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PubMed2004

Nutrition support for pediatric patients with inflammatory bowel disease: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology And Nutrition.

Impairment of growth and malnutrition are significant complications of inflammatory bowel disease (IBD) in pediatric patients. Since this topic was last reviewed in these pages (), a number of studies have further explored the epidemiology and pathogenesis of these nutritional complications of IBD in an effort to provide more effective interventions to prevent the long-term consequences of chronic nutrient deficiencies in childhood. In addition, during the past 15 years, the use of selected nutrients and microorganisms (probiotics) as primary or adjunctive therapy for the treatment of IBD has become an emerging area of great interest. The following is a Clinical Report from the Nutrition and Inflammatory Bowel Disease Committees of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Body Height↗
PubMed1998

Results of a vesicoureteral reflux practice pattern survey among American Academy of Pediatrics, Section on Pediatric Urology members.

PURPOSE: We evaluated practice patterns among urologists managing vesicoureteral reflux, and identified areas of consensus and controversy requiring further research. MATERIALS AND METHODS: A 1-page questionnaire addressing various aspects of reflux management, including screening, diagnosis, treatment and followup, was mailed to a cohort of 225 practicing urologists identified by the membership roster of the American Academy of Pediatrics, Section on Pediatric Urology. Coded returned mailers were blindly analyzed and tabulated by 2 reviewers. Questionnaires were subdivided using a coding system by decade (1970s or earlier, 1980s and so forth) of participant membership in the American Urological Association. Select questions were analyzed to determine whether time of training affected the response. RESULTS: Of 225 surveys 155 were returned and usable (overall 60.8% response rate). General agreement exists regarding several important points in the management of vesicoureteral reflux, including evaluation of patients at the initial urinary tract infection (78.1% of respondents), use of voiding cystourethrography and ultrasound at the initial evaluation (99.4 and 96.8%, respectively), and evaluation of sibling reflux (83.2%). Certain absolute and relative indications for surgical intervention require further clarification. Various reimplantation techniques are used today, stents are not placed by the majority of practitioners and significant variations exist in the duration of postoperative hospital stay. CONCLUSIONS: Today there is substantial consensus among urologists on many issues regarding vesicoureteral reflux management. However, the areas of controversy will only be clarified by further scientific and clinical outcomes based research.

Academies and Institutes↗
PubMed1994

Characteristics, workload, and job satisfaction of attending physicians from pediatric emergency medicine fellowship programs. Pediatric Emergency Medicine Collaborative Research Committee.

The purpose of this study was to determine the characteristics of academic Pediatric Emergency Medicine (PEM) faculty, the workload of these physicians, and the perceived effect this workload has had or will have on job satisfaction. A self-administered, seven-page, closed-end survey was used. participants were PEM departments with PEM Fellowship Training Programs. Surveys were completed by 37 PEM departments (84%). The average number of faculty per department was 7.33. Ninety-three percent of the faculty were board certified in Pediatrics, Emergency Medicine, or both. Only 15% of the faculty had an academic rank of associate or full professor. Fifty-four percent of the faculty had less than five years' experience. Average patient census per department was 43,400 per year. Physicians without administrative titles averaged 30 clinician hours per week. Attending physicians covered 85 to 100% of the overnight shifts in 17 programs (52%). Clinical workload was believed to be excessive in 17 programs (46%), with total number of hours given as the most common reason for this excess. In nine of these 17 programs, excess clinical workload had resulted in physician "burnout." Physicians from only eight programs (22%) believed they could practice PEM after 50 years of age. Shift work and overnight shifts were given as the most common reason. Stressed physician groups were significantly associated with programs whose attending physicians covered > or = 85% of the night shifts (P < 0.04) and reported excessive clinical workload (P < 0.002). Job satisfaction perceived by PEM faculty appears to be dependent on addressing the clinical workload and the adverse effects of overnight and shift work.

Burnout, Professional↗
PubMed2001

Risk factors for posttransplant lymphoproliferative disorder (PTLD) in pediatric kidney transplantation: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS).

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD) is an important complication of transplantation. The North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) database has documented 56 cases of PTLD, the largest such series to date. METHODS: We analyzed the available longitudinal and multicenter data in the NAPRTCS database to evaluate the demographic and therapeutic risk factors and the temporal trends for PTLD in children after renal transplantation. RESULTS: The overall incidence of PTLD was 1.2% of all patients or 298/100,000 posttransplantation years of follow-up. However, this incidence increased from 254/100,000 years between 1987 and 1991 to 395/100,000 years from 1992 onwards. In the same periods, the time to PTLD decreased from a median of 356 days (range 843048) to a median of 190 days (range 42-944). PTLD occurred with greater frequency in white children (P=0.003) and in cadaver donor transplants (P=0.019), but there was no significant predilection for gender, younger children (0-5 years), or primary diagnosis. No significant difference was found in the use of anti-T-cell antibodies or in doses of CsA, azathioprine, or prednisone at 1 month, 6 months, and 1 year. Between 1996 and 1997, 69 patients were initiated with tacrolimus. Eight cases of PTLD were identified in these recipients to date (prevalence rate 11.5%), compared with 46/4084 (1.1%) where cyclosporine was used (P<0.0001). CONCLUSIONS: There is a trend towards increasing incidence and earlier occurrence of PTLD in the pediatric renal transplant population. White race and cadaver donor sources are risk factors not reported before. Continued monitoring of tacrolimus immunosuppression is important.

Black or African American↗
PubMed2006

Moral distress in the pediatric intensive care unit: the impact on pediatric nurses.

PURPOSE: The purpose of this paper is to explore the concept of moral distress in particular as it impacts on the pediatric intensive care nurse caught between caring for infants and children who would not otherwise be alive were it not for the advances of modern medical technology, and their personal beliefs concerning the societal value of life at any cost. DESIGN/METHODOLOGY/APPROACH: Describes cases and real incidents to illustrate the moral distress experienced by-these nurses caught between caring for the children and at the same time interacting with the families. Such families are too often living on hope, with a profound faith in the ever advancing world of medical technology to keep loved ones alive with little thought to the consequences. FINDINGS: Suggests that the impact of moral distress on pediatric nurses, particularly as it relates to burnout, may well jeoparidize their ability to deliver effective care and is another unrecognized cost in the medical world. PRACTICAL IMPLICATIONS: Suggests that an ethical approach to care is necessary through hard to answer questions. Due to the fact that such questions are not often addressed, the author suggests consideration be given to medical ethicists to mediate and assist those caught in this dilemma. ORIGINALITY/VALUE: This paper will be of value to those concerned with how medical and life-saving technologies are outstripping our human abilities to comprehend and live with the consequences, and some of the ethical issues that arise.

Alberta↗
PubMed2006

Lessons learned from pediatric residents on a community pediatrics rotation.

Pediatric residents on block community rotations completed journals and exit interviews regarding their perceptions of the rotation. Three common themes present in residents' responses were identified via qualitative analysis: enlightenment and attitude change, impact of direct participation, and rotation challenges. Advantages and disadvantages to block rotations in community pediatrics, and their relationship to learning child advocacy skills, are discussed. Finally, the use of journals as a tool to document systems-based practice competency is explored.

Attitude of Health Personnel↗
PubMed2002

Hypnosis in pediatrics: applications at a pediatric pulmonary center.

BACKGROUND: This report describes the utility of hypnosis for patients who presented to a Pediatric Pulmonary Center over a 30 month period. METHODS: Hypnotherapy was offered to 303 patients from May 1, 1998 - October 31, 2000. Patients offered hypnotherapy included those thought to have pulmonary symptoms due to psychological issues, discomfort due to medications, or fear of procedures. Improvement in symptoms following hypnosis was observed by the pulmonologist for most patients with habit cough and conversion reaction. Improvement of other conditions for which hypnosis was used was gauged based on patients' subjective evaluations. RESULTS: Hypnotherapy was associated with improvement in 80% of patients with persistent asthma, chest pain/pressure, habit cough, hyperventilation, shortness of breath, sighing, and vocal cord dysfunction. When improvement was reported, in some cases symptoms resolved immediately after hypnotherapy was first employed. For the others improvement was achieved after hypnosis was used for a few weeks. No patients' symptoms worsened and no new symptoms emerged following hypnotherapy. CONCLUSIONS: Patients described in this report were unlikely to have achieved rapid improvement in their symptoms without the use of hypnotherapy. Therefore, hypnotherapy can be an important complementary therapy for patients in a pediatric practice.

Adolescent↗
PubMed2000

Phase I trials in pediatric oncology: perceptions of pediatricians from the United Kingdom Children's Cancer Study Group and the Pediatric Oncology Group.

PURPOSE: To identify areas of concern regarding the conduct of phase I trials, the perceived expectations and motivations of the parents of children entered, the expectations of toxicity and benefit, and the ethical concerns of pediatric hematologists and oncologists in the United Kingdom and North America. METHODS: A survey instrument consisting of 19 open- and closed-ended questions was sent to United Kingdom Children's Cancer Study Group (UKCCSG)- and Pediatric Oncology Group (POG)-affiliated pediatricians. RESULTS: Fifty-three UKCCSG- and 78 POG-affiliated pediatricians responded. Thirty-two UKCCSG and 51 POG respondents had previously entered at least one child into a phase I study. Overall, respondents believed that parents entered their children for medical benefit, altruism, and hope of cure. Although many respondents believed that children could benefit from medical improvement, feelings of altruism, and maintenance of hope, the chance of cure or complete remission was thought to be small. Similarly, parents were thought to potentially benefit through altruism and maintenance of hope. Whereas 83% of UKCCSG respondents indicated that phase I trials were associated with ethical difficulties, this was a concern for 48% of POG respondents. The main ethical concerns of respondents were risk of toxicity, consent of the child, unrealistic hope, and coercion. CONCLUSION: The respondents in this survey expressed mainly ethical concerns regarding the conduct of phase I trials and had realistic expectations of the potential for toxicity and benefit for those children who participate in these studies.

Adult↗
PubMed2004

Treatment of children and adolescents with stage II testicular and stages I and II ovarian malignant germ cell tumors: A Pediatric Intergroup Study--Pediatric Oncology Group 9048 and Children's Cancer Group 8891.

PURPOSE: To determine whether children with localized gonadal malignant germ cell tumors (MGCT) stage II testicular and stages I and II ovarian treated with four cycles of standard-dose cisplatin combined with etoposide and low-dose bleomycin (PEB) have an event-free survival (EFS) of at least 85% without significant toxicity. PATIENTS AND METHODS: Between May 1990 and July 1995, eligible pediatric patients with stage II or recurrent from stage I (as a stage II) testicular MGCT and stages I and II ovarian MGCT were enrolled onto this Pediatric Oncology Group and Children's Cancer Group study. PEB chemotherapy consisted of bleomycin 15 U/m2 on day 1, cisplatin 20 mg/m2/d on days 1 to 5, and etoposide 100 mg/m2/d on days 1 to 5. Patients received four cycles of therapy at 21-day intervals. RESULTS: Seventy-four patients with a median age of 10.5 years (range, 8.7 months to 16.7 years) were enrolled. Primary sites included: stage II testicular (n = 17), stage I ovarian (n = 41), and stage II ovarian MGCT (n = 16). Treatment with standard PEB resulted in 6-year EFS of 95% and overall survival (OS) of 95.7%. EFS and OS by primary site were as follows: stage II testicular, 100% and 100%; stage I ovarian, 95.1% and 95.1%; and stage II ovarian, 87.5% and 93.8%, respectively. Two patients died from recurrent disease, and one patient died of secondary acute myelocytic leukemia. Infrequent grade 3 to 4 hematologic toxicity was reported. No grade 3 to 4 renal, pulmonary, or ototoxicity was observed. CONCLUSION: Combination chemotherapy with PEB results in excellent EFS and OS with minimal toxicity in children and adolescents with localized gonadal MGCT.

Adolescent↗
PubMed1997

Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting.

BACKGROUND: Approximately 32 000 nonpowder firearm injuries are reported annually with more than 60% occurring in the pediatric population. Case reports of serious and fatal injuries have been described; however, no large inclusive series have been published. We reviewed an 11-year experience of an urban pediatric emergency department to evaluate the circumstances, spectrum of injuries, and outcomes attributable to nonpowder firearms. METHODS: A retrospective, descriptive case series of all children 18 years of age or younger evaluated at an urban children's hospital from January 1983 through December 1994 were eligible for study. Patients were identified using a computerized database, the National Electronic Injury Surveillance System, and the trauma registry in the department of surgery. Medical records were reviewed to collect demographic information, circumstances of injury, anatomic site and type of injury, treatment, and outcomes for nonpowder firearm injuries. RESULTS: One hundred eighty patients were identified, and a complete data set was available for 166 (92%). The mean age was 12 +/- 3.7 years, 24% of children were <10 years old, and 71% of the children were male. Three patients returned with a second nonpowder firearm injury during the study period. Forty-nine percent of injuries were intentional and 44% of all injuries occurred during the summer and early fall months. The most common sites of injury were the extremity/buttocks (39%), head and neck (33%), thorax (13%), and eye (8%). Serious injuries included intracranial hemorrhage, cardiac right ventricle laceration, hyphema, and abdominal visceral injury (liver laceration, pancreatic laceration, intestinal perforation). The majority of wounds required local wound care, and the children (74%) were discharged from the emergency department. Of the patients admitted to the hospital (27%), 45% required operative intervention. There were no deaths. Seven percent (12/166) of patients sustained some functional deficit with 42% (5/12) the result of an ocular injury. CONCLUSION: The majority of nonpowder firearm injuries are minor; however, the potential for serious injury should not be underestimated. Minor injuries can be treated with local wound care and tetanus prophylaxis, and patients can be discharged from the emergency department. Education of parents and children to the potential risks associated with these weapons is essential. Stricter regulations regarding ownership of nonpowder firearms and mandatory safety instruction should be considered.

Adolescent↗
PubMed1999

Guidelines for the pediatric perioperative anesthesia environment. American Academy of Pediatrics. Section on Anesthesiology.

The American Academy of Pediatrics proposes the following guidelines for the pediatric perioperative anesthesia environment. Essential components are identified that make the perioperative environment satisfactory for the anesthesia care of infants and children. Such an environment promotes the safety and wellbeing of infants and children by reducing the risk for adverse events.

Anesthesia↗
PubMed2002

Pediatric Organ Donation and Transplantation: policy statement: organizational principles to guide and define the child health care system and/or improve the health of all children: Committee on Hospital Care and Section on Surgery. American Academy of Pediatrics.

Pediatric organ donation and organ transplantation can have a significant life-extending benefit to the young recipients of these organs and a high emotional impact on donor and recipient families. Pediatricians should become better acquainted with evolving national strategies involving organ procurement and organ transplantation to help acquaint families with the benefits of organ donation and to help shape public policies that will aid in efforts to provide a system of procurement, distribution, and finance that is fair and equitable to children and adults. Major issues of concern are availability and access; oversight and control; pediatric medical and surgical consultation throughout the organ donation and transplantation process; ethical, social, financial, and follow-up issues; insurance coverage issues; and public awareness of the need for organ donors of all ages.

Adolescent↗
PubMed2005

Intentional injury management and prevention in pediatric practice: results from 1998 and 2003 American Academy of Pediatrics Periodic Surveys.

OBJECTIVE: Intentional injuries are significant causes of pediatric morbidity and mortality in the United States. A 1998 American Academy of Pediatrics (AAP) survey identified child abuse, domestic violence, and community violence as concerns for pediatricians, although the majority of pediatricians also reported feeling unprepared to manage these issues. A second AAP survey in 2003 analyzed trends in pediatrician experience and attitudes related to these issues. METHODS: Surveys were sent to national random samples of AAP members in 1998 (n = 1629) and 2003 (n = 1603); response rates were 62% and 53%, respectively. Surveys measured pediatrician experience in the past 12 months in managing injuries caused by child abuse, domestic violence, and community violence. Attitudes regarding available resources and adequacy of training about intentional injury management were also collected. Trends between surveys were analyzed using chi2 analysis. RESULTS: The proportion of pediatricians who reported treatment of intentional injuries increased between surveys. The percentage of pediatricians who indicated that screening for domestic violence and community violence risk should be included in routine health visits increased from 66% to 72% and 71% to 77%, respectively. Confidence in ability to identify and manage injuries that were caused by domestic violence and community violence increased but remained low, whereas the proportion of pediatricians who expressed confidence in ability to identify child abuse decreased (65% vs 60%). CONCLUSIONS: Despite overall improvement in acceptance of intentional injury prevention in routine care as well as confidence in intentional injury management, pediatrician confidence to identify and manage intentional injuries remains low.

Attitude of Health Personnel↗
PubMed2001

Behavior of pediatric dental patients throughout the course of restorative dental treatment in a private pediatric dental practice.

The purpose of this study was to describe and quantify patient behavior patterns observed throughout restorative dentistry appointments in a private pediatric dental practice. Patient behavior throughout the course of the first restorative dental visit was recorded using the Sarnat Behavior Scale. Behavior of patients in age groups 0 to 5 (0 to 60 months), 5 to 8 (61 to 96 months) and 8 to 12 (97 to 144 months) was noted at the start of the visit, during the procedure and when the patient was dismissed. Socio-demographic variables such as sex and method of payment as an indicator of socio-economic status were also considered. In addition, it was also noted whether, the child was referred by a general dentist. The results showed that the percentage of patients having Sarnat scores of 3, 4 or 5 (S345), which is indicative of negative behavior, increased after the start of the visit and then decreased to a lower level when the patient was dismissed. This observation was the same for all age groups, although the percentage of patients exhibiting negative behavior during all phases of the restorative appointment decreased with increasing age. In conclusion, pediatric dental patient behavior changes throughout the course of restorative dental treatment. There is an increase in negative behavior, while the teeth are being restored, which then decreases to levels below those observed at the start of the visit. This is related to age more than socio-economic or other factors confirming that as the child ages, the incidence of negative behavior decreases, but the pattern of change during the course of the restorative visit is the same regardless of age.

Age Factors↗
PubMed2000

Survey of dental treatments for pediatric patients referred to the pediatric dental clinic of a dental school hospital.

This survey was conducted to clarify which dental treatments in children are regarded as difficult by general dentistry practitioners. The subjects were 615 children who first visited Tokyo Dental College Chiba Hospital from January 1995 to August 1999 with reference letters. There were 615 children in the study; 571 (92.8%) came from Chiba City where our hospital is located and the 11 regions surrounding Chiba City. The prime reasons for referral in the order of frequency were treatments of dental caries, malalignment/malocclusion, traumatized teeth, supernumerary teeth, retarded eruption/impacted teeth, abnormal direction of erupted teeth, congenitally missing teeth, prolonged retention of deciduous teeth, and abnormal frenulum. Patients with dental caries or traumatized teeth in the deciduous dentition period and those with malalignment/malocclusion, supernumerary teeth, or retarded eruption/impacted teeth in the mixed dentition period were often referred to medical organizations specializing in pediatric dentistry because of the difficulties in controlling the patients' behavior and in providing adequate treatment. The information about pediatric dental treatments considered difficult by general dentists revealed by this survey appears to be useful and needs to be incorporated in the programs for clinical training of undergraduate students and education of postgraduate students.

Adolescent↗
PubMed1999

American Academy of Pediatrics. Pediatric Practice Action Group and Task Force on Medical Informatics. Privacy protection and health information: patient rights and pediatrician responsibilities.

Pediatricians and pediatric medical and surgical subspecialists should know their legal responsibilities to protect the privacy of identifiable patient health information. Although paper and electronic medical records have the same privacy standards, health data that are stored or transmitted electronically are vulnerable to unique security breaches. This statement describes the privacy and confidentiality needs and rights of pediatric patients and suggests appropriate security strategies to deter unauthorized access and inappropriate use of patient data. Limitations to physician liability are discussed for transferred data. Any new standards for patient privacy and confidentiality must balance the health needs of the community and the rights of the patient without compromising the ability of pediatricians to provide quality care.

Computer Security↗
PubMed2000

[Brain death in pediatric patients--from the viewpoint of pediatric intensive care].

In Japan, "brain death" has been discussed exclusively in connection with organ transplantation. However, the concept of brain death, which emerged with the progress in intensive care medicine, should be discussed in the context of palliative care in the ICU. It should be recognized that intensive care medicine includes not only life-saving high-tech therapeutic modalities, but also ethical and psycho-social aspects of modern medicine. In order to find out a decent solution to pediatric brain death issues, it is essential to develop pediatric intensive care in Japan.

Brain Death↗
PubMedDate not supplied

Validity of the updated pediatric risk of mortality score (PRISM III) in predicting the probability of mortality in a pediatric intensive care unit.

This study assessed the validity of the PRISM III scoring system in accurately predicting the probability of mortality in a pediatric intensive care unit (PICU) in Taiwan. We collected data from consecutive patients admitted to our PICU during a one-year period from November 1999 through October 2000. Our PICU had 412 admissions including 385 patients (202 boys and 183 girls) with an average age of 53.9 +/- 58.2 months (range: 1 month to 18 years). The most common reason for admission was respiratory failure (26.2%). Almost 60% of the patients had at least one underlying chronic disease. The average duration of stay was 4.52 +/- 8.43 days (range 1 day to 81 days). The average PRISM III score was 5.06 +/- 6.95 (range 0-44). The overall mortality rate in the PICU was 8.17%. The mortality rate was not significantly different from the predicted rate (7.56%) (p=0.65). The efficiency of care was 32.5% and the standardized PICU length of stay ratio (SLOSR) was 1.33. The SLOSR ratio was significantly higher than the predicted rate (p value < 0.001). The PRISM III score was validfor assessing mortality risk of PICU patients in this hospital in Taiwan. However, the SLOSR ratio obtained in this study was higher than predicted. Differences in the patterns of practicing medicine may play an important role in observed PICU length of stay. Special caution is needed in adopting a severity of illness scoring system to assess performance of care, particularly in contexts different from the ones in which the instrument was originally developed. Further study including more pediatric intensive care units and other regions would enable greater generalization of the validity of this instrument.

Adolescent↗