Jeffrey C. Weiss

Policy Statement—Prevention of Drowning

Drowning is a leading cause of injury-related death in children. In 2006, fatal drowning claimed the lives of approximately 1100 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

The effect of the prone position on venous pressure and blood loss during lumbar laminectomy

STUDY OBJECTIVE To determine the effects of three different prone support systems (Andrews spinal surgery frame, Cloward surgical saddle, and longitudinal bolsters) on inferior vena cava (IVC) and superior vena cava (SVC) pressures; the validity of measuring central venous pressure (CVP) for the determination of ideal positioning of the patient; and the relationship among frame type, blood loss, and hemodynamic measurements. DESIGN Prospective, randomized study of the hemodynamic effects of the prone position. SETTING Inpatient surgery at a university hospital (regional spinal cord injury treatment center). PATIENTS Eighteen patients free of significant coexisting disease (ASA physical status I and II) undergoing elective lumbar laminectomy. INTERVENTIONS Patients were assigned to one of three support frames and measurement of SVC pressure, IVC pressure, and mean arterial pressures (MAP) were obtained supine, prone, and after repositioning. These pressures and measured blood loss were obtained every 15 minutes during the surgical laminectomy portion of the procedure. MEASUREMENTS AND MAIN RESULTS Patients positioned on the Andrews frame had decreased mean SVC and IVC pressures from 8.7 mmHg and 8.4 mmHg in the supine position to 3.3 mmHg and 1.8 mmHg in the prone position, respectively (p less than 0.001). Prone position CVP also was significantly lower in the Andrews group compared with that in the other two groups (p less than 0.001). Repositioning efforts did not significantly decrease CVP. Blood loss was higher in the Cloward group (1,150 +/- 989 ml) than in the Andrews (245 +/- 283 ml) and bolsters (262 +/- 188 ml) groups (p less than 0.02). CONCLUSIONS Increased blood loss was not associated with increased SVC or IVC pressure, nor was there any significant correlation between any demographic or hemodynamic variable and blood loss. There was no evidence that CVP is useful in determining the ideal prone position in patients undergoing lumbar laminectomy.

Pseudotumor cerebri and nutritional rickets

A bulging fontanelle due to benign increased intracranial pressure is not generally recognized as a manifestation of nutritional rickets but should be considered in the appropriate clinical setting. Two children who we saw presented with bulging anterior fontanelles were found to have pseudotumor cerebri in association with nutritional rickets.

Investigating stress levels of residents: a pilot study.

A pilot study of the levels of stress among residents was conducted in three departments in a university hospital prior to initiating a programme in stress management for residents. The Beck Depression Inventory, which is a brief, standardized self-report measure of depression, was given to residents in anaesthesiology, paediatrics and psychiatry. Six additional questions were asked about the functioning of peers and services residents would like to have available. Of the 113 residents surveyed, 16% were experiencing a mild mood disturbance. The researchers feel this is probably under-reported. Residents felt that about 15% of their colleagues were emotionally impaired; 10% may have a drug and/or alcohol problem; 12% were having marital problems. Eighty per cent of all residents studied said that they would attend support groups if they existed. Approximately 60% thought coping skills/stress management seminars would be useful, and 30% of the paediatric and anaesthesiology residents (60% of the psychiatry residents) said they would use confidential individual psychotherapy if it were available.

House Officer Management of the Febrile Child A Survey

Questionnaires were used to survey 95 pediatric house officers in order to determine their reasons and methods for treating fever, as well as their knowledge of fever physiology. The reasons given for treating fever were to make the child comfortable (99%), to prevent seizures (63%), and to satisfy parents (44%). The average temperature at which antipyretic medication was started was 38.6 ± 0.3 C. Alternating doses of aspirin and acetaminophen were used by 53 per cent, and sponging was recommended by 76 per cent of the residents. The average tem perature at which sponging was started was 39.5 ± 0.6 C. The percentage of house officers who use sponging and/or alternating doses of antipyretics differed greatly from hospital to hospital. Sixty-one per cent of the residents felt that fever is a defense mechanism which does not require treatment. Despite this belief, the majority of these residents use vigorous means to lower fever in children.

The predictive validity of a resident selection system

This paper describes a new system for resident selection that uses a descriptive rating scale and a microcomputer to create a rank order list for the National Resident Matching Program. The methods utilized to analyze the time efficiency, interrater reliability, and predictive validity of the system are reported. Interrater reliability was found to be high. The rank list was shown to correlate with both clinical performance of Pl-1 and Pl-2 pediatric residents and the American Board of Pediatrics In-training Examination. Correlations for the Pl-2 year were stronger than for the Pl-1 year.

FACULTY DEVELOPMENT AND EVALUATION

There have been changes in the manner in which academic institutions appoint and evaluate faculty. The concept of tenure has been radically altered and a higher percentage of faculty are being appointed to positions in which tenure is not attainable. In these circumstances, it is important to provide younger faculty with the opportunity to plan their academic career and to make certain that older faculty do not become non-productive. We have developed a faculty development form that is educational and constructive. It divides each academic function (teaching, research, clinical, administrative, extramural and interpersonal) into seven levels of performance. No level is in itself inappropriate and the profile can be plotted for 10-year intervals, so that changes in the profile are apparent. Each faculty member plans his next years goals and objectives and the supervisor and the faculty member determine whether the new goals will change the faculty members profile. We have two years of data on the number of publications, abstracts and research applications during the program compared to previous years. That data indicate that this system stimulates academic growth and we believe it allows some faculty to conclude that academic medicine may not be an appropriate career choice early or even late in their careers. Most importantly, it forces the supervisor and faculty member to establish a written plan for each academic year. (Supported by NIH)

Clinical report - Intimate partner violence

The American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children.American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatri- cians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children. Pediatrics 2010;125:1094-1100

Policy statement - Prevention of choking among children

Choking is a leading cause of morbidity and mortality among children, especially those aged 3 years or younger. Food, coins, and toys are the primary causes of choking-related injury and death. Certain characteristics, including shape, size, and consistency, of certain toys and foods increase their potential to cause choking among children. Childhood choking hazards should be addressed through comprehensive and coordinated prevention activities. The US Consumer Product Safety Commission (CPSC) should increase efforts to ensure that toys that are sold in retail store bins, vending machines, or on the Internet have appropriate choking-hazard warnings; work with manufacturers to improve the effectiveness of recalls of products that pose a choking risk to children; and increase efforts to prevent the resale of these recalled products via online auction sites. Current gaps in choking-prevention standards for childrens toys should be reevaluated and addressed, as appropriate, via revisions to the standards established under the Child Safety Protection Act, the Consumer Product Safety Improvement Act, or regulation by the CPSC. Prevention of food-related choking among children in the United States has been inadequately addressed at the federal level. The US Food and Drug Administration should establish a systematic, institutionalized process for examining and addressing the hazards of food-related choking. This process should include the establishment of the necessary surveillance, hazard evaluation, enforcement, and public education activities to prevent food-related choking among children. While maintaining its highly cooperative arrangements with the CPSC and the US Department of Agriculture, the Food and Drug Administration should have the authority to address choking-related risks of all food products, including meat products that fall under the jurisdiction of the US Department of Agriculture. The existing National Electronic Injury Surveillance System–All Injury Program of the CPSC should be modified to conduct more-detailed surveillance of choking on food among children. Food manufacturers should design new foods and redesign existing foods to avoid shapes, sizes, textures, and other characteristics that increase choking risk to children, to the extent possible. Pediatricians, dentists, and other infant and child health care providers should provide choking-prevention counseling to parents as an integral part of anticipatory guidance activities.