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PubMed2002

Learning preferences of paediatric intensive care nurses.

AIM: This paper reports the views of students on the teaching and learning strategies used in paediatric intensive care nursing courses. STUDY METHODS: Qualitative methods of data collection and analysis were used. A case study of one paediatric intensive care nursing course was carried out, followed by group interviews with students from a further seven courses. Local ethics committee protocols were followed. Data were analysed using constant comparative analysis. STUDY FINDINGS: Qualified nurses undertaking paediatric intensive care nursing courses seek a specific knowledge base, relevant to their clinical practice. Their preferred way of learning in this situation is teaching by knowledgeable experts who are also prepared to discuss issues that arise. Although in some instances student centred or self-directed approaches were considered acceptable, Students still require clear guidance and structure in their learning. Students did not summarily oppose student centred approaches to teaching and learning, however, time considerations and whether this would reduce the amount of study time provided by their employers were important factors. There was evidence that students do not necessarily have one specific learning preference. LIMITATIONS: This study explored only paediatric intensive care nurse education, and was not intended to be generalizable beyond this field. CONCLUSION: The findings from this study indicate that no single educational approach is universally seen as the most attractive for PICU nurses. The major considerations in designing and implementing PICU nursing courses should be that content is clearly rated to the clinical speciality, theory is clearly linked to practice, and that the time constraints for students who are additionally in full time employment are taken into account.

Attitude of Health Personnel↗

PubMed1999

Population analysis for the optimization of digoxin treatment in Japanese paediatric patients.

BACKGROUND AND OBJECTIVES: Information about the pharmacokinetics of digoxin in paediatric patients is limited. We therefore aimed to investigate the effects of physiological factors on the digoxin clearance in Japanese paediatric patients. METHOD: We used routinely collected therapeutic drug monitoring data (n=544), derived from the steady-state serum concentrations of digoxin in 181 hospitalized paediatric patients. RESULTS: Of those physiological factors which have been examined in this study, age and total body weight were most closely correlated with digoxin clearance. Data on neonates within the first postnatal month indicated a tendency towards lower clearance for premature neonates than full-term neonates (P<0.01). Digoxin clearance was reduced by spironolactone in patients younger than 4 months (P<0.05). Patients with congestive heart failure showed a lower digoxin clearance than the others (P<0.001). Serum creatinine and gender did not have a statistically significant effect on digoxin clearance. CONCLUSION: Age and total body weight are important factors influencing digoxin clearance in children. Spironolactone affected digoxin clearance and needs to be considered when dosing paediatric subjects.

Age Factors↗

PubMed2003

Perioperative infusions in paediatric patients: rationale for using Ringer-lactate solution with low dextrose concentration.

To assess the usefulness of Ringer-lactate solution with 0.9% dextrose, fluid therapy during surgery in paediatric patients was reviewed. From the literature, the need for intravenous (i.v.) infusion and water could be established. The need for sodium was also evident and use of normonatraemic i.v. solutions should be recommended to avoid hyponatraemia. Little data were found about the value of the other electrolytes. Dextrose requirements have been the subject of debate for the last two decades. The choice of dextrose concentration is a compromise between avoiding hypoglycaemia and hyperglycaemia. Four clinical trials assessing the use of Ringer-lactate solution with 0.9 or 1% dextrose in paediatric patients suggest that it is appropriate for routine infusion in paediatric patients during the perioperative period. However, fluid therapy during surgery has rarely been studied, probably because it is inexpensive, rarely leads to problems and is used in very different clinical settings. Development of consensus clinical guidelines on the use of electrolyte infusions in paediatric surgery would be helpful.

Blood Glucose↗

PubMed1998

Developmental-behavioural problems in general paediatrics.

OBJECTIVE: To determine the current role of private general paediatrics in the care of children with problems of development and behaviour. METHODS: We surveyed all general paediatricians registered with the Australian College of Paediatrics to assess their current role in developmental-behavioural (DB) problems--their rate of referrals, their role in the continuing management, and opinions regarding duration of training in this area. RESULTS: Of 394 questionnaires sent, 284 replies were received (72%). From these 284 we analysed results for all 172 who spent more than 25% of their time in private general paediatric practice. On average, 32% of new referrals were for DB problems. With 10 DB clinical vignettes presented, paediatricians chose to continue to manage in conjunction with allied health services in 65% of cases. Other management choices included referral to a multidisciplinary team (16%), referral elsewhere (10%) and manage alone (7%). For training to be a general paediatrician, they indicated 3 months should be spent during basic training in each of the three areas of; DB paediatrics, developmental disabilities and child psychiatry (separately or concurrently); and 6 months of each during advanced training. Free comments highlighted lack of public allied health and psychosocial services. CONCLUSION: Private community-based general paediatricians are deeply involved in this area of work. The results raise questions about services for training and for clinical collaboration between public and private child health providers.

Australia↗

PubMed2000

Trends in the specialist workforce in paediatrics in Australia, 1981-1997.

OBJECTIVE: The Royal Australasian College of Physicians has conducted periodic workforce censuses of Fellows practising paediatric medicine in Australia since 1981. The aim of this study was to document trends in the supply of paediatricians and to project these trends into the early 21st century. METHODOLOGY: Time series analysis using least squares regression. RESULTS: The paediatric consultant workforce in Australia increased in a linear manner from 374 in 1981 to 777 in 1997. If this trend persists, the number of paediatricians will grow by 62% to 1255 in 2016. The ratio of population aged 0-14 years per paediatrician fell from 9960:1 in 1981 to 5040:1 in 1997. The projected national decline in the child population will result in a ratio of 3050 children per paediatrician in the year 2016. The proportion of women in the paediatric workforce was 22.4% in 1997 and is projected to rise to at least 36% by 2016. The proportion aged 50 years and older rose from 22% in 1981 to 33.6% in 1997 and is projected to be 45% by the year 2016. The average total weekly working hours fell from 58.2 in 1984 to 53. 4 in 1997. The proportion practising in regional centres rose from 12 to 17.9%. CONCLUSIONS: The paediatric workforce in Australia has grown rapidly over the past 16 years. If this trend continues, the ratio of child population per paediatrician will continue to fall, acccentuated by the projected decline in the child population. The trends towards an ageing workforce with an increasing proportion of women, declining working hours and rising proportion practising in regional centres are expected to continue unless workforce intake or retirement change dramatically.

Adolescent↗

PubMed2002

Is the practice of paediatric inpatient medicine evidence-based?

OBJECTIVE: To determine whether management provided to paediatric inpatients in general units was supported by high-level evidence. METHODS: A retrospective review was carried out of all patients (n = 142) admitted during one calendar month to two general paediatric units in the USA and Australia. For each patient, the primary diagnosis and primary treatment were determined. A literature review was performed to determine whether the therapy used was evidence-based. The main outcome measure was the level of evidence supporting the primary intervention for the primary diagnosis of each patient. RESULTS: Level I evidence (at least one randomized trial) supported the primary intervention used in 31% of paediatric admissions and level II evidence (convincing non-experimental evidence) supported the primary intervention in 44% of admissions. Primary interventions were not supported by evidence (level III) in only two patients. The remaining 24% of patients were admitted for observation or evaluation only, and received no primary medical or surgical intervention. Most patients whose interventions were supported by randomized trials were admitted with either asthma or appendicitis. CONCLUSIONS: Most primary interventions (75%) in paediatric inpatients were supported by high-level published evidence (level I or II). A large number of patients were admitted for evaluation or observation only, and received no therapeutic intervention. Evidence to support this action is not available.

Adolescent↗

PubMed2002

Sedation practices for Australian and New Zealand paediatric oncology patients.

OBJECTIVES: Paediatric oncology patients often require repeated bone marrow aspirates and lumbar punctures. These procedures commonly require sedation and analgesia. The Australian and New Zealand College of Anaesthetists and the American Academy of Pediatrics have published guidelines that provide recommendations on monitoring and staffing requirements during sedation of paediatric patients. A survey was conducted of the oncology units in Australia and New Zealand in order to compare current practices with published guidelines. METHODS: Telephone interviews were conducted with nursing or medical staff members. RESULTS: Fourteen oncology units collectively perform approximately 130 procedures each week, of which 74% are performed under general anaesthesia. Of the remainder, most are performed using conscious sedation. Most units adhere to published recommendations regarding equipment and staffing during procedures performed under sedation. Only a minority of units follow guidelines regarding documentation; fasting requirements; observation and documentation of vital signs during and after the procedure; and obtaining informed consent for procedures performed using sedation. CONCLUSION: Sedation practices among paediatric oncology units in Australia and New Zealand vary. None of the units fully adhere to published guidelines on childhood sedation. Paediatric oncology units should be familiar with the content of these guidelines and make an informed decision as to their usefulness, both in directing best clinical practice, and in supporting current practice in the event of medico-legal challenge.

Analgesics↗

PubMed2003

Emergency department attendances associated with drug-related problems in paediatrics.

OBJECTIVES: To determine the frequency and characteristics of paediatric emergency department attendances associated with drug-related problems (DRP) at three Victorian hospitals. METHODS: All paediatric medical patients attending the emergency department of the Royal Children's Hospital, Geelong Hospital or Box Hill Hospital were considered for inclusion. The investigator and attending medical practitioners screened eligible patients. A multidisciplinary panel reviewed collated data. Causality, preventability and clinical significance classifications were established by the panel. RESULTS: Combining data from the three hospitals, over 18 weeks of data collection, a total of 8601 patients met the eligibility criteria. Of these, 280 (3.3%, 95% CI 2.9-3.7%) were determined to have emergency department attendances associated with DRP. Of the 187 cases assessed for preventability, 51.3% were judged to be preventable. CONCLUSIONS: Emergency department attendances are associated with DRP in paediatrics. Given that the need to prevent DRP in adults is recognized, it is now time to act to reduce the consequences of DRP in paediatrics.

Adolescent↗

PubMedDate not supplied

Barriers to the use of interpreters in emergency room paediatric consultations.

OBJECTIVE: To identify barriers to the use of trained interpreters in emergency department (ED) paediatric consultations. METHODS: A cross-sectional survey of non-English-speaking-background (NESB) carers who presented a child aged 14 years or less to the Fairfield Hospital ED during a 3-month period was undertaken using a multilingual postal questionnaire or a phone interview with interpreter assistance. RESULTS: Of the 1388 paediatric consultations during the study period, 406 of the carers were registered as being of NESB, with 316 being eligible for study inclusion. Of the 278 (88%) respondents who completed the questionnaires, assistance with interpretation was required by 131 (47%) respondents: 55 (20%) used ad hoc interpreters, 47 (17%) used a trained interpreter and 21 (8%) did not receive the required assistance. Fifty-four (41%) carers who required interpreter assistance were identified as having this requirement at clerical registration in the ED, but only 18 of these were provided with a trained interpreter during the consultation. Limited English proficiency was self-reported by 127 (46%) respondents, with these respondents being more likely to need interpreter assistance (odds ratio (OR) 44.2; 95% CI 21.6-90.7), to have impaired understanding of the consultation (OR 8.2; 95% CI 4.7-14.1) and to consult a language concordant general practitioner (OR 10.1; 95% CI 5.1-19.4) compared with English proficient respondents. CONCLUSIONS: Barriers to the use of interpreters in ED paediatric consultations include poor identification of the need for and provision of an interpreter in the ED, and a preference for NESB carers to use ad hoc interpreters or no interpreter. Recommendations include the implementation in the ED of strategies to improve identification of NESB carers, as well as to improve awareness, access and use of trained interpreters during paediatric consultations. There is also a need to explore the experience of ED staff in accessing and using trained interpreters.

Adolescent↗

PubMed2003

Primary compliance with medication prescribed for paediatric patients discharged from a regional hospital.

OBJECTIVE: To establish the rate of primary compliance with medication of children discharged from the paediatric ward of a regional hospital. METHODS: All paediatric admissions to a regional hospital for a 14-week period from April to July 2000 were studied. Patient data were collected for those paediatric inpatients discharged on medication. Written prescriptions kept by the local Aboriginal Medical Service and computerized data from local pharmacies were collected and the numbers filled were compared to ward discharge prescriptions. RESULTS: There were 160 medical paediatric admissions. The median admission age was 19 months. There was no difference in patient sex, number of drugs prescribed, diagnosis of infection, mean age or the proportion of children under 2 years, between filled and unfilled prescriptions. In total, 49 prescriptions were filled from a total of 65 written (75%). This figure compares unfavourably with that of the metropolitan tertiary referral centre. CONCLUSIONS: : Primary compliance was suboptimal, with the majority of unfilled prescriptions being for antibiotics. These findings suggest that a remediable cause of treatment failure may be primary non-compliance with medication in regional settings.

Adolescent↗

PubMed2002

The use of the cuffed oropharyngeal airway in paediatric patients.

BACKGROUND: The cuffed oropharyngeal airway (COPA) is a device which has already been demonstrated to be suitable for anaesthetized adult patients undergoing either spontaneous or mechanical ventilation. There are few reports on the use of the COPA in children. In this study, the authors assessed the COPA in paediatric patients undergoing minor surgery. METHODS: The same anaesthesiologist inserted the COPA in 40 consecutive paediatric patients, ASA I and II, aged 1.8-15.3 years. (7.4 +/- 3.9), after induction of anaesthesia with N2O/O2/sevoflurane. COPA size was chosen by measuring the distal tip of the device at the angle of the jaw with the COPA perpendicular to the patient's bed. The proper positioning of the COPA was assessed by observing thoracoabdominal movements, regular capnograph trace, the reservoir bag movements and SpO2 > 94% with a fraction of inspired oxygen of 0.5. Anaesthesia was maintained with 1 MAC halothane, sevoflurane, or isoflurane in N2O/O2 (50%) and the patients were spontaneously breathing. The stability of the COPA following changes in head, neck and body position was tested. We recorded the duration time for COPA insertion, the side-effects of placement of the COPA and during the intraoperative period, the number of attempts, the type of manipulation in order to provide an effective airway and postoperative symptoms, such as the presence of blood on the device, sore throat, neckache, jaw pain and PONV. RESULTS: Successful COPA insertion at the first attempt was 90% and at the second attempt in the remaining 10%. The most frequent airway manipulations were head tilt in 27.5% (obtained by a pillow under shoulders) and chin lift in 5%. No complications both at COPA placement nor during the intraoperative period were observed. On the basis of weight and age, the COPA size was no. 8 in 50%, no. 9 in 30%, no. 10 in 12.5%, and no. 11 in 7.5%. The COPA demonstrated stability after changes in head, neck and body position. Postoperative complications were the presence of blood stains in one case and PONV in six cases (15%). CONCLUSIONS: The COPA is an extratracheal airway device suitable in paediatric patients undergoing general anaesthesia with spontaneous ventilation for minor surgery and other painful procedures. This study shows that for paediatric patients: (i) complications seem to be rare; (ii) the COPA allows hands free anaesthesia; (iii) specific indication for the COPA could be obese patients with a small mouth; and (iv) COPA sizing can be easily established by the weight or age of the patients.

Adolescent↗

PubMed1999

Paediatric intensive care in a district general hospital.

The report of the 'National Coordinating Group on Paediatric Intensive Care' (NHS Executive 1997) recommended that general (adult) intensive care units in district general hospitals should no longer continue to care for critically ill children apart from providing resuscitation prior to transfer to a specialist centre. This recommendation was made despite a lack of outcome data in the UK to support this conclusion. We wish to report our outcome data from one such unit. Over a four-year period, we have prospectively used Paediatric Risk of Mortality scoring to estimate the risk of death for 95 children cared for in our adult unit in a district general hospital (DGH) and have compared this with the observed outcome. The observed mortality of 2 deaths was less than the predicted mortality of 2.32 deaths. Our results suggest that an adult unit can provide a paediatric intensive care service that is associated with an acceptable outcome in terms of mortality. These data suggest that the role of such units with regard to the provision of paediatric intensive care should be considered further.

Adolescent↗

PubMed2002

Paediatric maxillofacial fractures: their aetiological characters and fracture patterns.

OBJECTIVE: Paediatric maxillofacial fractures are not common and carry different clinical features when compared with adults. To clarify the differences of aetiology and patterns of fractures in paediatric patients, a clinical retrospective analysis was performed. PATIENTS: One hundred seventy-four paediatric patients younger than 16 years of age treated in the First Department of Oral and Maxillofacial Surgery, Osaka University Dental Hospital during a 15-year period were analysed. STUDY DESIGN: Age, sex, fracture patterns, incidence, common locations of the mandibular fractures and treatment were studied according to the patients' charts and radiographs. RESULTS: The ratio of boys to girls was 2:1 and the largest age subgroup was 15-years old. The most common cause of injury was bicycle accidents (26%), followed by falls (25%). The distribution of causes and ages revealed that the incidence of the fall-related injuries decreased in patients older than 10 years, and assaults became a common cause in patients older than 12 years. The yearly distribution showed a decrease of the group between 6 and 10 years and of bicycle-related accidents in the last 5-year period (1992-1996). Mandibular fractures were most common (56%), followed by fractures of the alveolar process (31%). Condylar fracture was common in children younger than 14 years, especially in those below 6 years. Fractures of the mandibular angle were the most common in those above 13 years. CONCLUSION: These results document that the aetiological characters and patterns of paediatric maxillofacial fractures gradually shifted towards those found in adolescents.

Accidental Falls↗

PubMed1999

Paediatric intracranial aneurysms: results of a surgical series and literature review of Guglielmi detachable coil embolization.

It is known that the profile of aneursyms in the paediatric age group demonstrates a different biology and epidemiology than those in the adult population in terms of size, sex, location, multiplicity and complications such as vasospasm and rebleeding. As a consequence of their different behaviour, timing of surgery does not appear to be such a critical issue in their management decision. Surgical clipping is still the treatment of choice, however, with our growing experience of endovascular techniques, these might prove to be a suitable alternative in the future. We report the results of our surgical series of 17 paediatric and adolescent patients harbouring 18 arterial intracranial aneurysms (age range 7-18 years). Systemic diseases traditionally known to be associated with this entity were excluded. In order to assess endovascular techniques as a potential treatment alternative for this group of patients, we reviewed the current literature, dealing with Guglielmi detachable coil (GDC) embolization of arterial cerebral aneurysms in this age group. No current series deals purely with paediatric aneurysms; we have reviewed paediatric cases reported as part of large adult series. Copyright 1999 Harcourt Publishers Ltd.

Journal Article↗

PubMed1981

The use of paediatric cadaver kidneys for transplantation in adult recipients.

In view of the shortage of cadaveric donors a retrospective study has been performed to determine the results of transplantation of paediatric cadaver donor kidneys into adult recipients. Graft- and patient survival and renal function in the 31 cases analysed in this study showed no adverse effect of the use of paediatric donor kidneys. No vascular complications were encountered. Ureteric leakage occurred in only one case and it was treated successfully. It is concluded that paediatric age is no criterion for donor exclusion and that paediatric donors are to be regarded as a valuable source of cadaveric kidneys for transplantation.

Adult↗

PubMed2007

Rotavirus infections in paediatric oncology patients: a matched-pairs analysis.

OBJECTIVE: To conduct a systematic investigation of the clinical relevance of rotavirus infection in the setting of paediatric cancer patients receiving intensive chemotherapy. MATERIAL AND METHODS: Twenty-eight paediatric cancer patients with positive rotavirus antigen tests were eligible for a retrospective case-control study (January 1995-December 2004). Rota-positive patients were compared with 28 rota-negative patients matched for age, underlying disease and chemotherapy. The National Cancer Institute Common Toxicity Criteria were used to determine clinical severity. RESULTS: Median duration of rota-related symptoms (diarrhoea, fever and vomiting) was 7 days (range 4-34 days; 75th percentile 9 days). Median duration of viral shedding was 17 days (4-73 days; 75th percentile 39.5 days). The rota infection was nosocomially acquired in 19 patients (68%). The proportions of patients with diarrhoea > or =NCI II, fever >39 degrees C, clinically relevant dehydration, metabolic acidosis, mucositis and neutropenia were significantly higher in rota-positive patients. Rota-positive patients tended to have a prolonged period of hospitalization (median 8 versus 4 days; p=0.008). A higher proportion of rota-positive patients had to receive parenteral nutrition and tube feeding (p<0.001). CONCLUSIONS: Rotavirus is a clinically relevant but preventable pathogen in paediatric cancer patients, since many cases seem to be nosocomial in origin. Rapid microbiological testing and contact precautions should be strictly applied to any symptomatic patient and to their immediate contacts. Prolonged viral shedding in immunocompromised paediatric patients necessitates repeated testing in order to determine the duration of isolation.

Case-Control Studies↗

PubMed1999

Paediatric hospital admissions at a South African urban regional hospital: the impact of HIV, 1992-1997.

Rates of infection by the human immunodeficiency virus (HIV) have been increasing rapidly in South Africa over the last decade. This study documents the changes over time in prevalence of HIV infection amongst hospitalized children, and its effects on the profile of disease and in-hospital mortality over the period 1992-1997. Admissions to the paediatric medical wards between January 1992 and April 1997 were obtained from the routine computerized database held in the Department of Paediatrics at Chris Hani Baragwanath Hospital. HIV tests were performed on clinical indications only. Over the study period there were 22,633 admissions involving 19,918 children. Total annual admissions increased by 23.6% between 1992 and 1996. Prevalence of HIV infection increased from 2.9% in 1992 to 20% in 1997. HIV-infected children had a younger age distribution, longer median length of stay and more readmissions (p < 0.001) compared with HIV-negative and untested children. HIV-infected children accounted for the increased number of admissions for pneumonia, gastro-enteritis, malnutrition and tuberculosis, and the rise in in-hospital mortality by 42% from 4.3% in 1992 to 6.1% in 1997. Paediatric HIV infection has changed the profile of paediatric admission diagnoses and increased in-hospital mortality in the relatively short time between 1992 and 1997. Over the same period, HIV-negative children showed declining rates of malnutrition, vaccine-preventable diseases and admission to the intensive care unit.

AIDS-Related Opportunistic Infections↗

PubMedDate not supplied

Genetic disorders in a paediatric hospital in Cambodia.

Cambodia is an extremely underdeveloped country in Southeast Asia with a childhood mortality rate of 105/1000 live births. Angkor Hospital for Children is a paediatric teaching hospital in Siem Reap, northwest Cambodia, which serves as the provincial paediatric department but also sees children from provinces throughout northern Cambodia, and with training provided for health workers from all parts of the country. The impact of genetic disease on this paediatric population is discussed, addressing the areas of haematology (including thalassaemia and other haemoglobinopathies, glucose-6-phosphate deficiency and bleeding disorders), multifactorial disorders (cleft palate, congenital heart disease and neural tube defects), and uncommon genetic disorders and chromosomal syndromes. In the future, as low-income countries develop and their burden of infectious disease begins to subside, the contribution of these disorders to paediatric morbidity and mortality will become increasingly apparent. This transition needs to be considered in the allocation of health resources and in the structuring of undergraduate and postgraduate medical education.

Blood Coagulation Disorders, Inherited↗