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Racemic epinephrine use in croup and disposition
Original Contributions
Racemic Epinephrine Use in Croup and Disposition PHILLIP B. KELLEY, MD,* JOSEPH E. SIMON, MD*t The purpose of this study was to determine the effectiveness of a protocol for the outpatient management of laryngotracheitis (croup) using racemic epinephrlne and steroids. The authors retrospectively reviewed fifty consecutive charts of children with croup who were treated under this protocol in the Scottish Rite Children’s Medical Center Emergency Deparlment (Atlanta, GA) and discharged to home after 2 hours of observation. Forty-seven of the 50 children had strider at rest and/or retracting at rest on presentation to the emergency department. Forty-seven of the 50 patients did not require further medical care within 48 hours. One patient required another emergency visit and addltional treatment with racemlc epinephrine. Two patients were lost to follow-up. This study suggests that selected children presenting with croup and significant distress may be effectively treated with racemlc epinephrlne and steroids, observed for at least 2 hours, and safely discharged home. (Am J Emerg Med 1992;lO: 181-183. Copyright 0 1992 by W.8. Saunders Company)
Croup or laryngotracheitis is a common diagnosis in the fall and winter months in the emergency department. This condition is treated with supportive measures in mild cases and with aerosolized racemic epinephrine (RE) and corticosteroids in more severe instances. Many studies have examined the efficacy of these measures.‘.’ Aerosolized RE is associated with a rebound phenomenon in which the upper airway obstruction may return to an equal or greater extent compared with initial presentation.2,4 For this reason it is currently recommended to hospitalize children for observation after an initial treatment with RE.2,4 For the past 3 years at Scottish Rite Children’s Medical Center (SRCMC, Atlanta, GA) our protocol has permitted children who have received RE to be discharged after 2 hours of observation if certain clinical criteria were met. This study retrospectively reviews our experience with this protocol. METHODS Scottish Rite Children’s Medical Center is a 136-bed tertiary care children’s hospital. The emergency department at SRCMC cared for 30,000 patients during 1989. A retrospective chart review was conducted of consecutive children diFrom the *Scottish Rite Children’s Medical Center, Atlanta, GA; and tthe Medical College of Georgia, Augusta, GA. Manuscript received May 23, 1991; revision accepted October 21, 1991. Presented to the Section on Emergency Medicine, American Academy of Pediatrics, Boston, October 1990. Address reprint requests to Dr Simon, Scottish Rite Children’s Medical Center, 1001 Johnson Ferry Rd NE, Atlanta, GA 30363. Key Words: laryngotracheitis, racemic epinephrine, steroids. Copyright 0 1992 by W.B. Saunders Company 0735-6757/92/l 003-0001$5.00/O
agnosed with croup during the last 4 months of 1989. Historic data collected included age, sex, fever, nature of cough, etc. Clinical data collected both on initial presentation and after at least 2 hours of observation included evaluation of respiratory distress as evidenced by degree of stridor and intercostal retractions. Unfortunately, the retrospective design precluded determination of a croup score or other more objective measurement of the patients’ status on presentation. The data extracted from each chart on initial presentation was based upon the physician’s examination. This generally occurred, per protocol, after a period of mist therapy while awaiting physician examination. The duration of mist therapy could not be determined from our records. Diagnosis, though based on the treating physician’s clinical impression, was well supported by both the clinical findings in the chart and the patient’s subsequent course. Additional data collected included the number of RE aerosols, the use of corticosteroids, and the dosages used for each drug. Children who did not receive RE, or who were not observed for at least 2 hours, were tallied but excluded from the primary study group. Children requiring admission to the hospital were also tallied but excluded from the primary study group, except for one child who was admitted for an operative procedure already scheduled for the following morning. She would have been otherwise discharged. Follow-up consisted of phone calls to parents asking whether the child required another visit to a doctor or emergency department within 48 hours after being treated at SRCMC. If the answer was in the affirmative they were then asked whether the child required an additional breathing treatment and/or admission to the hospital. The primary study group consisted of 50 children who were treated consecutively with RE, observed at least 2 hours, and discharged home, with or without corticosteroid treatment, and with standard home-going instructions for the treatment of croup. RESULTS Three hundred eighty-five patients were seen for croup during the study period. Sixty-seven (17%) were admitted. Two hundred sixty-eight patients (70%) discharged home did not fulfill the study criteria. (Most did not require RE therapy.) Of the 50 that were included, 33 (66%) were boys and 17 (34%) were girls. Thirty-one (62%) were O-36months old, nine (18%) were 37-60 months old, and 10 (20%) were older than 60 months. At presentation 47 of these 50 children (94%) had stridor at 161
AMERICAN
182
JOURNAL
rest. Twenty-nine patients presented with retractions. Twenty-eight patients had both stridor at rest and retractions. Two patients had neither. In these two the triage nurse heard stridor. In one, the physician appreciated stridor on forced inspiration. In the other the physician found no stridor. In one child with lower intercostal retractions and no stridor at rest the triage nurse heard stridor while the physician noted stridor when agitated. In seven children who presented with stridor at rest it could not be ascertained from the chart whether or not retractions were present (see Table 1). We characterized mild distress as lower intercostal retractions, moderate distress as upper intercostal retractions, and severe distress as requiring assisted ventilation. The policy at SRCMC for the past 2 years has allowed selected patients to be discharged if, 2 hours after receiving RE, they were free of stridor and intercostal retractions at rest and appeared clinically well. One child was discharged with lower intercostal retractions, and five children were discharged with stridor at rest, contrary to written policy. The child discharged with stridor and retractions as documented by nurses’ notes was described by the physician as “chest-clear.” None of these children were subsequently hospitalized. One child required retreatment within 48 hours and was then discharged without sequelae. At her initial visit she was discharged without stridor or respiratory distress. Forty-six of the patients (92%) were discharged with steroid therapy. Seventeen patients were discharged on prednisolone with an average daily dose of 2.1 mg/kg. Twentylive patients were discharged after administration of intramuscular dexamethasone, with an average dose of .54 mg/ kg. Two patients received both dexamethasone and prednisolone. One patient received 2 mg/kg of methylprednisolone. Another patient received prednisone in a dosage that could not be ascertained from the chart. Forty-seven (94%) patients required no additional therapy within 48 hours of discharge. Thirty-seven did not seek follow-up. Eight returned to their private pediatrician and required no treatment. Subsequent oflice records of two additional patients revealed no evidence of recurrence of respiratory distress or stridor. One patient returned to the SRCMC emergency department within 48 hours and was treated with a second nebulization of RE and discharged home again. Two patients were lost to follow-up. The average charge for the visits of these 50 patients was $235.93. Of the patients admitted for croup the average charge per day was $1,311.70, with an average stay of 1.2 days. TABLE 1.
Clinical
Status
on Presentation
and
Discharge
No. of Patients NO Distress
No stridor at rest Stridor at rest Uncertain NOTE:
Numbers
2 (43) 12 (4) 0 (2)
Mild
Moderate
SWWe
Uncertain
1 (0)
0 (0)
0 (0)
0 (0)
4 (0)
0 (0)
7 (0)
0 (0)
0 (0)
0 (0)
24(l)
in parentheses
0 (0)
indicate
discharge
status.
OF EMERGENCY
MEDICINE
n Volume
10, Number
3
n May
1992
DISCUSSION Since Adair first reported the efficacy of RE by intermittent positive-pressure breathing (IPPB) in the treatment of croup there have been live double-blind randomized trials of the modality.s*6 Four of the five found that RE was successful in decreasing the upper airway obstruction found in croup. 1*2*4*7Skolnik points out that the study showing no effect on croup did not address the time elapsed between treatment and assessment5z8 One study demonstrated that nebulization is as effective as IPPB.’ Aerosolized RE is now accepted therapy in the treatment of croup. That the 50 patients in our study who received RE and were discharged did, indeed, have croup is based upon the clinical impression of the treating physician, the response to RE, and the patients’ subsequent course. The only challenge to this assumption might come from those who have attempted to define laryngotracheitis (croup) and spasmatic croup as separate disease entities.’ Skolnik, however, argues convincingly that these are the same disease but at different ends of a clinical spectrum, since they are similar in pathophysiology, infectious origin, and clinical symptomatology.5 Our study assumes one disease entity. In 1971 Adair reported that up to one third of patients with croup treated with RE by IPPB could be subsequently discharged.6 Since then, however, numerous investigators have reported that within 2 hours of treatment patients can experience a “rebound” phenomenon to a croup score equivalent to that on presentation or worse. Taussig and colleagues described 11 of 13 patients with croup scores which had deteriorated 2 hours after treatment.4 Westley et al reported no difference 2 hours after treatment between patients treated with saline and patients treated with RE, even though shortly after treatment the RE-treated patients were significantly improved.’ Fogel and coworkers also found no difference in croup score when comparing pretreatment scores with 2 hours’ posttreatment scores.* These data have precipitated the general practice of hospitalizing any child who receives RE as therapy for croup, regardless of posttreatment clinical status. Fogel and coworkers state, “Because of the transient nature of the response, we recommend that racemic epinephrine therapy be used only for hospitalized patients under close observation and not for patients in an outpatient setting.“’ Fleisher et al do “. . . not advocate the administration of racemic epinephrine to children in the emergency department who are not being hospitalized.“” Although controversial in the past, recent studies suggest that steroids are effective in the treatment of croup.3,7V” For example, in a prospective randomized double-blind study using a dose of .6 mg/kg dexamethasone intramuscularly, Super et al found a decrease in croup score and in the need for further RE treatments in hospitalized patients.3 Forty-six of our patients received various steroids. This probably contributed to the uneventful posttreatment course experienced by all but one of our patients, and should be included in the regimen of any child discharged after RE treatment. The child who required retreatment received .54 mg/kg dexamethasone intramuscularly. Our data suggest that children with croup can be safely discharged to home after being given RE and steroids in
KELLEY AND SIMON n CROUP: RACEMIC EPINEPHRINE AND DISPOSITION
therapeutic doses if: (1) they are observed for 2 hours after treatment, (2) they are free of stridor and retracting, and (3) they have access to appropriate follow-up care. The majority of the patients presenting to the SRCMC emergency department are followed by private pediatricians. Thus, close follow-up care was perhaps more easily guaranteed in our setting than for a patient population which relies on clinic follow-up. In addition to the obvious psychosocial benefits of not hospitalizing these patients, there are also economic benetits. In our study the savings per child, assuming only 1 day of hospitalization for croup, was $1,115. Extrapolated to the nation as a whole the cost benefit would be profound, given the frequency of hospitalization for children with croup in the fall and winter months. The authors gratefully acknowledge Jacqueline R. Medina.
the secretarial
assistance of
REFERENCES 1. Westley CR, Cotton EK, Brooks JG: Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child 1978;132:484-487 2. Fogel JM, Berg IJ, Gerber MA, et al: Racemic epinephrine in the treatment of croup: Nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr 1982;101:1028-1030
183
3. Super DM, Cartelli NA, Brooks LJ, et al: A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis. J Pediatr 1989;115:323328 4. Taussig LM, Castro 0, Beaudry PH, et al: Treatment of Iaryngotracheobronchitis (croup). Am J Dis Child 1975;129:790793 5. Skolnik NS: Treatment of croup: A critical review. Am J Dis Child 1989;143:1045-1049 6. Adair JC, Ring WH, Jordan WS, et al: Ten year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg 1971;50:649-654 7. Kuusela A, Vesikari T: A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup. Acta Peadiatr Stand 1988;77:99104 8. Gardner HG, Powell KR, Roden VJ, et al: The evaluation of racemic epinephrine in the treatment of infectious croup. Pediatrics 1973;52:52-55 9. Cherry JD: The treatment of croup: Continued controversy due to failure of recognition of historic, ecologic, etiologic and clinical perspectives. J Pediatr 1979;94:352-354 10. Fleisher GR, Ludwig S, Henretig FM, et al (eds): Pediatric Emergency Medicine. Baltimore, MD, Williams and Wilkins, 1988, pp 433-435 11. Kairys SW, Olmstead EM, O’Connor GT: Steroid treatment of laryngotracheitis: A meta analysis of the evidence from randomized trials. Pediatrics 1989;83:683-693
Racemic Epinephrine Use in Croup and Disposition PHILLIP B. KELLEY, MD,* JOSEPH E. SIMON, MD*t The purpose of this study was to determine the effectiveness of a protocol for the outpatient management of laryngotracheitis (croup) using racemic epinephrlne and steroids. The authors retrospectively reviewed fifty consecutive charts of children with croup who were treated under this protocol in the Scottish Rite Children’s Medical Center Emergency Deparlment (Atlanta, GA) and discharged to home after 2 hours of observation. Forty-seven of the 50 children had strider at rest and/or retracting at rest on presentation to the emergency department. Forty-seven of the 50 patients did not require further medical care within 48 hours. One patient required another emergency visit and addltional treatment with racemlc epinephrine. Two patients were lost to follow-up. This study suggests that selected children presenting with croup and significant distress may be effectively treated with racemlc epinephrlne and steroids, observed for at least 2 hours, and safely discharged home. (Am J Emerg Med 1992;lO: 181-183. Copyright 0 1992 by W.8. Saunders Company)
Croup or laryngotracheitis is a common diagnosis in the fall and winter months in the emergency department. This condition is treated with supportive measures in mild cases and with aerosolized racemic epinephrine (RE) and corticosteroids in more severe instances. Many studies have examined the efficacy of these measures.‘.’ Aerosolized RE is associated with a rebound phenomenon in which the upper airway obstruction may return to an equal or greater extent compared with initial presentation.2,4 For this reason it is currently recommended to hospitalize children for observation after an initial treatment with RE.2,4 For the past 3 years at Scottish Rite Children’s Medical Center (SRCMC, Atlanta, GA) our protocol has permitted children who have received RE to be discharged after 2 hours of observation if certain clinical criteria were met. This study retrospectively reviews our experience with this protocol. METHODS Scottish Rite Children’s Medical Center is a 136-bed tertiary care children’s hospital. The emergency department at SRCMC cared for 30,000 patients during 1989. A retrospective chart review was conducted of consecutive children diFrom the *Scottish Rite Children’s Medical Center, Atlanta, GA; and tthe Medical College of Georgia, Augusta, GA. Manuscript received May 23, 1991; revision accepted October 21, 1991. Presented to the Section on Emergency Medicine, American Academy of Pediatrics, Boston, October 1990. Address reprint requests to Dr Simon, Scottish Rite Children’s Medical Center, 1001 Johnson Ferry Rd NE, Atlanta, GA 30363. Key Words: laryngotracheitis, racemic epinephrine, steroids. Copyright 0 1992 by W.B. Saunders Company 0735-6757/92/l 003-0001$5.00/O
agnosed with croup during the last 4 months of 1989. Historic data collected included age, sex, fever, nature of cough, etc. Clinical data collected both on initial presentation and after at least 2 hours of observation included evaluation of respiratory distress as evidenced by degree of stridor and intercostal retractions. Unfortunately, the retrospective design precluded determination of a croup score or other more objective measurement of the patients’ status on presentation. The data extracted from each chart on initial presentation was based upon the physician’s examination. This generally occurred, per protocol, after a period of mist therapy while awaiting physician examination. The duration of mist therapy could not be determined from our records. Diagnosis, though based on the treating physician’s clinical impression, was well supported by both the clinical findings in the chart and the patient’s subsequent course. Additional data collected included the number of RE aerosols, the use of corticosteroids, and the dosages used for each drug. Children who did not receive RE, or who were not observed for at least 2 hours, were tallied but excluded from the primary study group. Children requiring admission to the hospital were also tallied but excluded from the primary study group, except for one child who was admitted for an operative procedure already scheduled for the following morning. She would have been otherwise discharged. Follow-up consisted of phone calls to parents asking whether the child required another visit to a doctor or emergency department within 48 hours after being treated at SRCMC. If the answer was in the affirmative they were then asked whether the child required an additional breathing treatment and/or admission to the hospital. The primary study group consisted of 50 children who were treated consecutively with RE, observed at least 2 hours, and discharged home, with or without corticosteroid treatment, and with standard home-going instructions for the treatment of croup. RESULTS Three hundred eighty-five patients were seen for croup during the study period. Sixty-seven (17%) were admitted. Two hundred sixty-eight patients (70%) discharged home did not fulfill the study criteria. (Most did not require RE therapy.) Of the 50 that were included, 33 (66%) were boys and 17 (34%) were girls. Thirty-one (62%) were O-36months old, nine (18%) were 37-60 months old, and 10 (20%) were older than 60 months. At presentation 47 of these 50 children (94%) had stridor at 161
AMERICAN
182
JOURNAL
rest. Twenty-nine patients presented with retractions. Twenty-eight patients had both stridor at rest and retractions. Two patients had neither. In these two the triage nurse heard stridor. In one, the physician appreciated stridor on forced inspiration. In the other the physician found no stridor. In one child with lower intercostal retractions and no stridor at rest the triage nurse heard stridor while the physician noted stridor when agitated. In seven children who presented with stridor at rest it could not be ascertained from the chart whether or not retractions were present (see Table 1). We characterized mild distress as lower intercostal retractions, moderate distress as upper intercostal retractions, and severe distress as requiring assisted ventilation. The policy at SRCMC for the past 2 years has allowed selected patients to be discharged if, 2 hours after receiving RE, they were free of stridor and intercostal retractions at rest and appeared clinically well. One child was discharged with lower intercostal retractions, and five children were discharged with stridor at rest, contrary to written policy. The child discharged with stridor and retractions as documented by nurses’ notes was described by the physician as “chest-clear.” None of these children were subsequently hospitalized. One child required retreatment within 48 hours and was then discharged without sequelae. At her initial visit she was discharged without stridor or respiratory distress. Forty-six of the patients (92%) were discharged with steroid therapy. Seventeen patients were discharged on prednisolone with an average daily dose of 2.1 mg/kg. Twentylive patients were discharged after administration of intramuscular dexamethasone, with an average dose of .54 mg/ kg. Two patients received both dexamethasone and prednisolone. One patient received 2 mg/kg of methylprednisolone. Another patient received prednisone in a dosage that could not be ascertained from the chart. Forty-seven (94%) patients required no additional therapy within 48 hours of discharge. Thirty-seven did not seek follow-up. Eight returned to their private pediatrician and required no treatment. Subsequent oflice records of two additional patients revealed no evidence of recurrence of respiratory distress or stridor. One patient returned to the SRCMC emergency department within 48 hours and was treated with a second nebulization of RE and discharged home again. Two patients were lost to follow-up. The average charge for the visits of these 50 patients was $235.93. Of the patients admitted for croup the average charge per day was $1,311.70, with an average stay of 1.2 days. TABLE 1.
Clinical
Status
on Presentation
and
Discharge
No. of Patients NO Distress
No stridor at rest Stridor at rest Uncertain NOTE:
Numbers
2 (43) 12 (4) 0 (2)
Mild
Moderate
SWWe
Uncertain
1 (0)
0 (0)
0 (0)
0 (0)
4 (0)
0 (0)
7 (0)
0 (0)
0 (0)
0 (0)
24(l)
in parentheses
0 (0)
indicate
discharge
status.
OF EMERGENCY
MEDICINE
n Volume
10, Number
3
n May
1992
DISCUSSION Since Adair first reported the efficacy of RE by intermittent positive-pressure breathing (IPPB) in the treatment of croup there have been live double-blind randomized trials of the modality.s*6 Four of the five found that RE was successful in decreasing the upper airway obstruction found in croup. 1*2*4*7Skolnik points out that the study showing no effect on croup did not address the time elapsed between treatment and assessment5z8 One study demonstrated that nebulization is as effective as IPPB.’ Aerosolized RE is now accepted therapy in the treatment of croup. That the 50 patients in our study who received RE and were discharged did, indeed, have croup is based upon the clinical impression of the treating physician, the response to RE, and the patients’ subsequent course. The only challenge to this assumption might come from those who have attempted to define laryngotracheitis (croup) and spasmatic croup as separate disease entities.’ Skolnik, however, argues convincingly that these are the same disease but at different ends of a clinical spectrum, since they are similar in pathophysiology, infectious origin, and clinical symptomatology.5 Our study assumes one disease entity. In 1971 Adair reported that up to one third of patients with croup treated with RE by IPPB could be subsequently discharged.6 Since then, however, numerous investigators have reported that within 2 hours of treatment patients can experience a “rebound” phenomenon to a croup score equivalent to that on presentation or worse. Taussig and colleagues described 11 of 13 patients with croup scores which had deteriorated 2 hours after treatment.4 Westley et al reported no difference 2 hours after treatment between patients treated with saline and patients treated with RE, even though shortly after treatment the RE-treated patients were significantly improved.’ Fogel and coworkers also found no difference in croup score when comparing pretreatment scores with 2 hours’ posttreatment scores.* These data have precipitated the general practice of hospitalizing any child who receives RE as therapy for croup, regardless of posttreatment clinical status. Fogel and coworkers state, “Because of the transient nature of the response, we recommend that racemic epinephrine therapy be used only for hospitalized patients under close observation and not for patients in an outpatient setting.“’ Fleisher et al do “. . . not advocate the administration of racemic epinephrine to children in the emergency department who are not being hospitalized.“” Although controversial in the past, recent studies suggest that steroids are effective in the treatment of croup.3,7V” For example, in a prospective randomized double-blind study using a dose of .6 mg/kg dexamethasone intramuscularly, Super et al found a decrease in croup score and in the need for further RE treatments in hospitalized patients.3 Forty-six of our patients received various steroids. This probably contributed to the uneventful posttreatment course experienced by all but one of our patients, and should be included in the regimen of any child discharged after RE treatment. The child who required retreatment received .54 mg/kg dexamethasone intramuscularly. Our data suggest that children with croup can be safely discharged to home after being given RE and steroids in
KELLEY AND SIMON n CROUP: RACEMIC EPINEPHRINE AND DISPOSITION
therapeutic doses if: (1) they are observed for 2 hours after treatment, (2) they are free of stridor and retracting, and (3) they have access to appropriate follow-up care. The majority of the patients presenting to the SRCMC emergency department are followed by private pediatricians. Thus, close follow-up care was perhaps more easily guaranteed in our setting than for a patient population which relies on clinic follow-up. In addition to the obvious psychosocial benefits of not hospitalizing these patients, there are also economic benetits. In our study the savings per child, assuming only 1 day of hospitalization for croup, was $1,115. Extrapolated to the nation as a whole the cost benefit would be profound, given the frequency of hospitalization for children with croup in the fall and winter months. The authors gratefully acknowledge Jacqueline R. Medina.
the secretarial
assistance of
REFERENCES 1. Westley CR, Cotton EK, Brooks JG: Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child 1978;132:484-487 2. Fogel JM, Berg IJ, Gerber MA, et al: Racemic epinephrine in the treatment of croup: Nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr 1982;101:1028-1030
183
3. Super DM, Cartelli NA, Brooks LJ, et al: A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis. J Pediatr 1989;115:323328 4. Taussig LM, Castro 0, Beaudry PH, et al: Treatment of Iaryngotracheobronchitis (croup). Am J Dis Child 1975;129:790793 5. Skolnik NS: Treatment of croup: A critical review. Am J Dis Child 1989;143:1045-1049 6. Adair JC, Ring WH, Jordan WS, et al: Ten year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg 1971;50:649-654 7. Kuusela A, Vesikari T: A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup. Acta Peadiatr Stand 1988;77:99104 8. Gardner HG, Powell KR, Roden VJ, et al: The evaluation of racemic epinephrine in the treatment of infectious croup. Pediatrics 1973;52:52-55 9. Cherry JD: The treatment of croup: Continued controversy due to failure of recognition of historic, ecologic, etiologic and clinical perspectives. J Pediatr 1979;94:352-354 10. Fleisher GR, Ludwig S, Henretig FM, et al (eds): Pediatric Emergency Medicine. Baltimore, MD, Williams and Wilkins, 1988, pp 433-435 11. Kairys SW, Olmstead EM, O’Connor GT: Steroid treatment of laryngotracheitis: A meta analysis of the evidence from randomized trials. Pediatrics 1989;83:683-693