Critical incidents in paediatric critical care: who is at risk?

We evaluated the characteristics of children for whom critical incidents (CIs) were reported by performing prospective collection of patient data and retrospective review of reported CIs in a multidisciplinary neonatal–paediatric intensive care unit of a tertiary care university children’s hospital. A period of 1 year was analysed (January to December 2007; 1,251 admissions). CIs comprised adverse events (actual patient injury), as well as near-misses. The report form of critical incidents was web-based and reporting was voluntary, anonymous and non-punitive. The severity of all CIs was divided into minor, moderate and major. Patients with and without CIs were compared regarding the following characteristics: Paediatric Index of Mortality (PIM2), duration of mechanical ventilation, length of stay in the intensive care, admission mode (surgery, cardiopulmonary bypass, cardiac/non-cardiac unit), age and sex. There were 360 CI reports (83 per 1,000 patient days; 13% major, 26% moderate, 61% minor severity). Of these, 310 CIs could be assigned to 198 specific patients. In the univariate analysis, patient-related risk factors for CIs were higher PIM2 score (p < 0.0001), increased length of stay (p < 0.0001), mechanical ventilation (p < 0.0001), increased ventilator days (p < 0.0001), male gender (p = 0.022) and young age (p < 0.0001). Using a logistic regression model, mechanical ventilation (p < 0.0001), male gender (p = 0.034) and length of stay (p < 0.0001) continued to be associated with the occurrence of CIs. Conclusion CIs often occur in paediatric intensive care. Among the patient-related factors, male gender, mechanical ventilation, and length of stay are independently associated with CIs. Already known at admission to intensive care are male gender and, usually, requirement for mechanical ventilation. Improved knowledge of the risk factors for CIs could help to minimize their frequency and thus improve quality of care.     

What the paediatricians need—the launch of paediatric research in Europe

Most parents and many paediatricians are not aware that medicines for children are often not tested, labelled, or approved for their prescribed use. In 1997, the Food and Drug Administration developed incentives for pharmaceutical companies to perform paediatric research in medications. The European Commission brought out its proposal for paediatric incentives after in-depth internal reflection. Now it should be adapted quickly to boost pharmaceutical paediatric research in the EU as soon as possible. Conclusion:The proposal must be balanced and aware that both incentives and requirements are mandatory in order to maintain and stimulate paediatric research on medicines in Europe.     

Over-the-counter drug use—estimations within the Swedish paediatric population

We have used three different sources to estimate the use of drugs sold over the counter (OTC) by the Swedish paediatric population during 2007–2008 as part of a European evaluation initiated by the European Medicines Agency. An estimation of the paediatric use from the total numbers of over-the-counter drugs (OTCD) packages sold by Swedish pharmacies and analyses of two separate questionnaires directed towards a population of 11- to 14-year-old children and another towards visitors to one of the paediatric emergency wards in Stockholm County were included in the study. In Sweden, 1.25 OTC packages are sold quarterly per child (0–18 years), and the children in both questionnaire studies use, on average, 0.9 OTC substances. Sixty-five percent of the children visiting an emergency ward and 67% of the 13-year-old Stockholm inhabitants had used at least one OTCD. OTCD use among children is common. Interpretation of OTCD data must be done carefully since questions with regard to OTCD use is subject to recall bias and the number of packages sold to children is hypothesised through a conversion factor.     

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.     

After-hours paediatric telephone triage and advice: the Neuchâtel experience

Delivery of paediatric primary care by call centres has emerged as a satisfactory system. It has been reported in the literature in the United States and Australia. European public-funded paediatric emergency departments (ED) have little epidemiological data to rely on to match the demand in care. Since 1996, we have run a free nurse-led after-hours paediatric telephone triage and advice (TTA) system. To determine whether other Swiss public paediatric departments practiced formal TTA, we conducted a nation-wide postal survey. To delineate who used our call centre and for what reasons, we embarked on a retrospective study of all the 1997/2000 calls. Most of the units run a TTA (27/35) but few specifically train their staff (14/27). A 43% increase in call numbers was seen between 1997 (3242) and 2000 (4628). During week-days, most of the calls were between 6 and 11 pm and at weekends, a mid morning activity peak was seen. Some 75% of calls were for children aged 5 years or less. Fever, earache and cough accounted for 42% of the main complaints. Of all calls, 27% were dealt by nurses advice only. About 15% of the calls were transferred to the on-call resident. About 50% led to a same day ED appointment. Conclusion: Nurse-led paediatric telephone triage and advice is common in Switzerland where training seems to be irregular. Our data can help units to better plan an eventual paediatric telephone triage and advice service.     

Imaging the paediatric lung: what does nanotechnology have to offer?

This review will provide an overview of current research into lung imaging with nanoparticles, with a focus on the use of nanoparticles as molecular imaging agents to observe pathological processes and to monitor the effectiveness of nanoparticulate drug delivery systems. Various imaging modalities together with their advantages and limitations for lung imaging will be discussed. We will also explore the range of nanoparticles used, as well as active or passive targeting of nanoparticles.     

MR urography: the future gold standard in paediatric urogenital imaging?

Background. Examination of the paediatric urogenital tract is traditionally performed using methods that utilise ionising radiation, such as intravenous urography (IVU), computerised tomography (CT), voiding cystourethrography (VCU), and scintigraphy, in addition to ultrasound (US). Objective. To determine the potential and effectiveness of MR urography (MRU) in infants and children. Materials and methods. 44 MRU examinations were prospectively performed in 39 patients (21 infants, mean age 3.5 months, and 18 children, mean age 6 years 2 months) with known or suspected pathology of the urinary tract. Non-enhanced, fast spin-echo sequences (TSE) were performed in all patients. In 70 % of the patients a contrast-enhanced, fast gradient-echo sequence (TFE) was included. The dynamic sequence was prolonged and supplemented with furosemide provocation in some patients with suspected urinary-tract obstruction. Results. Nine percent of examinations were non-diagnostic or interrupted due to movement. MRU contributed additional information in 66 %. Nine patients with suspected urinary-tract obstruction were examined with both contrast-enhanced MRU and scintigraphy. Three MRU examinations were less informative and one equal to scintigraphy when obstruction was the diagnosis. When using a technique with a prolonged dynamic sequence, including frusemide provocation, four MRU examinations were equal and one was superior to scintigraphy. Conclusions. MRU has the potential to replace traditional diagnostic methods which use ionising radiation in paediatric patients. Further studies are needed before definite conclusions can be drawn. Received: 18 June 1998 Accepted: 9 March 1999     

Are the career choices of paediatric residents meeting the needs of academic centres in Canada?

BACKGROUND:

Responsibility for training paediatric medical subspecialists in Canada lies primarily with the 16 academic paediatric departments. There has been no mechanism to assess whether the number of residents in training will meet the needs of currently vacant positions and/or the predicted vacancies to be created by anticipated faculty retirement in the next five years across the different paediatric medical subspecialties.

HYPOTHESIS:

At the present time, the training of the paediatric physician is not linked with the current and future needs of the academic centres where the vast majority of these paediatric subspecialists are employed.

METHODS:

The academic paediatric workforce database of the Paediatric Chairs of Canada (PCC) for the surveys obtained in 2009/2010 were analyzed. Data included the number of physicians working in each subspecialty, the number of physicians 60 years of age or older, as well as the number of residents and their level of training.

RESULTS:

There are some paediatric subspecialties in which the actual number of trainees exceeds the currently predicted need (eg, cardiology, critical care, hematology-oncology, nephrology, neurology, emergency medicine and genetic-metabolic). On the other hand, for other specialties (eg, adolescent medicine, developmental paediatrics, gastroenterology and neonatology), assuming there is no significant change to selection patterns, an important gap will persist or appear between the need and the available human resources.

CONCLUSION:

The present analysis was the first attempt to link the clinical orientation of trainees with the needs of the academic centres where the vast majority of these paediatric subspecialists work.     

Primary Sjögren syndrome in the paediatric age: a multicentre survey

Primary Sjögren syndrome (SS) is very rare in childhood. We collected a series of primary paediatric SS cases from different centres. A data collection form was prepared and sent to rheumatologists who were willing to participate. Data on 40 cases of primary SS with onset before the 16th birthday were collected. Almost all patients (35/40) were females, age at onset varied from 9.3 to 12.4 years (mean 10.7 years). Signs and symptoms at disease onset were mainly recurrent parotid swelling followed by sicca symptoms. Abnormal laboratory tests were found in the majority of cases. Regarding treatment, 22 patients were treated at some time with oral corticosteroids, seven with non-steroidal anti-inflammatory drugs, and five with hydroxychloroquine; two patients needed cyclosporine and one cyclophosphamide. Follow-up varied from 0 to 7.5 years from onset, without major complications in the majority of patients. Conclusion: recurrent parotid swelling is a common feature of primary Sjögren syndrome in childhood and often occurs as a presenting feature. Sicca symptoms may be rarer.Abbreviations ANA antinuclear antibodies - ENA extractable nuclear antigens - ESR erythrocyte sedimentation rate - NSAID non-steroidal anti-inflammatory drugs - RF rheumatoid factor - SS Sjögren syndrome     

Current evidence for the use of paediatric antiretroviral therapy – a PENTA analysis

The introduction of combination antiretroviral therapy has been associated with a dramatic clinical improvement in children with human immunodeficiency virus infection. However, the uptake of antiretroviral therapy has been variable across Europe. The Paediatric European Network for the Treatment of AIDS Steering Committee has performed a systematic literature review of paediatric antiretroviral therapy trials. An analysis of the evidence base for the commencement and maintenance of antiretroviral therapy was produced. Suggestions for when to commence antiretroviral therapy, which drugs to start with and how to monitor and sequence drug regimens are given. Conclusion The aim of these guidelines is to help in obtaining equity of access to a uniformly high standard of care for children with human immunodeficiency virus infection in all European countries. Received: 15 November 1999 / Accepted: 16 February 2000     

Global paediatric surgery: meeting an unmet need—the response of the British Association of Paediatric Surgeons

Aim

Outline the response from an organisation regarding the unmet needs in global children’s surgery

Method

The burden of global surgical disease, whilst daunting, is becoming increasingly better defined as agencies, surgical colleges and professional specialty associations all attempt to increase capacity in terms of manpower, support education and find sustainable solutions to the deficit of health in treating women and children. However, definition of the problem does not in itself create change and similarly, humanitarian activities including volunteering by established surgical practitioners and other non-governmental organisations (NGOs) make only marginal improvement in the standards of care on offer at a global level.

Results

The International Affairs Committee, British Association of Paediatric Surgeons (BAPS) has had its target firmly set on investing in potential leaders within paediatric surgery in low- and middle-income countries (LMICs), and sharing elements of the educational programme made available for training within the UK and Ireland with the aim of contributing to the solutions of inequity in the surgical standards available to the world’s children.

Conclusion

This article outlines some of the practical steps that have been deployed by BAPS by way of sharing the responsibility for problem-solving at a global level. It also highlights the need for clarity in advocacy and the route through which effective communication can translate into wider and more effective delivery of surgical care for children.

     

Intraoperative 3-Tesla MRI in the management of paediatric cranial tumours—initial experience

Background  

Intraoperative MRI (ioMRI) has been gaining recognition because of its value in the neurosurgical management of cranial tumours. There is limited documentation of its value in children.     

Cortical thickness at the time of the initial attack in two patients with paediatric relapsing–remitting multiple sclerosis

BackgroundMultiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system with a low incidence in the paediatric population; cortical atrophy is often striking, even in the early stages of the disease. Evidence of cortical thinning in childhood MS is scant.AimsThis study aimed to assess cortical thickness in paediatric patients during the initial attack of remitting–relapsing MS.MethodsWe report two cases of remitting–relapsing MS, with initial attacks at 12 and 16 years of age. We analysed brain cortical thickness (CTh) in these patients and compared these data to the CTh of a control group comprised of six 12-year-old females and six 16-year-old males.ResultsBoth cases exhibited a total brain CTh significantly below that of the control group. This difference was also observed when analysing the CTh of all lobes except the left parietal lobe in one of the cases.ConclusionsCortical atrophy is already present at the time of onset of MS. Studies with larger patient populations that have a more homogenous clinical presentation could identify the time of onset of cortical atrophy and use this parameter as a prognostic and/or treatment marker of MS.     

What's new in paediatric sleep?

The major recent advance in our understanding of paediatric sleep is the publication of reference values for sleep in children aged 3.2-8.6 years. These data show developmental changes reflecting a subtle process of the maturation of the central nervous system with regard to sleep in childhood. In infants, a significant negative correlation has been observed between a snore-associated arousal index and an infant development scale, underlining that snoring is less innocent than has been suggested. A link between obstructive sleep apnoea (OSA) and airway inflammation has been demonstrated, with children with OSA having significantly higher expression of the leukotriene (LT) 1 and 2 receptors and higher concentrations of LT C4/D4/E4 and LT B4 in adenotonsillar tissues than children with recurrent rhinitis who have no OSA. This explains the efficacy of treatment for OSA with montelukast, a LT receptor antagonist, alone or in combination with corticosteroids. By using peripheral arterial tonometry, a noninvasive technique that allows the moment-to-moment measurement of sympathetic tone, persistent waking-associated autonomic nervous system dysfunction has been demonstrated in young children with sleep-disordered breathing (SDB). As such, SDB in childhood may represent a cardiovascular risk factor in adulthood.     

Does the empiric use of vancomycin in pediatrics increase the risk for Gram-negative bacteremia?

BACKGROUND: Gram-negative bacteremia in children, a major cause of morbidity and mortality, may in part be induced by intensive treatment procedures and nonspecific use of antibiotics. Our primary objective was to study the causal relationship between the use of vancomycin and Gram-negative bacteremia, for which this antibiotic is not specifically indicated. METHODS: The study was conducted in a 105-bed tertiary care children's hospital in the period of 1994 to 1997. The study pertains to a cohort of children with suspected bacteremia, in whom a blood culture was performed during hospital stay. Using the bacteriologic laboratory registration system, we selected all pediatric cases with bacteriologically proved Gram-negative bacteremia (n = 105) and a random sample of 225 pediatric controls with negative blood cultures. Using logistic regression analysis we examined associations between Gram-negative bacteremia and the following factors: preceding use of antibiotics, antacids, corticosteroids, surgery, mechanical ventilation, parenteral nutrition, and invasive instrumentation; and the intensity of care assessed with the Therapeutic Intensity Scoring System (TISS 28). RESULTS: Gram-negative bacteremia was positively associated with the use of aminoglycosides, cephalosporins, surgical interventions, central venous catheters, parenteral nutrition, antacids and dexamethasone. The strongest association was with the use of vancomycin (odds ratio, 8.1; 95% confidence interval, 3.1 to 20.9). In a multiple logistic regression model containing all above-mentioned variables, the use of vancomycin remained positively and strongly associated with Gram-negative bacteremia (odds ratio, 3.88; 95% confidence interval, 1.34 to 11.21). Further adjustments and restrictions in the analysis did not materially change these findings concerning vancomycin. CONCLUSIONS: Among children suspected of bacteremia there are several drugs and clinical procedures influencing the risk for Gram-negative bacteremia. Empiric use of vancomycin is strongly and independently associated with Gram-negative bacteremia. The safety of using vancomycin solely on the basis of suspicion of bacteremia in children may not be warranted.     

When to do paediatric gastrointestinal endoscopy?

Over the last few decades, paediatric gastroenterology has rapidly developed into a well-established sub-specialty. Improvements in training and equipment have led to enhanced safety with fewer complications following endoscopies. In specialized units, diagnostic and therapeutic upper gastrointestinal endoscopy and proctosigmoidoscopy/colonoscopy are regularly performed under conscious sedation or general anaesthesia. Emerging guidelines and new advances in the diagnostic tools are being incorporated into routine paediatric gastrointestinal endoscopy practice.     

Where should paediatric surgery be performed?

We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals. There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre. Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in are than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK. There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists. The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that "Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient 'critical mass' for clinical effectiveness." Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results. The same seems to be true in the fields of oncology, radiology, pathology, and intensive care. The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states "that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management." The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England, the British Association of Paediatric Surgeons, the Senate of Surgery of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, the Audit