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PubMed2000

A 7-year review of deaths on the general paediatric wards at John Hunter Children's Hospital, 1991-97.

OBJECTIVE: To study the palliative management of children dying on the wards of a tertiary referral centre. In particular to identify areas of difficulty and discuss ways in which these can be improved. METHODOLOGY: All children between the ages 1 and 19 years dying on the general paediatric wards of the John Hunter Children's Hospital (JHCH) (a tertiary referral centre in New South Wales Hunter Valley) between 1991 and 1998 were included in the study. The main outcome measures were the duration of 'terminal care only' treatment; time spent in hospital in the previous year; analgesia used, dose and route of administration; adjuvant medications; quality of life in the final 24 h. RESULTS: Eighteen children (aged between 1 and 19 years) died on the general paediatric wards at JHCH between 1991 and 1998. The most common diagnosis was malignancy (five patients), with cystic fibrosis, cerebral palsy and a degenerative neurological disorder each accounting for four patients, and one child had herpes simplex encephalitis. In all children the terminal nature of their condition was recognized and in all but three patients there was documentation of 'not for resuscitation' (NFR) orders following discussion with the child's parents. The mainstay of analgesia was an intravenous narcotic infusion with 11 (61%) children needing a morphine infusion. Fifteen patients (83%) required other medications including antiemetics, anticonvulsants and corticosteroids. Twelve (66%) children were semiconscious or unconscious on the day of death. Three children were uncomfortable and distressed, one alert and symptom free and in two cases the level of consciousness was not recorded. Three children continued to have seizures until their death. CONCLUSION: The majority of terminally ill children were managed well with intravenous narcotics and adjuvant medications. There may be scope for such children to be managed successfully at home with appropriate support for the general practitioner by paediatric and palliative care specialists. Some cases in which palliation is difficult do remain in hospital and additional measures need to be employed to ensure a symptom free death for these children.

Adolescent↗

PubMed2003

Paediatric bronchiectasis in the twenty-first century: experience of a tertiary children's hospital in New Zealand.

OBJECTIVE: Despite its decline in developed countries, bronchiectasis appeared to be a common diagnosis in Auckland, New Zealand children. The aims of this study were: to document the number of children in Auckland with bronchiectasis, their severity, clinical characteristics and possible aetiologies; to assess whether there was a relationship between ethnicity and poverty; and to estimate a crude bronchiectasis prevalence rate for New Zealand. METHODS: A retrospective review of the case histories of all children attending a tertiary children's hospital in Auckland with bronchiectasis diagnosed by high-resolution chest computed tomography (CT) scan, during the period 1998-2000 was undertaken. Data collected included patient demographics, number of hospitalizations pre- and post-diagnosis, lung function tests, radiology and investigations. The New Zealand deprivation 1996 index was applied to the data to obtain a measure of socio-economic status. RESULTS: Bronchiectasis was found to be common, with an estimated prevalence of approximately one in 6000 in the Auckland paediatric population. It was disproportionately more common in the Pacific Island and Maori children. In Pacific Island children, bronchiectasis not caused by cystic fibrosis was nearly twice as common in the general population than cystic fibrosis. Socio-economic deprivation and low immunization rates may be significant contributing factors. The bronchiectasis seen was extensive. Ninety-three percent had bilateral disease and 64% had involvement of four or more lobes on chest CT scan. A wide range of comorbidities and underlying aetiologies were evident. CONCLUSIONS: Paediatric bronchiectasis in Auckland, New Zealand, is common but underresourced. Only the most severe cases are being recognized, providing a significant challenge for paediatric health professionals.

Administration, Inhalation↗

PubMedDate not supplied

Extended paediatrics: acute care in children's homes.

The Extended Paediatric Service was established in 1996 to provide acute care services to children in their homes with the aim of reducing the number of hospital admissions for children and shortening hospital stays while maintaining continuity of care. Extended Paediatrics builds on, and extends, the principles of Discharge Liaison and Hospital In The Home programmes. The service is staffed by nurses who also work within the paediatric ward of the Launceston General Hospital, providing a high degree of continuity of care for these children. Children are admitted to the service through consultation between medical staff, nursing staff and the child's family. Between August 1996 and December 1999 a total of over 1200 visits to 48 children have been made for various treatments, for tests, education or follow up. Improved outcomes for children and their families have been reported by both staff and parents as a result of the service.

Child↗

PubMed2002

Paediatric sedation in emergency department: what is our practice?

OBJECTIVES: The aim of the present study was to document the use of sedation in paediatric patients in emergency departments within Australia and New Zealand. METHODS: A questionnaire was sent to 54 emergency departments throughout Australia and New Zealand. RESULTS: A total of 45 departments (83%) responded to the survey. Because the adult departments (n 5) reported few paediatric attendances, they were not included in the analysis. Thirty-nine of 40 departments (97.50%) reported using sedation in children. Midazolam was used most frequently (77%) for sedation. There was marked variation in the route of delivery and the dose of midazolam used. Ketamine was reported as the most efficacious agent used, but it was used only in 12% of cases. Formal guidelines existed in all paediatric departments but only in 58% of mixed departments, and formal discharge criteria were used in only 52% of all departments. The use of topical anaesthesia in wound closure was reported in only 3,000 of departments. CONCLUSIONS: There exists wide variation in practice regarding the use of sedation in children in emergency departments throughout Australia and New Zealand. Thus, the development of adequate guidelines, including discharge instructions and the use of topical agents, will improve sedation for children.

Australia↗

PubMed1999

A comparison of two concentrations of bupivacaine and adrenaline with and without fentanyl in paediatric inguinal herniorrhaphy.

This study was designed to determine whether administration of caudal bupivacaine with fentanyl would have any effect on analgesia in paediatric patients undergoing inguinal herniorrhaphy repair. Fifty-six outpatient paediatric patients undergoing inguinal hernia repair were evaluated. Patients received, in a randomized manner, 1 ml.kg-1 of either bupivacaine 0.25% or 0.125% with or without fentanyl 1 microg.kg-1. There was no difference in pain scores in the hospital, the night of surgery, or 24 h postoperatively nor was there a difference in the oral analgesics administered between any of the groups. There was a higher incidence of vomiting at home in both 0.25% bupivacaine groups irrespective of the use of fentanyl. The 0.125% bupivacaine group had significantly more patients who received intravenous fentanyl in the PACU than did the other three groups (P<0.001). Increasing the concentration of bupivacaine from 0. 125% to 0.25% increased the incidence of postoperative vomiting. We recommend that clinicians utilize bupivacaine 0.125% with 1 microg. kg-1 fentanyl as the caudal injectate in paediatric patients undergoing inguinal hernia repair.

Administration, Oral↗

PubMed2000

The adult Bullard laryngoscope as an alternative to the Wis-Hipple 1(1/2) in paediatric patients.

This prospective, randomized study was undertaken to compare the adult Bullard laryngoscope (BL) with the Wis-Hipple laryngoscope (WhL) in paediatric patients with regards to laryngeal view and time to intubation, and whether its efficacy was related to age or weight. Fifty patients scheduled for general anaesthesia between the ages of 1 and 5 years were examined. Patients were randomized into two groups: one group had an initial laryngoscopy via the WhL and then had a laryngoscopy and intubation using the BL; the second group had an initial laryngoscopy with the BL and then had a laryngoscopy and intubation using the WhL. The laryngeal view, attempts at intubation, time to intubation and the reason for any difficulty with intubation were recorded. Correlation was then sought relating attempts and time to intubation with age, and weight. Mean time to intubation was 20 +/- 6 s in the WhL group and 26 +/- 9 s in the BL group (P < 0.02). The majority of the patients had similar laryngeal views in both groups; three patients had a superior view with the BL. Failed intubations occurred in two BL patients; the tracheas were both intubated with the WhL. In one patient, intubation was not possible with the WhL but it was successful with the BL. Multiple passes of the tube off the BL most frequently occurred because of right aryepiglottic fold contact or anterior vocal cord contact. The latter appears to be more problematic when the adult BL is used in the paediatric population. No relationship was found between the time to intubation and age or weight. In an occasional child, the BL provides a superior laryngeal view and provides a means for a successful intubation when a failure with the WhL occurs. Although intubation of children aged 1-5 years takes longer with a BL than a WhL, the adult BL complemented the WhL laryngoscope in paediatric patients.

Adult↗

PubMed2001

Perioperative management of total parenteral nutrition, glucose containing solutions, and intraoperative glucose monitoring in paediatric patients: a survey of clinical practice.

Infants and children, particularly those who are chronically ill and maintained on total parenteral nutrition (TPN), are at risk for perioperative hypoglycaemia [blood glucose < 2.2 mmol x l(-1) (40 mg x dl(-1))] and hyperglycaemia [blood glucose > 11 mmol x l(-1) (200 mg x dl(-1))]. We surveyed paediatric anaesthesiologists regarding their perioperative management of blood glucose and TPN in paediatric patients to determine the current practice and its perceived success. Questionnaires were mailed to all members of the Study Group on Pediatric Anesthesia and the response rate was 70%. Results indicate that the current perioperative management of blood glucose and TPN is somewhat varied. Furthermore, greater than 10% of those surveyed report that their management results in a variable response in the maintenance of normoglycaemia. While the detrimental effects of perioperative hypoglycaemia and hyperglycaemia are rare, they are serious. A Medline search shows that no studies have been published regarding perioperative management of paediatric patients receiving TPN, although it appears that clinical study is warranted.

Blood Glucose↗

PubMed2001

Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation.

A postal survey of the use of cuffed or uncuffed tracheal tubes for tracheal intubation in children and infants was performed to investigate the criteria used for deciding the choice of tube and the manner of inflating the cuff in the case of use of a cuffed tracheal tube (CTT). From 200 questionnaires despatched, replies were received from 130 paediatric anaesthesiologists (response rate 65%). In paediatric practice, the CTT was routinely used by 25% of respondents for more than 80% of their patients, while more than 37% of respondents use them in less than 20% of the cases. The three main criteria used for inflating a cuff were: (i) the presence of a leak, (ii) the type of surgery associated with the presence of a leak and (iii) the patient's age associated with the type of surgery and the presence of a leak. These criteria were specified, respectively, by 32%, 24% and 18% of the respondents. The cuff was inflated in response to a leak in 18% of the cases and as a response to a pressure manometer in 15% of the cases. Few paediatric anaesthesiologists use a cuffed tracheal tube routinely for tracheal intubation in children, and fewer actually use a pressure monitoring device, while it is suggested that the cuff pressure should be monitored in case of CTT.

Child↗

PubMed2002

Evaluation of a new paediatric scavenging valve.

BACKGROUND: Prolonged exposure to anaesthetic gases may be associated with adverse effects. Scavenging is in widespread use in adult anaesthesia but it has been more difficult to find a satisfactory solution for use in paediatric anaesthesia. The Exeter Paediatric T-piece Scavenging (Exeter PTS) valve has been designed for use with a modified Jackson-Rees system to allow connection to an active or passive Approved Gas Scavenging System. METHODS: Use of the Exeter PTS valve was evaluated in 35 spontaneously breathing paediatric patients (mean age 4.7 years, mean weight 16.7 kg) using each patient as their own control. Atmospheric pollution was measured using a Miran 1B infrared spectrophotometer. RESULTS: When using a modified Jackson-Rees breathing system with an open-ended bag, pollution levels of isoflurane exceeded the Occupational Exposure Standard of 50 p.p.m. When the Exeter PTS valve and an active scavenging system were used, pollution was significantly reduced to below 5% of the recommended limit. CONCLUSIONS: We conclude that there is a need to reduce atmospheric pollution when using a modified Jackson-Rees system in spontaneously breathing patients and that this can be achieved by use of the Exeter PTS valve.

Air Pollutants, Occupational↗

PubMed2002

Accuracy of visual estimation of body height and weight in supine paediatric patients.

BACKGROUND: When it is impossible to measure the weight and height of paediatric patients, these are usually estimated. We undertook this study to see how accurate these estimates are in practice. METHODS: Five observers estimated body height and weight, and subsequently calculated body surface area, in 48 paediatric inpatients who were lying on surgical ward trolleys. RESULTS: Regression analysis of the data revealed that good correlations existed between estimated and actual body size in all the investigators. However, we found large percentage errors in estimation for infants and younger children with small physical size, and a variation in scatter distribution of estimation errors among the five investigators. CONCLUSIONS: These findings suggest the necessity to titrate drug doses for administration in this small paediatric population.

Adjuvants, Anesthesia↗

PubMed2003

Paediatric intubation in Scottish emergency departments.

BACKGROUND: Intubation of children in the emergency department setting is uncommon. This prospective observational study examines the practice of paediatric intubation in Scottish adult/paediatric urban emergency departments. METHODS: A prospective observational study of every intubation attempt was performed in seven urban Scottish emergency departments in 1999 and 2000. Children were defined as those patients who were less than 13 years of age on the day of presentation. Prehospital intubations were only included if they were performed by a mobile medical team doctor from one of the seven hospitals. RESULTS: A total of 1713 patients were identified, 44 of whom (2.6%) were children. The median age was 4 years (range 0-12 years), and 57% (25 of 44) of intubations were performed on patients with traumatic injuries. Emergency physicians attempted intubation in 27% (12 of 44) of cases, anaesthetists in 73% (32 of 44); 18% (eight of 44) of patients were intubated in nontraumatic cardiac arrest, 68% (30 of 44) underwent rapid sequence intubation (RSI), one (2%) had inhalational anaesthesia and 13 (30%) were intubated without drugs. Eighty per cent (35 of 44) of patients were intubated at the first attempt; eight patients required two attempts, and one required three attempts. Three children were intubated prehospital by mobile medical teams. Emergency physicians intubated more patients with 'physiological compromise' (100% vs 91%). CONCLUSIONS: Paediatric intubation in the emergency department is uncommon. Collaboration and appropriate training for doctors in emergency medicine, anaesthesia and paediatrics is essential.

Adolescent↗

PubMed1998

Behavioural problems in children with urge incontinence and voiding postponement: a comparison of a paediatric and child psychiatric sample.

UNLABELLED: OBJECTIVE; To analyse prospectively the incidence of behavioural disorders and the subjective views of children with urge incontinence (defined by detrusor instability, sudden urge symptoms and frequent micturitions) and voiding postponement (characterized by delayed micturition in typical situations and a low voiding frequency) according to an identical protocol in a paediatric and a child psychiatric unit. PATIENTS AND METHOD: Ninety-four consecutive or randomly selected children aged 5.0-10.9 years with either voiding postponement (52) or urge incontinence (42) were examined prospectively using an intelligence test (CFT1 or CFT20), the Child Behaviour Checklist (CBCL 4/18), the ICD-10 child psychiatric diagnoses and a structured interview. RESULTS: In the groups from both centres combined, those postponing voiding had a significantly higher incidence of externalizing behavioural symptoms (31% vs. 8%; P < 0.01) and total problems (37% vs. 13%; P < 0.05) in the clinical range (CBCL), and a higher rate of at least one ICD-10 child psychiatric diagnosis (54% vs. 29% P < 0.05) and of expansive disorders (31% vs. 5%; P < 0.01). The incidence of children with behavioural symptoms was lower in the paediatric centre, being exceptionally low among urge incontinent children (only 6%, CBCL). In contrast, from the children's subjective appraisal, there were no significant differences in concepts, explanations and implications of wetting; 79% of urge incontinent children and 64% of those postponing voiding suffered emotionally from the adverse effects of wetting. Only a minority (3% vs. 6%) saw any advantages at all. CONCLUSION: Children with voiding postponement had a significantly higher incidence of behavioural problems, especially expansive/externalizing behaviour, 3-4 times higher than in the normal population. Children with urge incontinence had a significantly lower incidence of behavioural problems, mainly emotional/ internalizing behaviour, that was only slightly higher (1-2 times) than that in the normal population. Because of selection, similar trends but lower incidences were found in the paediatric setting, with very few problems among urge incontinent children. In contrast, the children's subjective views did not differ; disadvantages associated with emotional suffering were reported by all children.

Attitude to Health↗

PubMed2003

The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses.

Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.

Adaptation, Psychological↗

PubMed2001

New normal limits for the paediatric electrocardiogram.

AIMS: Previous studies that determined the normal limits for the paediatric ECG had their imperfections: ECGs were recorded at a relatively low sampling rate, ECG measurements were conducted manually, or normal limits were presented for only a limited set of parameters. The aim of this study was to establish an up-to-date and complete set of clinically relevant normal limits for the paediatric ECG. METHODS AND RESULTS: ECGs from 1912 healthy Dutch children (age 11 days to 16 years) were recorded at a sampling rate of 1200 Hz. The digitally stored ECGs were analysed using a well-validated ECG computer program. The normal limits of all clinically relevant ECG measurements were determined for nine age groups. Clinically significant differences were shown to exist, compared with previously established normal limits. Sex differences could be demonstrated for QRS duration and several amplitude measurements. CONCLUSIONS: These new normal limits differ substantially from those commonly used and suggest that diagnostic criteria for the paediatric ECG should be adjusted.

Adolescent↗

PubMed2002

Management of suspected cervical spine injuries--the paediatric perspective.

Paediatric cervical spine immobilisation and management is one of the most difficult tasks to master in the paediatric trauma population. The Royal Children's Hospital--Melbourne has admitted 54 patients with diagnosed cervical spine injuries since January 1999. The management of such patients admitted to acute care facilities with suspected cervical spine injuries is inconsistent and at times sub-optimal. Management controversies centre around, application of cervical collars, clearance of the c-spine, patient movement and general care principles. In an endeavour to address these issues, the Royal Children's Hospital Trauma Service, in conjunction with the Emergency Department developed cervical spine guidelines. Teams consulted in the formulation of these guidelines included, Emergency Department, Intensive Care Unit, Orthopaedics, Neurosurgery, Radiology and General Surgery. These guidelines were developed as a clinical tool to guide management and standardise the approach of care for these patients. Specifically, the guidelines address: immobilisation of the paediatric cervical spine; radiology; clearing the cervical spine of injury; suspected or proven cervical spine injury; guidelines for times to fitting Philadelphia collar; ongoing care.

Accidents↗

PubMed2002

An oral care protocol intervention to prevent chemotherapy-induced oral mucositis in paediatric cancer patients: a pilot study.

The likelihood of paediatric cancer patients experiencing oral mucositis has increased significantly as high-dose and multiple chemotherapy agents are used in the treatment of childhood cancer in recent years. The resulting oral ulcerative lesions can cause significant pain, dysphagia, alteration in nutritional status and increased risk for localized infections that could disseminate systemically. The purpose of this pilot study was to determine the clinical benefits of an oral care protocol intervention on the prevention and reduction of the severity of oral mucositis in paediatric patients receiving chemotherapy. Fourteen children were enrolled in the study; there were seven children in the control and seven in the experimental group. In the experimental group, children received a preventive oral care protocol consisting of tooth brushing, normal saline rinse and 0.2% chlorhexidine mouth rinse. Children in the control group received usual care according to the study's clinical setting. Data were collected at baseline, then twice a week for 3 weeks. The incidence of ulcerative lesions, severity of oral mucositis and the related pain intensity were used as the main outcome variables. The experimental group exhibited fewer and less painful oral mucositis lesions. The results of this study support the preventive use of oral care protocols in paediatric patients undergoing chemotherapy for cancer treatment.

Journal Article↗

PubMed2002

What's new in minimally invasive paediatric surgery?

There has been substantial progress in minimally invasive techniques in children in recent years. Numerous investigators have shown that laparoscopic and thoracoscopic paediatric surgery can be performed safely. It has been postulated that minimally invasive paediatric surgery is associated with low morbidity, a shorter hospital stay, lower costs and clinical results similar to those achieved by open surgery. The present article reviews information from the past 2 years on the pathophysiological effects, feasibility, standards, new techniques, the importance of the method in malignant diseases and robotics. However, most of these reports still focus on safety and feasibility. It would be preferable if the paediatric surgical society itself would discriminate between useful and useless or harmful techniques. Therefore, further systematic research on the advantages and limits of minimally invasive surgery in children is mandatory.

Child↗

PubMed2005

Paediatric trauma in Spain: a report from the HUGM Trauma Registry.

OBJECTIVES: To analyse the characteristics of the infant population suffering trauma in our setting. To evaluate the importance of the different aetiological mechanisms. To study the pre- and intra-hospital management of these children. To describe the relative significance of the different lesions. To establish the magnitude of paediatric trauma as a social problem in terms of morbidity and mortality. MATERIAL AND METHODS: From January 1995 to April 2002, a total of 2633 children admitted to our Centre (Hospital Universitario Gregorio Maranon) after suffering some type of injury were included in our Trauma Register. 108 variables have been analysed, including the identification of the patient, type, site and mechanism of the accident, pre-hospital care, transport, complete evaluation on admission, indices of injury severity, diagnostic tests, lesions, treatments performed and morbidity and mortality. RESULTS: The accidents were more frequent in boys than in girls (68.5 % versus 31.5 %). The predominant age group was the 12 - 15 year old group (36.8 %). There was a higher frequency of accidents in the street (37.2 %) than at home (19.4 %) or at school (13.8 %). The most frequent mechanism was a fall (35.6 %), followed by road traffic accidents (23.7 %). On admission, 14.7 % of the children had a Paediatric Trauma Score (P.T.S.) < or = 8 (n = 388). 3.8 % were considered severe multiple trauma patients, presenting an Injury Severity Score (I.S.S.) > or = 15 (n = 101). 4.2 % of the children required intensive care. The most frequent lesions were those of the locomotor system (58.1 %) and head injuries (34.9 %). Some type of surgical or orthopaedic procedure was performed under general anaesthesia in 1522 patients (57.8 %). The mean length of stay was 4.4 days (range 1 - 214 days). Sequelae of some form were detected in 36.4 % of the patients over 3 years of age. The total mortality was 0.5 % (n = 13), being 12.8 % in the group of patients with an I.S.S. > or = 15. CONCLUSIONS: Analysis of the data in our Registry has helped us to define the characteristics of the paediatric trauma population in our setting, to monitor the management of trauma in the different care levels and to develop prevention programmes. It has also enabled us to compare the results with those of other centres in terms of morbidity and mortality with the aim of identifying and correcting any possible deficiencies in the care system.

Accidents↗