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PubMedDate not supplied

A comparison of pediatric and adult trauma patients transported by helicopter and ground EMS: managed-care considerations.

INTRODUCTION: There is a paucity of data comparing injured pediatric patients transported by helicopter emergency medical services (HEMS) with patients transported by ground ambulance. The purpose of this study was to compare HEMS pediatric trauma patients to: 1) pediatric patients transported by ground to an urban level-1 trauma center (TC), and; 2) a similar cohort of adult patients. The managed-care consequences of these comparisons are highlighted. METHODS: All trauma patients flown directly from the scene by HEMS from January 1, 1990, to April 30, 1993, were compared to a cohort of trauma patients arriving by ground advanced life support (ALS). All patients were transported to the same level-1 TC. The data collected included the mechanism of injury and the prehospital procedures performed, the injury severity score (ISS), and outcome. RESULTS: There was no difference in the ISS between the HEMS (n = 216) and ground ALS (n = 355) pediatric patients (16.8 vs 17.1; p = 0.55). Adult HEMS patients (n = 202) had significantly higher ISS than did injured adults (n = 1652) transported by ground (18.0 vs 13.6; p < 0.0001). Overall, trauma patients transported by air directly from the scene have a higher ISS than patients transported by ground (17.5 vs 13.6; p < 0.001). CONCLUSIONS: Pediatric patients transported by HEMS were as severely injured as those transported by ground, in contrast to adult patients. We conjecture that since trauma triage schemes classically focus on adults, ground personnel are more selective about which patients are flown to a TC, and less selective for pediatric patients. Trauma centers and HEMS programs should develop pediatric trauma triage protocols that do not overemphasize physiologic parameters.

Adolescent↗
PubMed2004

[Environment and pediatric cancer].

BACKGROUND: Cancer is the final result of the variable combination of two determinants: endogenous or constitutional factors and exogenous or environmental factors. Between 85 % and 96 % of pediatric cancers (PC) are probably associated with environmental risk factors (RF), most of which have not been identified. The spectacular progress made in survival in PC contrasts with the lack of knowledge of the RF implicated in its etiopathogenesis. OBJECTIVE: 1) To analyze up-to-date knowledge of the interaction among environmental RF in the etiopathogenesis of PC, and 2) to inform pediatricians of the "Environment and Pediatric Cancer" research project directed by the Pediatric Environmental Health Specialty Unit of the Hospital Infantil Universitari La Fe in Valencia (Spain). MATERIAL AND METHODS: Current medical records focus almost exclusively on the diagnosis and treatment of cancer. The Pediatric Environmental Medical Record will contain the validated items required to document and presence or absence of endogenous and exogenous RF associated with PC described in the literature, as well as the main human cancerogenic agents identified by the International Agency for Research on Cancer and the US National Toxicology Program. RESULTS: The project aims to determine the frequency of endogenous and exogenous RF associated with PC in Spain. This project will enable hypotheses to be formulated for future epidemiologic case-control and cohort studies in Spain and other European countries, thus stimulating the introduction of educational and preventive policies in the Spanish population. CONCLUSIONS: The project requires the aid of all hospital and non-hospital pediatricians involved in pediatric cancer in informing parents and offering them the possibility of voluntarily collaborating in the "Environment and Pediatric Cancer" project by contacting the Pediatric Health Specialty Unit (Unidad de Salud Medioambiental del Hospital Infantil La Fe de Valencia [www.pehsu.org]). The collaboration of our colleagues will be essential in gaining greater insight into the RF associated with PC and in achieving prevention in the medium and long term.

Adolescent↗
PubMed2003

Mycophenolate mofetil without antibody induction in cadaver vs. living donor pediatric renal transplantation.

Mycophenolate mofetil (MMF) is a new immunosuppressive agent that blocks de novo purine synthesis in T and B lymphocytes via a potent selective inhibition of inosine monophosphate dehydrogenase. MMF has been shown to significantly reduce the incidence of acute rejection in both adult and pediatric renal transplantation. The impact of MMF on routine antibody induction therapy in pediatric renal transplantation has not been defined. Remarkably, a recent North American Pediatric Transplant Cooperative Study concluded that T-cell antibody induction therapy was deleterious for patients who received MMF. Our study examines the use of MMF in an evolving immunosuppressive strategy to avoid antibody induction in both living (LD) and cadaver (CAD) donor pediatric renal transplantation. We retrospectively analyzed the records of 43 pediatric renal transplants that received MMF-based triple therapy without antibody induction therapy between November 1996 and April 2000. We compared CAD (n = 17) with LD (n = 26). The two groups were similar demographically except that CAD had significantly younger donors than LD, 26.1 +/- 13.7 vs. 36.2 +/- 9.2 yr (p = 0.006). All the patients received MMF at 600 mg/m2/b.i.d. (maximum dose of 2 g/d) and prednisone with cyclosporine (86%) or tacrolimus (14%). Mean follow-up was >36 months for each group. Acute rejection rate at 6 months was 11.8% (CAD) vs. 15.4% (LD) (p = 0.999) and at 1 yr was 23.5% (CAD) vs. 26.9% (LD) (p = 0.999). Mean estimated glomerular filtration rate (ml/min/1.73 m2) at 6 months was 73.3 +/- 15.3 (CAD) vs. 87.6 +/- 24.2 (LD) (p = 0.068). Patient survival at 1, 2, and 3 yr was 100, 100, and 100% for CAD vs. 100, 96, and 96% for LD, respectively. Graft survival at 1, 2, and 3 yr was 100, 100, and 94% for CAD vs. 96, 88, and 71% for LD, respectively. Graft loss in CAD was because of chronic rejection (n = 2) while in LD it was because of non-compliance (n = 6), post-transplant lymphoproliferative disorder (n = 1), and sepsis (n = 1). In conclusion, MMF without antibody induction in both CAD and LD pediatric renal transplantation provides statistically similar and effective prophylaxis against acute rejection at 6 months and 1 yr post-transplant. The short-term patient and graft survival rates are excellent, however, non-compliance remains a serious challenge to long-term graft survival. Additional controlled studies are needed to define the role of MMF without antibody induction therapy in pediatric renal transplantation.

Adolescent↗
PubMed2001

Therapeutic drug monitoring of tacrolimus in pediatric liver transplant patients.

The clinical utility of tacrolimus monitoring in adults has been well documented. The present study compared tacrolimus monitoring in a pediatric population of 34 liver transplant patients in four US centers with an adult population of 111 patients in six US centers. Subjects (adult and pediatric) were evaluated, at defined intervals over 12 weeks post-transplantation (Tx), for tacrolimus trough concentrations and 12 additional laboratory chemistries. Pediatric patient and graft survival for the 12 weeks were 91% and 88%, respectively, as compared to 97% and 93%, respectively, for the adult population. The mean oral dosage of tacrolimus for pediatric patients was 0.13 +/- 0.1 mg/kg/day at week 1, increased to 0.30 +/- 0.3 mg/kg/day by week 3 and remained constant for the remainder of the study. These dosages were two- to three-fold higher than the dosage used in the adult population. In contrast, the mean whole-blood trough concentration, as determined by PRO-Tractrade mark II enzyme-linked immunosorbent assay (ELISA), decreased from 11.3 +/- 5.1 ng/mL at week 1 to 6.3 +/- 3.7 ng/mL by week 12 and was not significantly different from the trough concentration in adults. The incidence and distribution of the clinical end-points for the pediatric subjects (rejection, nephrotoxicity, death, re-Tx) were different from those observed in adults. The total percentage of pediatric subjects reaching any end-point was 74%, as compared to 54% in the adult population. These data indicate several differences between the adult and pediatric populations in their response to tacrolimus.

Child↗
PubMed2004

Superior long-term results of simultaneous pancreas-kidney transplantation from pediatric donors.

The shortage of cadaveric donors for simultaneous pancreas-kidney transplantation has prompted the use of cadaveric organs from pediatric donors. The long-term outcome and its impact on overall long-term survival are unknown. A total of 680 recipients receiving cadaver Simultaneous pancreas-kidney (SPK) transplantation from pediatric and adult donors between July 1986 and September 2001 were analyzed and compared. Ten-year kidney and pancreas graft survival for SPK transplantation from donors aged <18 years (n = 142) were 80% and 72%, respectively, compared to 61% pancreas and kidney graft survival from donors > or =18 years of age (n = 538; p = 0.03 and 0.05, respectively). Five years post-transplant, blood glucose, HbA1c and creatinine clearance were significantly better in recipients from pediatric donors (85.3 +/- 13 mg/dL, 5.5 +/- 3.5% and 65.6 +/- 16 mL/min, respectively), compared to recipients from adult donors (95.1 +/- 29 mg/dL, 5.9 +/- 3.5% and 58.3 +/- 17 mL/min; p = 0.001, 0.01 and 0.002, respectively). Causes of graft failure for kidney and pancreas transplants were similar between the two groups. No statistically significant difference was observed in patient survival between recipients from pediatric donors compared to adult donors (85% vs. 76%, p = 0.29). When recipients of SPK from pediatric donors were stratified according to age (3-11 years and 12-17 years) and compared, no difference in kidney or pancreas graft survival was observed (kidney 76.4% vs. 81.3%, p = 0.15; pancreas 75% vs. 76%, p = 0.10, respectively). Pediatric donors represent a valuable source of organs, providing excellent short- and long-term outcomes. Wide utilization of pediatric organs will substantially increase the donor pool.

Adolescent↗
PubMed2004

Inflammatory bowel diseases in pediatric and adolescent patients: clinical, therapeutic, and psychosocial considerations.

Inflammatory bowel diseases (Crohn's disease and ulcerative colitis) primarily affect young adults, but in 15%-25% of cases, the initial disease starts in childhood. Many aspects of inflammatory bowel disease, including initial evaluation, nutritional support, medical and surgical intervention, and the direction of future research, are encountered in both adult and pediatric patients. However, it is important to delineate issues specific to pediatric patients, especially growth velocity impairment, derangements in and treatment of abnormal bone mineralization, and transitional care issues; the lack of extensive randomized, controlled pediatric therapeutic trials is also a concern. This article reviews the epidemiology of pediatric inflammatory bowel disease incidence and prevalence worldwide, clinical issues (including impairments of growth velocity and bone density), diagnostic and therapeutic interventions, and psychosocial issues unique to pediatric patients. Future research directions defined by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and opportunities provided by existing pediatric research databases are highlighted.

Adolescent↗
PubMed2001

Pediatric asthma assessment: validation of 2 symptom diaries.

Accurate assessment of the value of asthma interventions in pediatric clinical trials is an essential step toward the improvement of the treatment of this disorder in children. Conventional pulmonary function measures can be infeasible and unreliable in younger children, particularly for use in multisite studies. As an alternative or supplemental approach, diary questionnaires completed by the patients or their caregivers may provide valuable data regarding the efficacy of asthma interventions in pediatric clinical trials. These questionnaires, however, have routinely not been validated for use in pediatric populations. Two pediatric diary questionnaires (the child-completed Pediatric Asthma Diary [PAD] and the parent/caregiver-completed Pediatric Asthma Caregiver Diary [PACD]) were designed to evaluate asthma symptoms in children aged 6 to 14 years and 2 to 5 years, respectively. The validity of these diary questionnaires was evaluated in 2 separate prospective studies that included children who were divided into 2 asthma groups: stable (requiring no additional asthma medication) and unstable (requiring either an increase in or the addition of asthma medication). Both scales displayed significant discriminant validity, construct validity, and responsiveness to change in asthma therapy. Only the PACD detected differences between groups in nighttime symptoms, such as awakenings caused by asthma. These validity studies suggest that diary questionnaires such as the PAD and PACD can be valuable as an alternative for the evaluation of interventions in pediatric asthma when pulmonary function testing is inappropriate or as an adjunct to such objective measures.

Asthma↗
PubMed2002

Usefulness of a pediatric colonoscope for routine colonoscopy in women who have undergone hysterectomy.

BACKGROUND: Colonoscopy can be difficult in some women who have undergone hysterectomy, which can be associated with a fixed, angulated sigmoid colon caused by postoperative pelvic adhesions. Our goal was to determine whether colonoscopy is easier and more comfortable for women after hysterectomy when performed with a pediatric colonoscope, which is thinner in diameter and more flexible than a standard "adult" colonoscope. METHODS: One hundred women with a history of hysterectomy undergoing outpatient colonoscopy were randomized in unblinded fashion to colonoscopy with a standard colonoscope (CF-100L or CF-Q140L, Olympus) or with a pediatric colonoscope (PCF-100, Olympus). All procedures were performed by a faculty endoscopist and timed. After examination, the endoscopist graded procedure difficulty, and patients were given a questionnaire that assessed their experience. RESULTS: The cecum was intubated more frequently in the pediatric colonoscope group than in the standard colonoscope group (96.1% vs. 71.4%, p < 0.001). Success increased in the standard colonoscope group to 89.8% when the pediatric colonoscope was used to complete the examination. There were no differences in the two groups in terms of mean total procedure times (21.4 minutes vs. 22.6 minutes), mean doses of meperidine administered (57 mg both groups), mean doses of midazolam administered (1.5 mg vs. 1.7 mg), scales of procedure difficulty as graded by the endoscopists, and comfort scales as graded by patients. For the cases in which the cecum was intubated, the mean time to reach the cecum (11.7 minutes for the pediatric colonoscope group vs. 12.7 minutes for the adult) was similar. CONCLUSIONS: The pediatric colonoscope is a reasonable choice for colonoscopy in women who have had a hysterectomy. Alternatively, if the endoscopist elects to start the procedure with a standard colonoscope, it is helpful to have a pediatric colonoscope available for use should a fixed, angulated sigmoid colon be encountered that cannot be easily or safely traversed with the standard colonoscope.

Cecum↗
PubMed2005

Prevalence of probable mental disorders among pediatric asthma patients in an inner-city clinic.

OBJECTIVE: To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. METHOD: In this pilot study, a consecutive sample of pediatric asthma patients aged 5-11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. RESULTS: Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. CONCLUSIONS: These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.

Ambulatory Care Facilities↗
PubMed1999

Videotape increases parental knowledge about pediatric pain management.

UNLABELLED: Pediatric pain management often depends on parents recognition and assessment of their child's pain and their beliefs as to whether the pain should be treated. Parental misconceptions concerning pain assessment and pain management may therefore result in inadequate pain treatment, particularly in patients who are too young or too developmentally handicapped to self-report their pain. We hypothesized that viewing a concise, educational videotape would provide parents with instructive information that could correct misconceptions concerning pain and pain management in children. To do this, we evaluated the impact of an educational videotape on parental responses to a questionnaire about pediatric pain management. Parents of children scheduled for inpatient, postoperative hospital care were studied. After answering 30 questions, parents were randomly assigned to either view (Group 1) or not view (Group 2) a 19-min educational videotape. Immediately after viewing the videotape (Group 1), or 30 min after taking the first test (Group 2), parents were asked to answer the same questionnaire a second time. The effect of seeing the videotape was assessed by comparing post-pre test score differences using paired t-test. One-hundred parents were studied. Randomization was effective in assigning equitable groups. Initial scores of percent answers correct in each group were not different ([mean +/- SD] Group 1 [n = 50]: 68.7% +/- 18.8% vs Group 2 [n = 50]: 61.5% +/- 22.7%; P = 0.09). Viewing the videotape effectively increased test scores: paired t-test within groups demonstrated a significant difference in Group 1 (22.4% +/- 16.5%, P < 0.0001), whereas Group 2 scores changed to a much lesser degree (2.7% +/- 8.3%, P = 0.0271). All parents who viewed the videotape stated that it was informative regarding their understanding of their child's pain management. This study demonstrates the effectiveness of an educational videotape in changing parental knowledge concerning postoperative pediatric pain. This effective and efficient teaching medium may be useful in improving pain management in postoperative pediatric surgical patients. IMPLICATIONS: Pediatric pain management often depends on parents recognition and assessment of their child's pain and their beliefs as to whether the pain should be treated. This prospective, randomized, controlled study demonstrated the effectiveness of an educational videotape in changing parental knowledge concerning postoperative pediatric pain. This effective and efficient teaching medium may be useful in preventing inadequate pain management in postoperative pediatric surgical patients.

Adult↗
PubMed1994

A population-based multivariate analysis of the association of county demographic and medical system factors with per capita pediatric trauma death rates in North Carolina.

OBJECTIVE: This study analyzed the association between demographic and medical system factors and the pediatric trauma death rate in North Carolina. SUMMARY BACKGROUND DATA: Trauma is the leading cause of death in children. Various medical system factors have been suggested to reduce pediatric morbidity and mortality rates, but the association with these rates has not been tested. METHODS: Data were obtained from the North Carolina medical examiner's database. The dependent variable was the county per capita pediatric trauma death rate. Twenty-one demographic and medical system measures were selected as independent variables. RESULTS: Nine hundred forty-one pediatric trauma deaths from 1986 to 1989 were included in our sample. Multivariate analysis identified the variables most highly associated with the dependent variables. The presence of advanced life support (ALS) training was the only medical system factor associated significantly with pediatric trauma death rates. Trauma centers, emergency (911) telephone access, and other medical resource variables had no significant association. CONCLUSIONS: The study confirms other reports showing that demographic factors have an important predictive association with the trauma death rate in children. Advanced life support was the only medical system resource associated significantly with pediatric trauma death rates. This study underlines the significance of pre-hospital care in the treatment of pediatric trauma.

Adolescent↗
PubMedDate not supplied

"Oh no, the patient is six, not sixty!": the pediatric endoscopy patient.

The success of a pediatric endoscopic procedure from the point of view of both the nurse and the child depends on many factors. It is necessary for the nurse to prepare the pediatric patient both physically and emotionally. The physical preparation includes diet orders, colon preps, and venipuncture techniques. The emotional preparation includes preparing the pediatric patient in a developmentally appropriate manner. Nurses facilitate the child's tolerance of the procedure through the processes of trust, understanding, and mastery. These preparations are viewed as essential in order for the child to integrate this medical experience into his/her already existing repertoire of experiences as positive. Conscious sedation and recommendations for monitoring child safely are important pediatric considerations, as are recovery and discharge instructions. A table for pediatric vital signs, an endoscopy unit scoring sheet, and sample discharge instructions are included in this article. The information presented in this article can help the experienced pediatric nurse, as well as the nurse who only occasionally cares for the pediatric patient, make the endoscopy procedure more successful.

Adolescent↗
PubMed1996

Inhaled nitric oxide in neonatal and pediatric acute respiratory distress syndrome: dose response, prolonged inhalation, and weaning.

OBJECTIVE: Inhaled nitric oxide is a potent and selective pulmonary artery vasodilator. We studied the effects of nitric oxide inhalation in neonatal and pediatric acute respiratory distress syndrome (ARDS) patients with respect to dosage, prolonged inhalation, and weaning. DESIGN: Prospective, open-label study. SETTING: Neonatal and pediatric intensive care units of a level three university hospital. PATIENTS: Seventeen patients with severe ARDS (1 day to 6 yrs of age [mean 1.75]; oxygenation index of > 20 cm H2O/torr) were enrolled. INTERVENTIONS: To identify the optimal dosage for continuous nitric oxide inhalation, doses between 1 and 80 parts per million (ppm) of nitric oxide were tested after the patients had stabilized. Daily withdrawals of nitric oxide were made, according to predetermined criteria. MEASUREMENTS AND MAIN RESULTS: Nine neonatal and eight pediatric ARDS patients (mean Pediatric Risk of Mortality score 28.4 +/- 6.1; mortality risk 54 +/- 15%) were studied. The following variables changed within 24 hrs of nitric oxide inhalation: mean oxygenation index decreased by 56% (from 34 +/- 12 to 15 +/- 7 cm H2O/torr, p = .0004); alveolar-arterial O2 gradient decreased by 31% (from 579 +/- 71 to 399 +/- 102 torr (77.2 +/- 9.5 to 53.2 +/- 13.6 kPa), p = .0004); and mean systemic arterial pressure increased by 15% (from 49 +/- 10 to 57 +/- 12 mm Hg, p = .0029). The optimal dose of nitric oxide was 20 ppm in neonates (with additional persistent pulmonary hypertension of the newborn) and 10 ppm in pediatric patients. Prolonged inhalation (4 to 21 days) was associated with continuous improvement of oxygenation. An oxygenation index of < 5 cm H2O/torr predicted successful withdrawal, with a sensitivity of 75% and a specificity of 89%. None of the patients had to be rescued with extracorporeal membrane oxygenation and 16 of the 17 patients survived. CONCLUSIONS: Inhaled nitric oxide enhances pulmonary gas exchange, with concomitant hemodynamic stabilization, in neonatal and pediatric ARDS. Best effective doses were 10 ppm of nitric oxide in pediatric ARDS and 20 ppm in neonates. Treatment should be continued until an oxygenation index of < or = 5 cm H2O/torr is achieved. Effects on outcome need verification in larger controlled trials.

Administration, Inhalation↗
PubMed1996

Regulatory issues in pediatric psychopharmacology.

Labeling claims for the effectiveness of drugs in the treatment of psychiatric illnesses in children and adolescents must be based on data from adequate and well-controlled investigations. The preferred design for demonstrating the effectiveness of a drug in pediatric psychopharmacology is generally a placebo-controlled trial. Safety information in labeling may be derived from more diverse sources. The Food and Drug Administration (FDA) has taken several steps to encourage more informative labeling of drugs for pediatric use, including a recent labeling initiative that emphasizes the possibility of extrapolating effectiveness data from adult studies to pediatric populations under appropriate circumstances. This recently finalized regulation requires pharmaceutical sponsors to reexamine existing data for their drugs to determine whether there is a sufficient basis for modifying labeling for pediatric use. Included in this new rule is a reminder that in certain situations the FDA may require new pediatric studies, thereby signaling the FDA's determination to improve labeling for the pediatric use of drugs. Improved preclinical models for predicting drug effects on growth and development, as well as improved clinical methods for detecting such changes, need to keep pace with the expansion of research in pediatric psychopharmacology.

Adolescent↗
PubMedDate not supplied

The efficacy of pediatric blood culture sets in the determination of burn bacteremia.

A blood culture is an essential laboratory procedure necessary to confirm a septic episode. However, it is important to collect the blood sample at the appropriate time with an acceptable technique. The standard method is to collect at least 5 to 10 ml blood per culture bottle from patients with fevers. However, this volume of blood is an unrealistic amount to take from the frequently febrile pediatric patient. Alternatively, the pediatric blood culture bottle allows the collection of 1 ml blood per bottle to perform the same evaluation. We evaluated the two techniques of blood-culture collection over a 9-month period and compared the results between adult and pediatric blood culture bottles. Seventy-six patients, from November 1988 through February 1989, had blood cultures performed with the adult culture bottles, which produced a total of 1314 samples. A total of 113 patients, from March through July 1989, had blood cultures performed with the pediatric culture bottles, which produced a total of 758 samples. Percent recovery for the adult bottles versus the pediatric bottles was 13.95% versus 22.8% (p less than 0.0001). Since the amount of blood necessary to isolate an infectious agent is critical not only for laboratory identification but also for the volume of blood of pediatric patients, these data clearly establish the efficacy of pediatric blood culture bottles and the utilization of smaller amounts of blood. Not only did this approach significantly enhance organism recovery rate, but it may well be more cost-effective because fewer cultures need to be performed to isolate the infectious organism.

Adult↗
PubMed2001

Ketamine sedation for pediatric gastroenterology procedures.

BACKGROUND: Although the dissociative sedative ketamine is used commonly for pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience with ketamine sedation for pediatric gastroenterology procedures was reviewed to document the safety profile of this agent and to identify predictors of laryngospasm during esophagogastroduodenoscopy (EGD). METHODS: The study was a retrospective consecutive case series of children receiving ketamine administered by pediatric gastroenterologists skilled in basic airway management to facilitate pediatric gastrointestinal procedures during a 5-year period. Patient's records were reviewed to determine indication, dosage, adverse effects, drugs, inadequate sedation, and recovery time for each sedation. A multiple logistic regression analysis was performed to identify predictors of laryngospasm during EGD. Outcome measures were descriptive features of sedation, including adverse effects and predictors of laryngospasm during EGD. RESULTS: During the study period pediatric gastroenterologists administered ketamine 636 times, primarily for EGD (86%) and primarily by the intravenous route (98%). The median loading dose and total dose were 1.00 mg/kg and 1.34 mg/kg, respectively. Inadequate sedation was noted in seven (1.1%) procedures. Adverse effects included transient laryngospasm (8.2%), emesis (4.1%), recovery agitation (2.4%), partial airway obstruction (1.3%), apnea and respiratory depression (0.5%), and excessive salivation (0.3%). There were no adverse outcomes attributable to ketamine. Nearly half (46%) the subjects had severe underlying illness (American Society of Anesthesiologists (ASA] class > or =3). All instances of laryngospasm occurred during EGD (9.5% incidence), and the only independent predictor of laryngospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (< or =6 years) children and was 3.6% in school-aged (>6 years) children (difference 10.3%, 95% confidence intervals 5.5-14.9%). No dose relationship was noted with laryngospasm, and the risk did not increase with underlying illness. CONCLUSION: Pediatric gastroenterologists skilled in ketamine administration and basic airway management can effectively administer this drug to facilitate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in preschool than in school-aged children.

Adolescent↗
PubMed2004

Recurrent abdominal pain: symptom subtypes based on the Rome II Criteria for pediatric functional gastrointestinal disorders.

OBJECTIVES: Recurrent abdominal pain (RAP) is a common childhood complaint rarely associated with organic disease. Recently, the Pediatric Rome Criteria were developed to standardize the classification of pediatric functional gastrointestinal disorders (FGIDs) using a symptom-based approach. The authors tested the hypothesis that most patients with childhood RAP could be classified into one or more of the symptom subtypes defined by the Pediatric Rome Criteria. METHODS: Using a prospective longitudinal design, new patients with RAP (n = 114) were studied at a tertiary care children's medical center. Before the medical evaluation, parents completed a questionnaire about their child, assessing symptoms defined by the Pediatric Rome Criteria. RESULTS: Of the 107 children for whom medical evaluation revealed no organic etiology for pain, 73% had symptom profiles consistent with the Pediatric Rome Criteria for one of the FGIDs associated with abdominal pain (irritable bowel syndrome, 44.9%; functional dyspepsia,15.9%; functional abdominal pain, 7.5%; abdominal migraine, 4.7%) CONCLUSIONS: This study provides the first systematic empirical evidence that RAP, originally defined by Apley, includes children whose symptoms are consistent with the symptom criteria for several FGIDs defined by the Rome criteria. The pediatric Rome criteria may be useful in clinical research to (1) describe the symptom characteristics of research participants who meet Apley's broad criteria for RAP, and (2) select patients with particular symptom profiles for investigation of potential biologic and psychosocial mechanisms associated with pediatric FGIDs.

Abdominal Pain↗
PubMed2002

Helicopter transport of pediatric trauma patients in an urban emergency medical services system: a critical analysis.

BACKGROUND: Helicopter transport of pediatric trauma patients in an urban Emergency Medical Services system remains controversial. METHODS: A retrospective review of pediatric patients transported by helicopter to a pediatric trauma center in Los Angeles, California, was conducted over a 3-year period. Pediatric patients (age < 15 years) are transported by helicopter if ground transport to a pediatric trauma center would exceed 20 minutes. Emergency Medical Services reports and hospital records were reviewed for key prehospital and outcome indicators. RESULTS: One hundred eighty-nine patients met the study inclusion criteria. The median age was 5 years (range, 0-14 years). The most common mechanisms of injury were falls and automobile versus pedestrian crashes. Eighty-two percent of patients had a Revised Trauma Score > 7. Of the 175 (93%) patients whose hospital records were available, 24 (14%) were intubated in the emergency department, 32 (18%) were admitted to the intensive care unit, and 7 (4%) were taken directly to the operating room. Injury Severity Scores (ISSs) were as follows: ISS 0 to 15, 146 (83%); ISS 16 to 30, 26 (15%); and ISS > 30, 3 (2%). Fifty-seven (33%) patients were discharged home from the emergency department. CONCLUSION: The majority of pediatric trauma patients transported by helicopter in our study sustained minor injuries. A revised policy to better identify pediatric patients who might benefit from helicopter transport appears to be warranted.

Adolescent↗