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PubMed2005

Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines.

BACKGROUND: American Pediatric Surgical Association consensus guidelines for children with blunt spleen injuries have been defined and validated in children's hospitals, but large administrative data sets indicate that only 10% to 15% of children with blunt spleen injuries are treated at children's hospitals. We sought to identify the frequency and compare the treatment of children with spleen injury in hospitals with and without recognized trauma expertise, with the aim of identifying a meaningful target for dissemination of benchmarks and consensus guidelines. STUDY DESIGN: State health departments' administrative data sets from California, Florida, New Jersey, and New York were analyzed for 2000, 2001, and 2002. All children with head injury or other nonspleen abdominal injuries requiring surgery were excluded. Injury Severity Scores were determined by ICDMAP-90. RESULTS: There were 3,232 patients with blunt spleen injury. Trauma centers had a significantly lower rate of operation for both multiply injured patients (15.3% versus 19.3%, p < 0.001) and those with isolated injury (9.2% versus 18.5%, p < 0.0001) when compared with nontrauma centers. The operative rates at both trauma centers and nontrauma centers exceed published American Pediatric Surgical Association benchmarks for all children with spleen injury (5% to 11%) and the subset with isolated spleen injury (0% to 3%). Independent risk factors for splenectomy included ages 15 to 19 years (p < 0.002), spleen injury severity (p < 0.0001), and presence of multiple injuries (p < 0.04). Adjusted odds ratio for risk of splenic operation in all patients with spleen injury was 2.122 (95% CI:1.455- 3.096) when treated at a nontrauma center (p < 0.0001). CONCLUSIONS: These multistate discharge data indicate that treatment of children with blunt spleen injury differs significantly when comparing trauma centers and nontrauma centers. Because nearly two-thirds of these children were treated at trauma centers, dissemination of American Pediatric Surgical Association guidelines and benchmarks through state or regional trauma systems may reduce the number of children having operations for splenic injury.

Adolescent↗
PubMed2005

The impact of the 80-hour workweek on pediatric surgical training: an Association of Pediatric Surgery Program Directors-sponsored study.

BACKGROUND/PURPOSE: The aim of this study was to determine the preliminary impact of work hour regulations on pediatric surgical training. METHODS: An anonymous survey was sent to all program directors (PDs) and fellows to identify changes in pediatric surgery fellowship programs. RESULTS: Ninety-three percent of programs and 87% of PDs responded. Thirty programs hired additional personnel, including nurse practitioners, physician assistants, and fellows outside the training program. Thirteen programs reported increased attending coverage. The daily composition of the surgical team has changed, with postcall fellows and residents leaving in the morning. Residents and fellows also take call less frequently. More than 50% of PDs felt that quality of care had declined and three quarters of respondents felt that continuity of care was worse. Half of the respondents feared missed educational opportunities. However, half of the fellows felt more rested, 61% reported more family time, and 22% reported increased social time. In contrast, no PDs perceived life-style improvements. CONCLUSIONS: The work hour regulations have resulted in fundamental changes in pediatric surgical training. Ongoing assessment is needed to prioritize quality of care, improve continuity of care, and track changes in operative, clinical, and didactic experiences of the trainees. The added impact of these changes on the time spent available for commitment to teaching by the faculty should be assessed.

Attitude of Health Personnel↗
PubMed1990

Life beyond pediatrics. Transition of chronically ill adolescents from pediatric to adult health care systems.

Transition from pediatric to adult health care is fraught with difficulties. On the one hand, the adult care system is not properly prepared to receive patients who are survivors of the so-called childhood disorders. On the other hand, patients and families have difficulty leaving the protective environment created by pediatric caregivers, who in turn may have mixed feelings about letting the patients go. Normalization of development and social adaptation for chronically ill adolescents, however, should include a change in the environment in which health care is received. This article examines some of the issues surrounding transition and transfer from pediatric to adult health care systems and propose some avenues toward implementation of such programs.

Adolescent↗
PubMed2001

Rejection profile of recent pediatric renal transplant recipients compared with historical controls: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS).

Historically, higher acute rejection rates, earlier first rejection, and an inability to reverse the rejection characterize pediatric renal transplantation. In recent years, short-term (1-year) graft survival of pediatric renal transplants has steadily improved. To test the hypothesis that these improvements were mediated by changes in acute rejection, we considered the rejection profile of patients who received a renal allograft between 1987 and 1989 (cohort A) and compared it with recipients transplanted between 1997 and 1999 (Cohort B). Cohort A comprised 1469 transplants and cohort B comprised 1189 transplants. Restricting the data to the first year of follow-up, rejection ratios were 1.6 and 0.7, respectively (p < 0.001). Sixty per cent of the later cohort (B) were rejection free at 1 year, compared with 29% for the earlier cohort (A) (p < 0.001). Controlling for donor source, the rejection reversal rate for the later cohort was significantly better than that of the early cohort (p < 0.001). Cumulative distribution of times to first rejection was significantly better for cohort B (p < 0.001). One-year graft survival for cohort B at 94% was significantly better than 80% for cohort A (p < 0.001). We conclude that the improved short-term graft survival is mediated by improvements in the rejection profile in more recently transplanted patients and that this may translate into a better half-life for pediatric renal transplant recipients who received an allograft in the years 1997-99.

Adolescent↗
PubMedDate not supplied

The role of APD in the management of pediatric patients: a report of the North American Pediatric Renal Transplant Cooperative Study.

In an attempt to delineate the role of automated peritoneal dialysis (APD) in the management of the pediatric patient with end-stage renal disease (ESRD), the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) dialysis registry database was queried concerning the incidence and outcome of APD compared to those enrolled who were undergoing continuous ambulatory peritoneal dialysis (CAPD). During the 10-year period from January 1, 1992 to January 1, 2002, 65% of the 4150 index dialysis patients enrolled in NAPRTCS underwent peritoneal dialysis (PD). APD was the dialysis modality of 69% of those choosing PD, indicating that APD was the primary dialysis modality for children during this time interval. This initial comparison of APD and CAPD from the NAPRTCS dialysis registry database indicated that there was a higher percentage of younger patients choosing APD, the time to transplantation was shorter for the CAPD patient, and the incidence and time to first peritonitis episode was significantly (p = 0.006) better in the APD population. There was no difference in the other parameters evaluated between the APD and CAPD patients. These data indicate the significant role of APD in the management of pediatric patients with ESRD, especially in infants, who frequently require an extended period of dialysis prior to reaching the eligibility criteria for transplantation.

Automation↗
PubMed1999

Empirically supported treatments in pediatric psychology: pediatric obesity.

OBJECTIVE: To review the efficacy of existing interventions for pediatric obesity with reference to the Chambless criteria. METHODS: Chambless criteria for determining treatment efficacy were applied to 42 randomized studies involving nonschool-based programs targeting childhood and adolescent weight loss. RESULTS: We summarize the following dimensions of the pediatric obesity treatment literature: description of participants, diagnostic criteria for study participation, experimental design, treatment protocol, treatment outcome, and follow-up. CONCLUSIONS: There is strong evidence for the short- and long-term efficacy of multicomponential behavioral treatment for decreasing weight among children relative to both placebo and education-only treatments. Conclusions about adolescent obesity treatment programs are more tentative as they have been less frequently examined, less rigorously controlled, and usually have not conducted long-term follow-up. Current research appears to be working to identify more efficacious treatments for pediatric obesity by exploring the specific behavioral strategies that will be most effective in modifying children's eating and physical activity habits.

Behavior Therapy↗
PubMed1991

Use of the Pediatric Risk of Mortality score to predict nosocomial infection in a pediatric intensive care unit.

OBJECTIVE: To define infection rates in patients with Pediatric Risk of Mortality (PRISM) scores greater than and less than 10 on admission to the pediatric ICU (PICU). DESIGN: Descriptive. SETTING: An 18-bed PICU admitting patients of all ages except nonsurgical neonates; within a 585-bed tertiary care pediatric hospital. PATIENTS: Patients admitted to the PICU from July 1987 to February 1988 inclusive. Of 685 admitted, 480 were followed for greater than or equal to 72 hr. METHODS: The baseline state of the patients on admission was determined by a designated intensivist using the PRISM score. Other variables included age, length of stay, and hospital day of onset of infection. Infections were identified by a designated intensivist who undertook prospective daily bedside observation, chart, radiographic, and laboratory review. MEASUREMENTS AND MAIN RESULTS: Equal portions of patients had PRISM scores less than and greater than 10. Significantly more infections occurred in the high PRISM population (10.8% vs. 3.4%, p less than .001). This association held through age, service, and length of stay. Sensitivity, specificity, positive and negative predictive values of a PRISM score greater than 10 were 75%, 53%, 11%, and 97%, respectively. Bacteremias accounted for 36% of infections, skin/eye/drain site 22%, respiratory 16%, wound 15%, and urine 9%. The most prevalent organisms were coagulase-negative staphylococci (32%), Pseudomonas aeruginosa (23%), Candida sp. (20%), and S. aureus (9%). CONCLUSIONS: A PRISM score greater than 10 on PICU admission characterizes a population within the PICU at increased risk of infection. However, 93% of patients did not develop infection and thus, a negative predictive value of 97% yields little additional information.

Adolescent↗
PubMed1999

Epidemiology and cost analysis of varicella in Italy: results of a sentinel study in the pediatric practice. Italian Sentinel Group on Pediatric Infectious Diseases.

BACKGROUND: Describing the epidemiology of varicella is relevant to the development of specific prevention strategies and to building up of economic models evaluating the cost:efficiency ratios of these strategies. AIM: Our study was designed to describe the epidemiology of chickenpox among Italian children and to assess the resulting economic and health burden on the country. METHODS: Thirty-nine Italian pediatricians participated in a sentinel network on pediatric infectious diseases representing a total pediatric population of 30 168 children. Each case of varicella observed from January through December, 1997, was recorded. Economic analysis was conducted from the societal point of view. All costs were broken down into two groups: direct and indirect costs. RESULTS: A total of 1599 cases of varicella were reported among children 0 to 14 years old. There were 1266 primary cases (mean age, 4.5 +/- 2 years) and 333 secondary cases (mean age, 3.6 +/- 3.2 years). The global incidence of chickenpox was 51.01/1000/year. Complications were seen in 56 cases (3.5%). Drugs were prescribed in 672 cases. A group of adults (364 susceptible and 193 with uncertain status) were exposed to primary cases. Seventy (12.5%) were eventually infected among whom there were 4 pregnant women. For pediatric patients an average cost of $146.90 (250 400 lire) was estimated; this is largely accounted for by indirect costs. CONCLUSIONS: The epidemiology of varicella in Italy is consistent with that found in previous studies in industrialized countries. Severe complications did not occur in our population. We believe that the health arguments in favor of universal vaccination of children > 18 months of age do not differ in our own country from those of other industrialized nations. Our data could now be incorporated into pharmacoeconomic models to establish cost-efficient strategies for Italy.

Adolescent↗
PubMed2004

Agreement among pediatric health care professionals with the pediatric Canadian triage and acuity scale guidelines.

OBJECTIVES: To compare triage level assignment, using case scenarios, in a pediatric emergency department between registered nurses (RNs) and pediatric emergency physicians (PEPs) based on the Pediatric Canadian Triage and Acuity Scale (P-CTAS) guidelines. To compare triage level assignment of the RNs and PEPs to that done by a panel of experts using the same P-CTAS guidelines. METHODS: A cross-sectional questionnaire survey (55 case scenarios) was sent to all RNs and PEPs working in the emergency department after the P-CTAS was implemented. Participants were instructed to assign a triage level for each case. A priori, all cases were assigned a triage level by a panel of experts using the P-CTAS guidelines. Kappa statistics and the mean number (+/-1SD) of correct responses were calculated. RESULTS: A response rate of 85% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (95% CI) among RNs was 0.51 (0.50-0.52) and was 0.39 (0.38-0.41) among PEPs (P < 0.001). The mean number of correct responses (+/-1SD) for RNs was 64% +/- 27% and for PEPs 60% +/- 22% (P = 0.31). Levels of agreement did not vary according to experience or type of shift work done or work status of RNs and PEPs. CONCLUSIONS: With the introduction of the P-CTAS, the level of agreement and accuracy of triage categorization remained moderate for both RNs and PEPs. The reliability of the P-CTAS needs to be further assessed and the requirements for revisions considered prior to its widespread use.

Acute Disease↗
PubMed2001

Pediatric emergency assessment tool (PEAT): a risk-adjustment measure for pediatric emergency patients.

OBJECTIVE: To develop a multivariable model predicting the level of care required by pediatric patients for use as a risk-adjustment tool in the evaluation of emergency medical services for children. METHODS: A random 10% sample of records of all visits over a 12-month period to a suburban, university-affiliated pediatric emergency department (PED) was selected and abstracted. The outcome variable, level of care received, was categorized in three levels: routine care only (R); diagnostic or therapeutic procedures performed in the ED but patient not admitted (EDT); and admission to hospital (ADM). Predictor variables included information routinely elicited and recorded at the time of triage. Using multinomial logistic regression, a predictive model was derived from a subset of 70% of the selected visits, and was validated in the remaining 30%. RESULTS: The total sample included 2,287 visits. The overall rate of each outcome was R-37%, EDT-53%, and ADM-10%. The final regression model included the following predictors significantly associated with the outcome: age, past medical history, temperature, abnormal respiratory rate or pulse oximetry in triage, chief complaint, and triage level (model likelihood ratio chi-square, 14 df = 332, p < 0.00001, R(2) = 0.14). The number of outcomes was well predicted by the model in both subsamples. Analysis of variance showed a significant association between Pediatric Emergency Assessment Tool (PEAT) score (weighted sum of the predicted probabilities of EDT and ADM) and both ED charges and time spent in the ED (p < 0.001). CONCLUSIONS: A model based on easily and routinely measured variables can accurately predict the level of care rendered in the PED. The predicted probabilities from such a model correlate well with other outcomes of care and may be useful in adjusting for differences in risk when evaluating quality of care.

Child, Preschool↗
PubMed1999

Pediatric blunt carotid injury: a review of the National Pediatric Trauma Registry.

Blunt carotid injury (BCI) is an uncommon yet potentially devastating entity which has received little attention in the pediatric literature. In an attempt to better characterize pediatric BCI, a review of the National Pediatric Trauma Registry was performed. Records were obtained from all children diagnosed with internal or common carotid injury associated with blunt trauma. The incidence of BCI was 0.03% (15 of 57,659 blunt trauma patients). Variables examined included: age, gender, mechanism of injury, associated injuries, various injury severity scores, and outcome. Various injuries were associated with an increase in BCI incidence including chest trauma (4-fold), combined head and chest trauma (6-fold), basilar skull fractures (4-fold), intracranial hemorrhage (6-fold), and clavicle fractures (8-fold). Thirty-three percent of the patients diagnosed with BCI suffered neurological complications directly attributable to their carotid injuries. Current practices regarding screening, diagnosis, and treatment are reviewed.

Adolescent↗
PubMed1992

Screening for psychosocial dysfunction in pediatric practice. A naturalistic study of the Pediatric Symptom Checklist.

This study examined the routine implementation of the Pediatric Symptom Checklist (PSC), a brief questionnaire which screens for psychosocial dysfunction in school-aged children in an outpatient pediatric practice. Results indicated that the PSC was well-accepted by parents and adequately tolerated by busy clinic staff. When the PSC was included as part of the standard procedure for well-child visits, the referral rate for psychosocial problems due to positive PSC scores rose to 12% from the clinic baseline referral rate of 1.5%, a significant increase (P < .01). Half of the children who screened positive on the PSC had not been previously identified by their pediatricians as having psychosocial problems, and more than half had never received any psychological treatment. When implementation of the PSC was discontinued, the referral rate fell to 2%, a rate similar to baseline. The findings suggest that it is possible to incorporate the PSC into routine pediatric practice and that the PSC can help pediatricians identify and better serve children experiencing psychosocial difficulties. The study also suggests that further work is needed to understand the barriers to ongoing implementation.

Adolescent↗
PubMed2000

Identifying nursing research priorities in a pediatric clinical trials cooperative group: the Pediatric Oncology Group experience.

If nurses involved in pediatric oncology clinical trials are to use resources and manpower most effectively, nursing research priorities must be set that meet the nursing care issues of nurses at the bedside. Using a Delphi technique, nurses from the Pediatric Oncology Group (POG) were surveyed in Round 1 to discover patient care concerns or other issues in pediatric oncology nursing related to clinical trials. The 87 research ideas generated were reviewed by a panel of nurse experts, and a total of 57 unique research topics were delineated. These topics were then used for Round 2 of the Delphi study, which identified the top 10 nursing research priorities of the POG nurses participating in the study.

Clinical Trials as Topic↗
PubMed1994

The 1992 APON Delphi study to establish research priorities for pediatric oncology nursing. Association of Pediatric Oncology Nurses.

The Association of Pediatric Oncology Nurses (APON) recently sponsored a two-wave Delphi study to identify the most important research priorities for pediatric oncology nursing. Seventy-five research priorities were rated for importance by 227 APON members. The majority of these members were inpatient or ambulatory care nurses who had been in pediatric oncology more than 25 months. The top 10 research priorities were primarily about nursing procedures and psychosocial care needs of patients and families. The top priority was to "measure the quality of life and late effects of treatment in long-term survivors of childhood cancer." Study findings will be used to encourage researchers to conduct research on these priorities and to encourage funding organizations to support research related to these priorities.

Child↗
PubMedDate not supplied

Pediatric residents buckle up: a child safety seat training program for pediatric residents.

OBJECTIVES: To assess the effectiveness of supervised installation of child safety seats (CSSs) as a teaching tool for pediatric residents and to evaluate acceptance of this hands-on learning experience. METHODS: Pediatric residents were divided into an intervention group and a control group. All residents completed an initial questionnaire regarding knowledge about CSS use. The intervention group listened to a CSS lecture, viewed a video, and installed CSSs under the supervision of certified CSS technicians. The control group received no intervention. A second questionnaire was administered to all residents. We compared the knowledge gained since the initial questionnaire. The intervention group answered questions regarding their acceptance of this learning experience. RESULTS: Sixty-one residents participated in the study. Most residents had never installed a CSS and felt uncomfortable with their CSS knowledge. The percentage of the intervention group that received a passing score for knowledge increased from 3% initially to 97% on the posttest (P <.001). There was no change in the passing rate of the control group. The intervention group rated the CSS installation session as extremely helpful. CONCLUSION: A hands-on educational program can be an effective, well-accepted method for increasing pediatric residents' knowledge about CSS use.

Adult↗
PubMed1997

Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada Study.

OBJECTIVE: To determine nosocomial transmission of respiratory syncytial virus (RSV) in Canadian pediatric hospitals, outcomes associated with nosocomial disease, and infection control practices. DESIGN: A prospective cohort study in the 1992 to 1994 winter respiratory seasons. SETTING: Nine Canadian pediatric university-affiliated hospitals. PARTICIPANTS: Hospitalized children with symptoms of lower respiratory tract infection (at least one of cough, wheezing, dyspnea, tachypnea, and apnea) and RSV antigen identified in a nasopharyngeal aspirate. RESULTS: Of 1516 children, 91 (6%) had nosocomial RSV (NRSV), defined as symptoms of lower respiratory tract infection and RSV antigen beginning >72 hours after admission. The nosocomial ratio (NRSV/[com-munity-acquired RSV {CARSV})] + NRSV) varied by site from 2.8% to 13%. The median length of stay attributable to RSV for community-acquired illness was 5 days, but 10 days for nosocomial illness. Four children with NRSV (4. 4%) died within 2 weeks of infection, compared with 6 (0.42%) with CARSV (relative risk = 10.4, 95% confidence interval: 3.0, 36.4). All sites isolated RSV-positive patients in single rooms or cohorted them. In a multivariate model, no particular isolation policy was associated with decreased nosocomial ratio, but gowning to enter the room was associated with increased risk of RSV transmission (incidence rate ratio 2.81; confidence interval: 1.65, 4.77). CONCLUSIONS: RSV transmission risk in Canadian pediatric hospitals is generally low. Although use of barrier methods varies, all sites cohort or isolate RSV-positive patients in single rooms. Children with risk factors for severe disease who acquire infection nosocomially have prolonged stays and excess mortality.

Canada↗
PubMed2001

American Academy of Pediatrics. The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care. Committee on Psychosocial Aspects of Child and Family Health.

In 1993, the American Academy of Pediatrics adopted the policy statement "The Pediatrician and the 'New Morbidity.'" Since then, social difficulties, behavioral problems, and developmental difficulties have become a main part of the scope of pediatric practice, and recognition of the importance of these areas has increased. This statement reaffirms the Academy's commitment to prevention, early detection, and management of behavioral, developmental, and social problems as a focus in pediatric practice.

Adolescent↗
PubMed2004

Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System.

OBJECTIVE: To examine whether increasing duration of breastfeeding is associated with a lower risk of overweight in a low-income population of 4-year-olds in the United States. METHODS: Visit data were linked to determine prospectively the duration of breastfeeding (up to 2 years of age) and weight status at 4 years of age. Overweight among 4-year-old children was defined as a body mass index (BMI)-for-age at or above the 95th percentile based on the 2000 Centers for Disease Control and Prevention growth charts. Logistic regression was performed, controlling for gender, race/ethnicity, and birth weight. In a subset of states, links to maternal pregnancy records also permitted regression analysis controlling for mother's age, education, prepregnancy BMI, weight gain during pregnancy, and postpartum smoking. Data from the Pediatric Nutrition Surveillance System, which extracts breastfeeding, height, and weight data from child visits to public health programs, were analyzed. In 7 states, data were linked to Pregnancy Nutrition Surveillance System data. A total of 177 304 children up to 60 months of age were included in our final pediatric-only analysis, and 12 587 were included in the pregnancy-pediatric linked analysis. RESULTS: The duration of breastfeeding showed a dose-response, protective relationship with the risk of overweight only among non-Hispanic whites; no significant association was found among non-Hispanic blacks or Hispanics. Among non-Hispanic whites, the adjusted odds ratio of overweight by breastfeeding for 6 to 12 months versus never breastfeeding was 0.70 (95% confidence interval: 0.50-0.99) and for >12 months versus never was 0.49 (95% confidence interval: 0.25-0.95). Breastfeeding for any duration was also protective against underweight (BMI-for-age below the 5th percentile). CONCLUSION: Prolonged breastfeeding is associated with a reduced risk of overweight among non-Hispanic white children. Breastfeeding longer than 6 months provides health benefits to children well beyond the period of breastfeeding.

Adult↗