for Further Discussion
    1. What U.S. government agency produces the National Guideline Clearinghouse website that lists current guidelines from multiple institutions and organizations?
    2. What are the five T’s of congenital heart disease?
    3. What medications are recommended for treatment of IE?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Endocarditis
    and Congenital Heart Defects.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    American Dental Association. Infective Endocarditis. Available from the Internet at http://www.ada.org/prof/resources/topics/infective_endocarditis.asp (rev. 4/19/07, cited 5/2/07).

    American Heart Association Rheumatic Fever,
    Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular
    Disease in the Young, and the Council on Clinical Cardiology, Council on
    Cardiovascular Surgery and Anesthesia, and the Quality of Care and
    Outcomes Research Interdisciplinary Working Group. Prevention of Infective Endocarditis
    Guidelines. Circulation. 2007;115: Available from the Internet at http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095 (cited 5/3/07).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 18, 2007