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PubMed2001

Male physicians' narratives about being in ethically difficult care situations in paediatrics.

This study is a part of a comprehensive investigation into the narratives of male and female physicians and nurses concerning their experience of being in ethically difficult care situations in paediatrics. Seventeen male physicians with a range of levels of expertise, working on various wards in paediatric clinics at two university hospitals in Norway, narrated 78 stories. The transcribed interview texts were subjected to hermeneutic analysis. All the interviewees related problems in both an action and a relation ethics perspective. The main focus was on ethical problems concerning life and death decisions. The central theme was overtreatment, which they felt they could easily slip into because of a lack of exact knowledge about the outcome of life-saving treatment. The less experienced physicians required criteria and ethical guidelines that could tell them when to stop treatment, and they expected the more experienced physicians to be able to teach them about such things. The more experienced physicians, however, told a different story about life-saving practices in paediatrics. They spoke of a very demanding life situation. In such a situation communication seems decisive, not only to clarify treatment questions, but primarily to cope with life. The physicians' main concern seemed to be the parents rather than the children. Both groups underlined the importance of professional distance to patients and to ethical problems.

Adult↗

PubMed1999

Paediatric basic life support: a practical assessment.

Current European Resuscitation Council (ERC) guidelines for paediatric basic life support advocate delivery of 20 cycles/min at a compression rate of 100/min and a compression:ventilation ratio of 5:1 (Resuscitation 1997;34:115-27; Resuscitation 1998;37(2):97-100). We have evaluated whether cardiopulmonary resuscitation (CPR) can be delivered at this rate by hospital providers. We recruited 24 rescuers, all of whom had successfully completed a training course in paediatric life support. Each was asked to perform single rescuer CPR on a Resusci-Junior mannequin (Laerdal, Kent, UK) for 5 min, following the current ERC guidelines. Compressions and ventilations were recorded in real time by inductance plethysmography. Maintenance of the 5:1 ratio was ensured by investigator observation. Cycles of CPR in the first and fifth minutes of resuscitation were counted. The average duration of compression, ventilation and 'transfer time' spent between these two activities was calculated as a percentage of the average duration of a cycle of CPR. All 24 rescuers completed 5 min of resuscitation. Twenty-three of 24 were unable to deliver 20 cycles of CPR in either the first minute (range 8-27; median 11; interquartile range (IQR) 10-13.75) or in the fifth minute (8-26; 11.5; 10-13.75). The median (IQR) duration of a cycle of CPR was 5 s in the first and fifth minutes. Transfer time comprised 30% of total cycle time. In this study, over 95% of single rescuers trained in paediatric life support were unable to deliver 20 cycles of CPR/min. The guidelines make no allowance for time spent moving between compression and ventilation activity. Future consensus statements should take account of this transfer time. Any changes in recommendations should obviously be prospectively audited with Utstein-style reporting and studies of practicability.

Cardiopulmonary Resuscitation↗

PubMed1986

Autologous bone marrow transplantation in paediatric solid tumours.

Massive therapy with ABMT is now an established treatment modality in paediatric oncology. The technical aspects and most treatment-related complications have been clarified and many phase II studies have shown encouraging results. In advanced neuroblastoma the poor outlook with conventional chemotherapy has stimulated extensive investigation of forms of massive therapy. Current results from several centres indicate that although the median survival is increased, long-term survival in an unselected group of stage IV patients is unlikely to exceed 30% with current regimens. In the future, management of this disease may involve the use of more intensive induction regimens to improve the quality of remission at the time of ABMT, which remains the single most important prognostic factor. Improved purging procedures involve the possible use of double massive therapy regimens and a combination of immunological and chemical treatments. In other paediatric tumours, the relative rarity and limited indications for ABMT make the evaluation of its role more difficult. Preliminary results in advanced rhabdomyosarcoma and Ewing's sarcoma are none the less encouraging and justify further investigation. The value of purging procedures remains controversial and their assessment has been hampered by the lack of sensitive clonogenic assays to detect residual tumour cells. However, neuroblastoma has provided a useful model for the investigation of physical, immunological and chemical procedures. Massive therapy is expensive, time consuming, and carries a high cost in patient morbidity and stress to the families involved. As with any new treatment, it must be adequately assessed in phase III, randomized studies. The ENSG and SIOP trials are a beginning and the future of massive therapy in the paediatric patient will, we hope, be based on a rigorous and scientific comparison with other treatment modalities.

Alkylating Agents↗

PubMed2002

Potential of modern sonographic techniques in paediatric uroradiology.

OBJECTIVE: To describe the potential of modern sonographic techniques in paediatric uroradiology. METHOD: Ultrasound (US)-now being the primary imaging tool-has revolutionised imaging diagnostic in the urinary tract. Constant developments and technical refinements have secured the role of US in uroradiology. Colour Doppler Sonography (CDS) and innovative applications such as the transperineal approach or application of m-mode US to the urinary tract have helped to develop US from just a basic tool to a sophisticated and respected method. The ongoing introduction of new and even more sophisticated methods further enhance the sonographic potential, which shall be demonstrated by a more detailed discussion of these methods. RESULTS: Harmonic imaging, extended field of view US, amplitude coded CDS, echo-enhanced US, and three-dimensional US as the most recent new sonographic techniques are successfully applicable to paediatric urinary tract disease. They improve sonographic diagnosis in many conditions, such as detection of vesico-ureteral reflux, renal parenchymal volume assessment, comprehensive visualisation of hydronephrosis and complex pathology, evaluation of renal perfusional disturbances or defects, superior documentation with improved comparability for follow-up, or simply by offering clearer tissue delineation and differentiation. CONCLUSION: Modern US techniques are successfully applicable to neonates, infants, and children, further boosting the value of US in the paediatric urinary tract. However, as handling became more sophisticated, and artefacts have to be considered, modern urosonography became not only a more powerful, but also a more demanding method, with the need for expert knowledge and dedicated training.

Child↗

PubMed2003

Common tasks and problems in paediatric trauma radiology.

Scope of this article is to give practical hints for the most common, typical and important topics of trauma radiology in children to those radiologists who are not exclusively occupied with paediatric imaging. Due to the increased radiation sensitivity of children compared with adults balancing radiation protection and necessary image quality is of utmost importance. Outlines for this optimisation process are given. Especially in imaging of the extremities perhaps the greatest difficulties are posed by the dynamically changing face of the immature, growing, only partially ossified skeleton. Lack of experience must be compensated by meticulous comparison with the normal skeletal development as shown in standard textbooks, and by knowledge of the radiological image of the developmental variants. Besides general remarks about paediatric trauma radiology, some important topics are discussed into more detail. Especially the elbow joint poses a challenge for those less experienced with its radiological appearance in children. More than in adults, ultrasound should remain the primary imaging modality of choice especially in the assessment of abdominal trauma, and CT be tailored to radiological and clinical findings. Imaging and diagnosis of non-accidental injury (NAI) may be a less common task for the general radiologist, however, the severe social implications of physical child abuse mandate a basic knowledge about the radiological symptoms and the imaging management of this problem for all physicians occupied with paediatric radiology.

Child↗

PubMed1998

B mode ultrasonography--spectrum of paediatric ocular disease.

BACKGROUND: Despite having appropriate sonographic equipment available many radiologists remain unfamiliar with B mode sonography of the eye. OBJECTIVE: This article reviews the advantages and disadvantages of B mode sonography of the paediatric eye. We illustrate the spectrum of eye abnormalities occurring in paediatric practice and the sonographic appearance of clinical entities for which sonography is appropriate. MATERIALS AND METHOD: We reviewed our experience of eye sonography within a paediatric radiology department over 8 years. A total of 212 sonographic examinations were performed on 206 eyes in 103 children, aged from 3 days to 16 years (mean 4.6 years). RESULTS: Sonography was well tolerated by the children, was a very useful imaging modality and was the only diagnostic imaging modality required in 94%. Supplementary computed tomography (CT) was performed in ten of 206 eyes (5%) and magnetic resonance imaging (MR) was performed in two of 206 eyes (1%). CONCLUSIONS: B mode sonography is a very useful imaging modality for suspected ocular or orbital pathology in children and is often the appropriate first line investigation following clinical evaluation. Radiologists familiar with sonography of the eye can provide valuable support to their ophthalmology colleagues.

Adolescent↗

PubMed2003

[High frequency jet ventilation in paediatric anaesthesia].

High frequency jet ventilation (HFJV) is an alternative ventilatory mode during anaesthesia for laryngeal microsurgery. This procedure ensures good visualization of the operating field but is not without risk. Thus, its use in paediatric patients requires sound knowledge of respiratory physiology of children and infants. In children up to 8 years, the jet ventilator adjustments must take into account the lower pulmonary compliance and the higher airway resistance (time-constant). In order to avoid barotrauma, which is the main HFJV complication, the jet ventilator has to include a monitoring airway pressure system. The driving pressure and the frequency must be gradually increased while checking thoracic expansion. Total intravenous anaesthesia with profound muscular relaxation using a thin transglottic catheter is the most commonly used technique. Standard monitoring of anaesthesia does not preclude strict clinical supervision so as to detect any pulmonary distension. The air-oxygen mixture must be adjusted to provide the lowest FIO2 possible (< or = 30%) when using the CO2 laser. The main indications for the use of HFJV in paediatric laryngeal microsurgery are laryngomalcia, laryngeal papillomatosis and subglottic haemangioma. HFJV is a reliable and useful technique in airway paediatric surgery providing the operator has good knowledge of the physiological particularities in children.

Anesthesia↗

PubMed2000

De novo cancers in paediatric renal transplant recipients: a multicentre analysis within the North Italy Transplant programme (NITp), Italy.

The purpose of this study was to determine the frequency and the outcome of de novo malignancies in a cohort of renal transplant paediatric patients. The records of 493 kidney transplants, carried out in 454 paediatric recipients at the three paediatric transplant centres of the North Italy Transplant programme (NITp, Italy) were reviewed. 10 cases of malignancies (2.2%) comprising both PTLD (post-transplant lymphoproliferative disorders) (6 cases, 1.3%) and non-PTLD malignancies (4 cases, 0.88%) were reported. Non-PTLD included one urothelial carcinoma and one Wilms' tumour of the recipient's left native kidney, one abdominal dysgerminoma and one optic nerve glioma of the left eye. The PTLD consisted of localised or disseminated Epstein-Barr virus (EBV)--associated B-lymphocyte monoclonal (5 cases) and polyclonal (1 case) proliferations. All patients suffering from PTLD had been EBV-negative at the time of transplantation, but developed EBV primary infection after transplantation. All PTLD patient donors were EBV-positive. In addition, all but 1 patient received, before and/or after transplantation, a range of immunosuppressive drugs in addition to the baseline prophylactic immunosuppressive regimen. Moreover, 3 patients suffered from syndromes associated with a genetic predisposition to cancer. Finally, the malignancies reported here were associated with 20% graft failure and 20% mortality rates.

Adolescent↗

PubMed2002

A research review to identify the factors contributing to the development of pressure ulcers in paediatric patients.

The aim of this research review was to answer the clinical question 'what factors contribute to the development of pressure ulcers in the paediatric population?' A sensitive, systematic search was undertaken to identify all empirical studies that could answer this question. The question was broken down using facet analysis to identify the key terms that were used in the search strategy. All relevant databases were searched and a hand search of key journals was also undertaken. The review found very little empirical data that could answer the question. The majority of studies focused on the paediatric intensive care (PIC) population and had small sample sizes. Some factors were identified that contributed to the development of pressure ulcers in the PIC population. All of these factors except one were related to the acuity of the child's illness. The small sample sizes and limited populations mean that these studies cannot be generalised to the whole paediatric population and there is a need for more primary research to answer the question.

Child↗

PubMed1996

Antiepithelial cell antibodies do not impair paediatric renal allograft survival but appear to be associated with acute viral infections.

There is a reported association between antiepithelial cell (AEC) antibodies and increased renal allograft loss in paediatric recipients. Our unit experienced a dramatic fall in 1-year graft survival so we undertook a study to determine if AEC antibodies could account for such losses. We also studied healthy children and adults as well as a group of individuals with serologically proven viral infection in an attempt to determine the prevalence and possible aetiology of these antibodies. Sera were screened for AEC antibodies in a microcytotoxicity test using a lung epithelial cell line (A549) as target. The prevalence of these antibodies in our paediatric recipients was similar to that reported elsewhere but we found no correlation between the presence of AEC antibody and allograft loss. Within the control populations, we found the antibody was more prevalent in children than in adults (p < 0.0001). We also found a strong age banding pattern, with antibody being present in 50% of children under 10 years and declining with increasing age, so that by the age of 16 years the seroprevalence was similar to that found in our adults. However, AEC antibody had a significantly higher prevalence in individuals with active viral infection than in our healthy control groups (p = 0.00003). A positive association was noted between rubella and respiratory syncytial virus and AEC antibody presence and a negative association with varicella zoster. We conclude that AEC antibodies do not correlate with increased paediatric renal allograft loss but appear to be linked to certain viral infections.

Acute Disease↗

PubMed2002

Significant merits of a fibrin sealant in the presence of coagulopathy following paediatric cardiac surgery: randomised controlled trial.

OBJECTIVES: The efficacy of a fibrin sealant in paediatric cardiac surgery has been demonstrated. However, its effectiveness in the presence of significant untreated coagulopathy has not been addressed. This study was designed to investigate the role of the topical application of a fibrin sealant, Beriplast P (BP), in the presence of coagulopathy following paediatric cardiac surgery. METHODS: After confirming the presence of significant post-bypass coagulopathy, patients undergoing repair of congenital heart defects using cardiopulmonary bypass were randomised to the use of BP (group BP) or no intervention (group C). BP was applied over suture lines and microvascular bleeding sites. Criteria for transfusion of blood and blood products were standardised for both groups. Outcome variables were: (1) post-operative bleeding; (2) transfusion of blood and blood products; (3) theatre time to achieve haemostasis; (4) ventilation time, intensive therapy unit (ITU) and hospital stay. RESULTS: Fifty-two patients (n=26 in each group), aged 3 days to 17.4 years were recruited. There were no hospital deaths and no significant differences in demographic or intraoperative variables that might have affected the chosen endpoints. After protamine, all patients in both groups had significant coagulopathy (P< or = 0.05 versus baseline). There were fewer patients receiving transfusions of fresh frozen plasma (FPP) in the intervention group, when compared to the control group (P< or = 0.05). Patients receiving BP spent less time in theatre to achieve haemostasis (P< or = 0.05), had a lesser amount of bleeding intraoperatively (P< or = 0.01), at 4h (P< or = 0.05) and at 24h (P< or = 0.05), required a lower amount of transfusions of red cells (P< or = 0.01), FPP (P< or = 0.05) and platelets (P< or = 0.05). There were no differences in ventilation time, length of stay in ITU or in hospital. CONCLUSIONS: Even in the presence of significant coagulopathy, intraoperative use of fibrin sealant in paediatric cardiac surgery reduces the amount of bleeding and need for transfusions of blood and blood products. The theatre time necessary to achieve haemostasis is also significantly reduced. These findings have a potential to improve clinical outcomes and enhance cost benefits.

Adolescent↗

PubMed2005

Dishing the drugs: a qualitative study to explore paediatric nurses' attitudes and practice related to medication administration.

AIMS: The objectives of this study were to identify nurses' attitudes toward medication policies and the perceived factors that influence nurses' adherence to the medication policy or their ability to follow policy in the clinical environment of a tertiary paediatric hospital. METHODS: Using a focus group methodology, data were collated from a group of 32 nurses working in eight clinical areas of a tertiary paediatric hospital. Each discussion was transcribed and the data were subjected to a qualitatively based content analysis. RESULTS/FINDINGS: Four main categories emerged from the data including accessibility of information, time constraints, practice issues and professional conflict. CONCLUSIONS: Medication administration is a complex area of paediatric nursing practice. In an innovative attempt to assist in understanding nursing medication practice, this research has directly obtained nurses' perceptions of the factors that may influence their adherence to medication policy in the clinical environment. These results will inform future risk management strategies related to nursing medication practice.

Attitude of Health Personnel↗

PubMed2003

Update on Cochrane data on paediatric respiratory diseases.

INTRODUCTION: Systematic reviews seek to describe and summarise the best evidence for a given intervention by pooling data from relevant quality clinical trials. The Cochrane Collaboration has fostered the development and dissemination of systematic reviews throughout the world. We have identified and summarised The Cochrane systematic reviews of relevance to the paediatric pulmonologist. METHODS: We performed an expert search of the Cochrane Database of Systematic Reviews using a combination of medical subject headings and free text terms relating to paediatric respiratory disease. RESULTS: The search identified 120 systematic reviews with interventions specific to children with some relevance to pulmonary disease, and 327 reviews with interventions relating to pulmonary disease in adults and children. After pragmatic exclusions, 81 reviews were sorted by disease and 59 of these are discussed in detail. CONCLUSIONS: There are now many systematic reviews that make a positive contribution to paediatric pulmonology. The majority of reviews (69%) found evidence that either confirmed or refuted an accepted practice. The remaining reviews concluded that the evidence for an accepted practice is poor and sometimes wholly absent. Clinicians must be aware that lack of evidence of effect is not the same as evidence of lack of effect. Caution must be exercised before applying the conclusions of systematic reviews based upon adult data to childhood disease.

Adolescent↗

PubMed2002

The Italian experience on paediatric liver transplantation: 1988-1999 report.

BACKGROUND: Liver transplantation is the treatment of choice for end-stage liver disease in both adult and paediatric patients. The Italian experience in paediatric liver transplantation during the period 1988-1999 is reported herein. PATIENTS AND METHODS: This report concerns 228 liver transplantations performed in 207 patients (100 male, 107 female, mean age 5.1+/-4.4 years) in 11 Italian centres. The mean waiting time on the transplantation list was 6.1+/-8.9 months and the main indications for the procedure were biliary atresia, inborn metabolic disorders, liver cirrhosis, liver neoplasms, Alagille syndrome, and fulminant hepatic failure. RESULTS: The cumulative survival rate was 77%, 76%, 73%, and 71% at 1, 3, 5, and 7 years. The overall prevalence of acute rejection was 54%. Survival was significantly affected by re-transplantation (p=0.0002), by United Network for Organ Sharing 4 status at transplantation (p=0.016), and, among the indications for the procedure, by fulminant hepatic failure (p=0.004). Fifty patients (24%) died during the observation period. The main causes of death were primary non-function of the graft and sepsis CONCLUSIONS: This study shows that liver transplantation in paediatric age, in Italy, is an effective procedure providing a 5-year survival rate comparable to that attained in the largest published series.

Cause of Death↗

PubMed2006

Paediatric quality of life instruments: a review of the impact of the conceptual framework on outcomes.

With an increasing number of paediatric quality of life (QOL) instruments being developed, it is becoming difficult for researchers and clinicians to select the most appropriate instrument. Reviews of QOL instruments tend to report only basic properties of the instruments such as domains and psychometric properties. This paper seeks to appraise critically the conceptual underpinnings of paediatric QOL instruments. A systematic review was conducted to identify QOL instruments for children aged 0 to 12 years, and to examine and compare their conceptual frameworks, definitions employed, and structure. Both generic and condition-specific measures were reviewed. Fourteen generic and 25 condition-specific QOL instruments were identified. Eleven types of definition of QOL and health-related QOL and three theories of QOL were identified. QOL was measured by a variety of domains including emotional, social and physical health, and well-being. Items commonly assessed difficulties, or intensity/frequency of feelings/symptoms, in contrast to positive aspects of life and happiness. The findings highlight the diversity that is apparent in the conceptualization of paediatric QOL and draw attention to the lack of empirical evidence for many of the fundamental assumptions. The impact of the conceptual underpinnings of the instruments on the resulting QOL scores is discussed.

Affect↗

PubMed1993

Paediatric care and immunisation among Jordanian children.

This paper investigates the behavioural aspects of health care use for Jordanian children from birth to 3 years using data from a national survey. Statistical analyses indicate differences in the determinants of the use of paediatric care and immunisation: whereas immunisation coverage was already good in 1983 (and has improved subsequently), paediatric care is used for fewer than half of the children under 1 year of age. Socioeconomic and demographic characteristics of the population, especially female education, and maternal health care use, are important determinants of these patterns of child health care. The absence of differences in paediatric care and immunisation by sex of the child are discussed.

Adolescent↗

PubMed1986

The role of the paediatric endoscopist.

The role of the paediatric endoscopist has been a changing one. When I first commenced at the Royal Alexandra Hospital for Children in Sydney 25 years ago, paediatric endoscopy of the upper respiratory tract and oesophagus was a limited and poorly defined field. Most endoscopic examinations were requested, often reluctantly, by a paediatrician in the investigation of stridor. In fact my first consultation involved instructions to perform a laryngoscopy, but not a bronchoscopy and general anaesthesia was not to be used! How different the situation is now--the paediatric endoscopist is regarded as a true consultant and his opinion is sought in the investigation and management of congenital or acquired airway and intra-thoracic problems.

Anesthesia, General↗

PubMed1996

The developing role of a paediatric voice clinic: a review of our experience.

OBJECTIVE: We report our experience in developing a paediatric voice clinic within a tertiary otolaryngology department and describe the emerging role of this specialized clinic. MATERIALS: Currently our referral base is divided between other otolaryngologists within our department who require voice assessment as part of the pre- or post-operative management of laryngeal disorders (e.g. cysts, webs, vocal fold palsies, laryngo-tracheal reconstruction) and other professionals within our hospital who require characterisation of voice within the broader task of defining medical conditions in which voice abnormalities exist (e.g. mucopolysaccharidoses, functional dysphonias). METHODS: The patients were assessed by a team consisting of a paediatric laryngologist and a speech and language therapist. Each patient underwent a perceptual voice assessment and qualitative voice assessment using electrolaryngography. Direct visualisation was attempted and methods of and suitability for, such examination are discussed. RESULTS: Our experience is reviewed and guidelines for the establishment of a paediatric voice clinic are presented.

Adolescent↗