Savithiri Ratnapalan

Pain in children: assessment and nonpharmacological management.

Pain perception in children is complex, and is often difficult to assess. In addition, pain management in children is not always optimized in various healthcare settings, including emergency departments. A review of pain assessment scales that can be used in children across all ages, and a discussion of the importance of pain in control and distraction techniques during painful procedures are presented. Age specific nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures.

Needs Assessment in Postgraduate Medical Education:A Review

Abstract: Although the concept of needs assessment in continuing medical education is well accepted, there is limited information on needs assessment in postgraduate medical education. We discuss the learning needs of postgraduate trainees and review the various methods of needs assessment such as: questionnaire surveys, interviews, focus groups, chart audits, chart-stimulated recall, standardized patients, and environmental scans in the context of post graduate medical education.

“Doctor, will that x-ray harm my unborn child?”

Abstract: Exposure to ionizing radiation can be a source of anxiety for many pregnant women and their health care providers. An awareness of the radiation doses delivered by different techniques and the acceptable exposure thresholds can help both patients and practitioners. We describe exposure to radiodiagnostic procedures during pregnancy and suggest an approach to assess the potential risk.

Management of Infantile Colic: A Review

Infantile colic is an easily identified childhood entity that has no clear treatment guidelines. The management of infantile colic varies among physicians, and families are often frustrated by the medical communitys inability to prescribe a cure for colic. This article reviews the current concepts for management options of infantile colic.

Omental Infarction in Children

OBJECTIVES To analyze the clinical presentation, radiologic features, management, and outcome in children diagnosed with omental infarction. STUDY DESIGN This was a retrospective chart review of patients diagnosed with omental infarction in a tertiary care pediatric emergency department. Images and reports of the radiologic investigations were re-examined by a staff radiologist and analyzed for sensitivity. RESULTS A diagnosis of omental infarction was made in 19 children (mean age, 9.3 +/- 3.5 years). The presentation was acute right lower quadrant pain in 47% of the children and associated gastrointestinal symptoms in 63%. The sensitivity of abdominal ultrasound (US) to detect omental infarction at our institution was 64%, and the sensitivity of abdominal computed tomography was 90%. Fourteen children were treated conservatively without complications after an accurate diagnosis of omental infarction done by imaging examination. Only 5 children underwent surgery based on clinical suspicion of appendicitis. CONCLUSIONS Early identification of omental infarction by abdominal US appears to prevent unjustified surgical procedures and reduce the length of hospital stay.

Medication errors in paediatrics: a case report and systematic review of risk factors.

The inadvertent administration of drug doses greater than intended is not uncommon in the paediatric patient. These errors may arise from misunderstanding of the prescribed dose by the child’s caregiver or from mistakes of health professionals. Such errors have the potential to cause serious complications and their prevention is of paramount importance. Cyclosporin is an effective immunosuppressant which is most often used in organ transplantation; it is also used increasingly in non-transplant immunological and rheumatological conditions. The long term therapeutic use of cyclosporin is associated with several adverse effects, of which nephrotoxicity and hypertension are the most prominent.[1] Hepatotoxicity and CNS symptoms have also been described.[2-4] Human experience in the context of acute cyclosporin overdose is relatively limited and largely confined to adults.[5-11] Experience in children with accidental oral overdose is scarce.[12-14] The incidence of acute cyclosporin overdose in the paediatric population may increase as use of the drug increases. The objective of this article is to present a case of accidental oral overdose in an infant resulting from a 10-fold error in administration, and to highlight mechanisms and approaches for preventing such errors.

Periurethral Cleaning Prior to Urinary Catheterization in Children: Sterile Water versus 10% Povidone-Iodine:

Objective. To compare urinary infection rate in children cleaned with sterile water versus a 10% povidone-iodine before bladder catheterization. Methods. Prospective randomized controlled study of children requiring bladder catheterization in the emergency department whose parents consented to the study were randomly assigned to either of 2 groups, in which sterile water (the “sterile water” group) or 10% povidone-iodine (the “10% povidone-iodine” group) was to be used for peri-urethral cleansing prior to catheterization. Results. The sterile water group had 92 patients and the povidone-iodine group had 94. Most children (87%) were under 12 months of age. Urine cultures were positive in 16% of children in the povidone-iodine group and in 18% in the water group. There was no significant difference in signs and symptoms between the 2 groups. There was no significant association between solution preparation and cultures on univariate regression analysis. Conclusions. Cleaning the periurethral area of children with sterile water prior to catheterization is not inferior to cleaning with povidone-iodine.

Intussusception in Children Presenting to the Emergency Department

A retrospective chart review of children diagnosed with intussusceptions from March 2005 to March 2007 was conducted at a tertiary care pediatric hospital. There were 152 children with 170 episodes of intussusceptions during the study period. Around one third (30%) of children diagnosed with intussusceptions had a concurrent infection. There were 114 large bowel intussusceptions, with a mean age of 27 months (SD = 25) and a success rate of 91% for air enema reductions. Bowel resection was performed in 8.8% of children with large bowel intussusceptions. Small bowel intussusceptions (n = 38) were associated with gastrostomy tubes in 42% (n = 16) of patients, and 81% needed tube shortening. The varying age range of many children diagnosed with intussusceptions and the high incidence of intercurrent illnesses and fever in our study alert health professionals to suspect intussusceptions in children presenting with abdominal pain or crying.

Nontraumatic Dental Complaints in a Pediatric Emergency Department

Objective: To determine the prevalence, types, and treatment of nontraumatic dental emergencies that present to a tertiary care pediatric emergency department (ED). Methods: A retrospective chart review of all children coming to a tertiary care pediatric emergency department with nontraumatic dental complaints from January 2005 to December 2005 was conducted. Demographic information, the time and day of presentation, presenting complaints, history of previous dental treatment, interventions, and disposition details were collected and analyzed. Results: The 247 visits for nontraumatic dental complaints comprise 0.5% of all patients who presented to the ED in 2005. Fifty-nine percent were younger than 5 years (primary dentition), with males representing 52% of the children. Half of the visits were during normal dental office hours, and more than half presented during the weekday. Fifty-three percent complained of pain. Twenty-eight percent were referred to the dental clinic after being seen by an ED physician. Eight percent of children required hospitalization for intravenous antibiotics. Most children (82%) were discharged from the ED with oral antibiotics. Conclusions: The ED is an important point of care for nontraumatic pediatric dental complaints, and about 60% of these children are younger than 5 years. Only 8% of them had severe infections requiring hospitalization, and most patients could have been treated in the community.

Improving the palatability of activated charcoal in pediatric patients.

Objectives: To compare the taste preference and ease of swallowing of activated charcoal among healthy teenagers when mixed separately with 3 different additives: chocolate milk, Coca-Cola, and water. Methods: Healthy volunteers between 14 to 19 years of age were selected for the study. Five grams of activated charcoal (25 mL of 0.2 g/mL of Charcodote [Pharma Science, Montreal, Canada]) was mixed with 25 mL of chocolate milk, Coca-Cola, or water individually to make up 50 mL. The volunteers drank the 3 cups of the charcoal-additive mixture separately and then rated taste and ease of swallowing on a 10-cm visual analogue scale. The subjects then indicated their preferred charcoal-additive mixture if he/she had to drink 9 more portions of charcoal (this would estimate the dose of charcoal for a 50-kg child). Results: A total of 44 subjects were recruited (25 boys and 19 girls). The mean scores for taste preference for chocolate milk, Coca-Cola, and water mixtures of charcoal were 5.5, 6.3, and 2.0, respectively, on a 10-cm visual analogue scale. Thus, subjects preferred the taste of charcoal mixed with chocolate milk or Coca-Cola over charcoal mixed with water (P = 0.0003 for both comparisons). The subjects did not show a statistically significant difference for ease of swallowing between the 3 charcoal-additive mixtures. Overall, 48% preferred the chocolate milk mixture, 45% preferred the Coca-Cola mixture, and 7% preferred charcoal mixed with water. Conclusions: Healthy teenaged subjects identified that activated charcoal (Charcodote) mixed with chocolate milk or Coca-Cola (in a 1:1 ratio) improved taste but had no significant effect on improving ease of swallowing. Overall, the addition of chocolate milk or coke improves the palatability of charcoal and is favored over charcoal mixed with water alone.