Paediatricians involvement in paediatric emergency care. A study in hospitals and paediatricians offices in the North of France]

Paediatrician involvement in paediatric emergency care is often considered insufficient. OBJECTIVES: To assess paediatrician involvement in paediatric emergency care, and how paediatric emergencies were dealt with in emergency department, paediatric emergency department, paediatric department and paediatrician offices. METHODS: Prospective multicentric study, January 29th, 2001, including all the emergency visits of children admitted to an emergency department, paediatric emergency department, paediatric department or in paediatrician offices. RESULTS: Paediatricians examined an average number of 21 children, 58% were considered as "urgent" (mean: 53% +/- 25% by paediatrician). Thirty five percent of paediatricians were available on call that night. In the 18 hospitals, 705 children were admitted that day, 42% to an emergency department, 40% to a paediatric emergency department, 18% to a paediatric department. The mean age was 6 years +/- 5 years. Trauma represented 40% of all cases and was more frequent in emergency department than in paediatric emergency department or paediatric department (63% versus 33% and 2%, p < 10(-8)). Hospitalisation rate was lower in paediatric emergency department than in emergency department and paediatric department, especially for non-traumatic conditions. CONCLUSION: Our findings prove paediatrician involvement in paediatric emergency care, in paediatrician offices and in hospital. This study points out the complementarity and insufficiencies of these different services.     

The European Regulation on medicines for paediatric use

The European Regulation on medicines for paediatric use entered into force on 26 January 2007. It marks a radical change in the European Union in terms of encouraging the development of medicines for paediatric age groups and improving the availability of information on the use of medicines in children. How will the new Paediatric Regulation achieve this? For the first time, companies will be required to study medicines in the paediatric population and develop age-appropriate formulations. As a reward or incentive for conducting these studies, companies will be entitled to extensions of patent protection and market exclusivity. The Regulation establishes a European paediatric clinical trials network and a paediatric study programme for off-patent medicines, the latter to be funded through the Community Framework Programmes. A Paediatric Committee, based at the European Medicines Agency, will be responsible for agreeing the paediatric investigation plan (PIP) with companies. This will describe the clinical trials and other measures necessary to investigate a particular medicine in the paediatric population. A European paediatric clinical trials database, partly accessible to the public, will hold the details and the results of all paediatric trials conducted in line with these PIPs. All medicines authorised for a paediatric use will be identified by a new symbol on the package label. After 5 years, there will be a stocktake with a view to making changes to the Regulation if necessary.     

Impact of the new european paediatric regulatory framework on ethics committees: overview and perspectives

Aim: To evaluate the impact of the new European paediatric regulatory framework on the activities of Ethics Committees operating in Europe and to assess their involvement and interest in paediatric research. Methods: Task‐force in Europe for Drug Development for the Young Network of Excellence and Relating Expectations and Needs to the Participation and Empowerment of Children in Clinical Trials project set up an inventory of Ethics Committees existing in Europe and conducted a survey on their approach to paediatric trials. Results: Ethics Committees operating in 22 European Countries participated in this survey. Results showed a high lack of knowledge, understanding and awareness of the current European paediatric regulatory framework and a lack of involvement of Ethics Committees in paediatric research, especially in terms of training and education, demonstrated also by the decreasing number of Ethics Committees answering exhaustively to the whole questionnaire. The majority of participating Ethics Committees expressed interest in future initiatives related to paediatric research. Conclusions: Despite a limited knowledge and understanding of the current paediatric regulatory framework, a significant number of Ethics Committees operating in Europe show interest in initiatives related to paediatric research. Networking may be an essential tool to be used to enhance Ethics Committees role in supporting paediatric research. Any initiative should be undertaken at European level in collaboration with European Union Institutions.     

Paediatric problems in a paediatric surgical department

It is not unusual for paediatric surgical patients to suffer from paediatric diseases in addition to their surgical problems. These diseases demand further diagnostic procedures and pre- or postoperative therapy. The aim of this study was to discover how many and what kinds of additional paediatric diseases are seen in our paediatric surgical inpatients. We retrospectively evaluated the hospital charts of all inpatients for 1 year. The following data were collected: cause of admission, therapeutic procedure (conservative/operative), surgical discharge diagnosis, additional paediatric diagnoses, and transfer to other departments. A total number of 5,026 hospital stays for 5,840 operations in 4,300 children was evaluated. In 38% of all hospital stays, the children had one or more paediatric diseases. These could be divided into two groups: acute diseases and chronic conditions. In the acute group, 638 children suffered from acute infectious diseases such as respiratory infections and enteritis/gastroenteritis. The most common chronic conditions were allergy, asthma, epilepsy, anaemia, and mental retardation. A special group of patients consists of 21% of the children admitted because of suspected appendicitis. These children not only had a significantly higher incidence of additional paediatric diseases (mostly acute infectious diseases), but also a higher incidence of atopic diseases compared with the patients admitted for other reasons. The early diagnosis and treatment of additional paediatric diseases is essential for the success of paediatric surgery. The paediatrician has a significant role in caring for surgical patients and assisting in the perioperative management, but the paediatric surgeon should also be aware of the spectrum of medical diseases.     

Nouveaux enjeux de la recherche clinique en psychopharmacologie chez l’enfant et l’adolescent

A large proportion of medicines used in children are actually prescribed off-label, which can place children at a direct risk of under- or overdosing and a delayed risk of long-term adverse effects, and children have often been denied access to new or innovative medications. Many generations of paediatricians and other physicians have learned to live with the situation. But because such situation is nowadays considered as unethical, the need to obtain paediatric information for medicines used in children seems a matter of consensus on a global basis. If the therapeutic effects of amphetamines in hyperactive children were first described in 1937, thus, preceding the major discoveries of adult psychopharmacology, since this little innovation has occurred in paediatric psychopharmacology. However, it is widely recognized that mental disorders in children and adolescents lead to a major burden for them and for their families. Over the past decade, under the impulsion of the US paediatric legislation, the number of high quality paediatric psychopharmacological studies has dramatically increased. Like what happened in the US, it was clear in European Union, that there was a need for a legal obligation for Pharmaceutical Companies to perform studies in paediatric populations, and a new Paediatric European Regulation came into force in 2007, opening a new era in the history of European regulation with the ambition of improving the health of children and adolescents. Therefore drug development is changing; the concern of protecting children against clinical research fading away, a new paradigm is now emerging, i.e. protecting children through clinical research. In Europe, paediatric development is no longer an option but needs to be truly integrated in clinical development plans with paediatric evaluations being a regular part of every drug development process. It seems reasonable to anticipate that more research may occur as well in paediatric psychopharmacology and more studies will be enrolling paediatric patients all over the world in the forthcoming years. But paediatric clinical development is difficult and the hurdles of conducting clinical trials in paediatric population are numerous. This article presents briefly the new European Paediatric Regulation, illustrates its purpose through the example of antidepressants in children and adolescents, and discusses new research challenges in paediatric psychopharmacology. Ultimately, it is through well-conducted research that children will gain access to new medications and receive safe and optimal drug therapy.     

Paediatric psychotherapy: a service in a general outpatient clinic.

The service of paediatric psychotherapy to a general paediatric outpatient clinic is described. Using techniques developed to suit paediatric patients a median of nine patients each clinic were treated. Referral symptoms resolved in a median time of four months after a median of seven sessions. This model for the management of paediatric patients with emotional and behavioural difficulties may allow an effective and efficient use of psychotherapy time.     

The scope of emergency paediatric surgery in Tanzania

This article helps to outline the scope of emergency paediatric operations in Tanzania by quantifying the nature of cases seen over a 12 month period in a teaching hospital. Data collected at the Kilimanjaro Christian Medical Centre (KCMC) showed that operative paediatric surgical emergencies represented 4% of all paediatric admissions. Of emergency procedures, 47 (43%) were for congenital abnormalities, 32 (29%) for infections, 19 (17%) for trauma and 12 (11%) for other reasons. Emergency operative mortality was 34%. The challenges to meet patient needs in the African setting include: a scarcity of surgeons with training in paediatric surgery, the variety of conditions which all surgeons must manage, a lack of equipment (e.g., neonatal ventilators) and educational resources. Potential avenues for overcoming these challenges are discussed, including the promotion of paediatric surgery as a profession, by the expansion of existing facilities, promoting African associations of paediatric surgery and highlighting the need for resources and continued education and training. We argue that surgical training in developing countries should include the skills needed to treat those paediatric conditions most likely to require urgent surgical intervention.     

Consultant paediatric outreach clinics--a practical step in integration.

Ten years' experience of paediatric outreach clinics is reviewed and evaluated. The advantages and disadvantages of paediatric outreach and its possible place in the new era of contracting and more developed community paediatric services are discussed. It is concluded that paediatric outreach increases parental and professional choice and access to paediatric consultant services, increases service flexibility, reduces unnecessary hospital visits, and enables more rational and relevant clinical decision making. Outreach is particularly relevant in areas of deprivation where paediatric needs are greatest.     

Consultant paediatric outreach clinics--a practical step in integration

Ten years' experience of paediatric outreach clinics is reviewed and evaluated. The advantages and disadvantages of paediatric outreach and its possible place in the new era of contracting and more developed community paediatric services are discussed. It is concluded that paediatric outreach increases parental and professional choice and access to paediatric consultant services, increases service flexibility, reduces unnecessary hospital visits, and enables more rational and relevant clinical decision making. Outreach is particularly relevant in areas of deprivation where paediatric needs are greatest.     

Creating and being created: the changing panorama of paediatric rehabilitation

Paediatric rehabilitation as a discipline is rapidly changing, especially during the last decades. In the past, paediatric rehabilitation was characterized by merely adult intervention strategies in a miniaturized form, delivered by a merely adult patients-oriented profession. Theories on childhood development, however, changed, as did the focus of interventions: from impairments to function, from the child itself to family, community and peers. The call for outcome-oriented and evidence-based medicine lastly, changed paediatric rehabilitation into a mature paediatric profession with it's own scientific framework. This is reflected among other things in the increasing number of paediatric measures and instruments specifically geared to the paediatric rehabilitation profession, for example the Gross Motor Function Measure, Paediatric Evaluation of Disability Inventory and Movement ABC. More recently, paediatric exercise physiologists are pointing to the benefits of an active lifestyle and training for patients with chronic diseases and disabilities. Several studies have evaluated the effects of such training programmes and came up with positive results. It shows that paediatric rehabilitation continues to develop as a dynamic profession, having growth, childhood development and childhood activities as it's core business.     

Quality in paediatric emergency medicine: Measurement and reporting

There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality ‘scorecard’ that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.     

Non‐urgent paediatric emergency department presentation: A systematic review

There has been an increase in the use of the emergency department (ED) for non‐urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non‐urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non‐urgent ED presentation in paediatric populations. Thirty‐one articles met the inclusion criteria. The mean proportion of non‐urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non‐urgent ED use in paediatric populations. The findings of this review suggest that non‐urgent ED use in paediatric populations is high. However, non‐urgent ED use and the reasons for the visits in paediatric populations remain understudied.     

ESPR Uroradiology Task Force and ESUR Paediatric Working Group—Imaging recommendations in paediatric uroradiology, Part V: childhood cystic kidney disease, childhood renal transplantation and contrast-enhanced ultrasonography in children

The ESPR Uroradiology Task Force and the ESUR Paediatric Working Group present two new recommendations on imaging in childhood cystic kidney disease and in childhood renal transplantation, and address the presently restricted availability of contrast-enhanced (ce) US in children. New insights into the genetics require an updated classification of paediatric cystic kidney disease along with a new concept of diagnostic imaging. Characteristic imaging features are key to the new classification. Available recommendations for imaging renal transplantation in children are not satisfactory. The following consensus-based algorithm proposes a more effective and more uniform imaging concept, reducing invasiveness, enhancing diagnostic accuracy, and facilitating future multicentre studies and meta-analysis. At present, ce-US in children can only be performed off-license, since the only approved US contrast agent (CA) for children has been taken off the market. Nevertheless, paediatric ce-US is practiced at multiple places using Sonovue® (Bracco, Milan, Italy), a generally available agent in Europe. From a medical and scientific perspective, paediatric ce-US should be promoted, and efforts are undertaken to collect data on paediatric US-CA applications. Routine paediatric imaging depends on local expertise and availability of equipment. The imaging recommendations and supportive data are intended to ease the physicians’ difficult task of dealing with the specific diagnostic demands of paediatric paediatric cystic kidney disease and transplantation.     

Does a paediatric after-hours clinic use evidence-based guidelines in the management of acute otitis media?

OBJECTIVE:

To determine whether a paediatric after-hours clinic uses evidence-based management in the treatment of acute otitis media, and compare this management with that provided in a paediatric emergency department and a general hospital emergency department.

METHODS:

A retrospective chart review of 573 patients (aged six months to five years) with a discharge diagnosis of acute otitis media was conducted in three after-hours settings: a paediatric after-hours clinic, a tertiary paediatric hospital emergency department and a secondary general hospital emergency department. The patients’ age, weight, sex and allergy to antibiotics were recorded as baseline characteristics. The physicians’ antibiotic choice, dose and duration, and the use of investigations were recorded as outcome variables.

RESULTS:

Amoxicillin was prescribed to 68% of patients at both the paediatric after-hours clinic and the paediatric hospital emergency department, compared with 53% of patients at the general hospital emergency department (P<0.01). The mean dose of amoxicillin prescribed at the paediatric after-hours clinic and the paediatric hospital emergency department were similar (43.4±9.7 mg/kg per day and 42.4±14.3 mg/kg per day, respectively) and higher than that prescribed at the general hospital emergency department (38.6±8.8 mg/kg per day, P<0.01). The paediatric after-hours clinic used investigations less often than did emergency departments (0.5% of cases compared with 9% and 20%, P<0.01).

CONCLUSION:

The paediatric after-hours clinic provided a high level of adherence to a clinical practice guideline and had a low utilization of resource intensive investigations.     

Forty years of European paediatric surgery

Summary An attempt is made to outline the development of paediatric surgery in Europe since the last war. The pioneering work of a few surgeons before the war led to the systematic introduction of paediatric surgery during the post-war period. In spite of considerable opposition, this branch of surgery progressed rapidly and by the 1960s paediatric surgery was recognised as a specialty in most of the countries in Western Europe. The mechanism of this astonishingly quick progress is analysed. During the 1970s and even more in the 1980s the success story of paediatric surgery became marred by several negative developments, including the increasing tendency of organ specialists to take over certain areas of surgery in childhood. These developments are reviewed with reference to the views expressed to the author by 19 paediatric surgeons from 14 West European countries. Some ways of overcoming these difficulties are proposed.     

Determinants of stress for staff in a neonatal intensive care unit.

Components of stress for 22 paediatric consultants and 29 nursing sisters working in neonatal intensive care units were studied. Ten situations were rated for their intensity of stress and their frequency of occurrence. For intensity of stress, significantly more paediatric consultants rated the competing demands of personal life versus work as highly stressful, than did nursing sisters. For frequency of stress, significantly more paediatric consultants rated 4 situations as frequently occurring than did nursing sisters (priorities of care, understaffing/overwork, personal life versus work, condition of outborn infants). However, significantly more nursing sisters found problems in working with their peers a frequently occurring stress than paediatric consultants. Total scores calculated for intensity and frequency of stress showed that although the overall intensity of stress experienced was similar, paediatric consultants had a significantly higher mean score for frequency of stress than nursing sisters in the neonatal intensive care unit.     

Institutional review boards’ attitudes towards remuneration in paediatric research: Ethical considerations

Remuneration in paediatric research poses an ethical dilemma. Too large a sum might cause parents to enrol their children in research projects with no benefit for the child, whereas too modest a sum might hamper recruitment. The institutional review boards have the responsibility to only approve remuneration in paediatric trials with ethically sound research plans. However, little is known about which factors influence institutional review boards’ evaluation of remuneration in paediatric research.     

Strategic planning in academic paediatric hospitals: The need for child health input

Over the past two decades, a number of Canadian paediatric academic programs, previously operated as separate hospitals, have been integrated into larger teaching hospitals or regional health authorities. The present article describes the recent experience of the Children’s Hospital of Western Ontario within the London Health Sciences Centre (London, Ontario) to illustrate the potential deleterious effects of planning, system and program changes in a large academic hospital without child health input at the executive decision-making level. The vision of the London Health Sciences Centre Executive Leadership Team and Board of Directors was divergent from that of the paediatric health care providers, which resulted in the resignation of a number of paediatric subspecialists and compromised the ability of the Department of Paediatrics to deliver paediatric care and educate future professionals. The present article highlights the need for the involvement of paediatric stakeholders in strategic planning in the hope that other academic centres can learn from this experience.     

Guias de ingreso,alta y triage para las unidades de cuidados intensivos pediátricos en España

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.     

The evolving role of community-based general paediatricians: the Barwon experience

OBJECTIVE: To detail the acute and chronic paediatric service and community-orientated activities and responsibilities of community-based general paediatricians. METHODOLOGY: Data were collected over the 12 months July 1996 to June 1997 relevant to (i) acute neonatology and paediatrics, (ii) the different community paediatric service organizations with which the paediatricians were involved, and (iii) the quantification of the amount of time spent in non-consulting paediatric work. RESULTS: Findings revealed decreasing hospital admissions, infrequent severe neonatal resuscitation requirements, extensive involvement in community organizations and a great deal of time spent in non-consulting paediatric work. CONCLUSIONS: Ongoing training and upgrading in acute paediatric diagnostic and procedural skills, rationalization of resuscitation expertise, training in management and administrative skills and models of care for the chronically ill should become part of the training of community-based general paediatricians.