Simon Young

«Sucrose analgesia» and diphtheria-tetanus-pertussis immunizations at 2 and 4 months

In human newborns, small amounts of sucrose reduce crying with procedural pain by about 50%. To determine whether “sucrose analgesia” could be extended to painful procedures beyond the newborn period, 57 infants were randomly assigned to receive three 250-

Using Video Recording to Identify Management Errors in Pediatric Trauma Resuscitation

mUl doses of 50% sucrose solution (g/100 mL) or water before their diphtheria-tetanus-pertussis immunizations at 2 and 4 months of age. Crying during and after injection was measured separately to determine whether sucrose modified crying during the noxious stimulus, recovery from the stimulus, or both. Sucrose was effective in reducing crying only from 83 to 69%, and the reduction was limited to the postinjection period. We conclude that, although sucrose continues to have some effect beyond the newborn period, the effect is limited to recovery from the noxious stimulus, is clinically modest, and is probably smaller than in the newborn period.

EFFECTS OF INTRA-ORAL SUCROSE ON CRYING, MOUTHING AND HAND-MOUTH CONTACT IN NEWBORN AND SIX-WEEK-OLD INFANTS

OBJECTIVE. To determine the ability of video recording to identify management errors in trauma resuscitation and to compare this method with medical record review. METHOD. The resuscitation of children who presented to the emergency department of the Royal Childrens Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. RESULTS. Ninety resuscitations were video recorded and analyzed. An average of 5.9 errors per resuscitation was identified with this method (range: 1–12 errors). Twenty-five children (28%) had an injury severity score of >11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement. CONCLUSIONS. Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial

To determine whether a single intra‐oral administration of sucrose would calm infants and elicit mouthing and hand‐mouth contact, crying newborn and six‐week‐old infants were given sucrose solution before one feed and sterile water before another in a cross‐over trial. Six‐week‐old infants were also given sucrose and water after feeding. For the newborn infants, the calming effect was rapid, substantial and lasted for at least four minutes. Mouthing and hand‐mouth contact increased, but for shorter durations. For the six‐week‐old infants, sucrose calmed for one minute only before feeding, but had no effects on mouthing or hand‐mouth contact. The results imply that intra‐oral sucrose has acute age‐related effects on crying and suckling‐feeding behaviour mediated by a pre‐absorptive mechanism. Sucrose may tap a functional system for reducing distress related to feeding and/or regulation of infant state.

When benzodiazepines fail: How effective is second line therapy for status epilepticus in children?

BACKGROUND Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions. METHODS We did a randomised controlled double-blind trial of children admitted to The Royal Childrens Hospital (Melbourne, VIC, Australia) who needed intravenous maintenance hydration for 6 h or longer. With an online randomisation system that used unequal block sizes, we randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) for 72 h or until their intravenous fluid rate decreased to lower than 50% of the standard maintenance rate. We stratified assignment by baseline sodium concentrations. Study investigators, treating clinicians, nurses, and patients were masked to treatment assignment. The primary outcome was occurrence of hyponatraemia (serum sodium concentration <135 mmol/L with a decrease of at least 3 mmol/L from baseline) during the treatment period, analysed by intention to treat. The trial was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN1260900924257. FINDINGS Between Feb 2, 2010, and Jan 29, 2013, we randomly assigned 690 patients. Of these patients, primary outcome data were available for 319 who received Na140 and 322 who received Na77. Fewer patients given Na140 than those given Na77 developed hyponatraemia (12 patients [4%] vs 35 [11%]; odds ratio [OR] 0·31, 95% CI 0·16-0·61; p=0·001). No clinically apparent cerebral oedema occurred in either group. Eight patients in the Na140 group (two potentially related to intravenous fluid) and four in the Na77 group (none related to intravenous fluid) developed serious adverse events during the treatment period. One patient in the Na140 had seizures during the treatment period compared with seven who received Na77. INTERPRETATION Use of isotonic intravenous fluid with a sodium concentration of 140 mmol/L had a lower risk of hyponatraemia without an increase in adverse effects than did fluid containing 77 mmol/L of sodium. An isotonic fluid should be used as intravenous fluid for maintenance hydration in children. FUNDING National Health and Medical Research Council, Murdoch Childrens Research Institute, The Royal Childrens Hospital, and the Australian and New Zealand College of Anaesthetists.

Understanding parental motivators and barriers to uptake of child poison safety strategies: a qualitative study

Objectives:  To define the characteristics and management of children presenting to the ED of a major tertiary paediatric hospital with convulsive status epilepticus (CSE). To determine the timing and efficacy of therapeutic interventions in this group and to identify factors that influence the effectiveness of treatment.

Teaching paediatric resuscitation skills in a developing country: introduction of the Advanced Paediatric Life Support course into Vietnam

Objectives: To develop an understanding of factors acting as barriers and motivators to parental uptake of child poison safety strategies. Design: A qualitative study involving semistructured interviews and focus groups. A grounded theory approach was used for the collection and analysis of data. Participants: Sixty five parents of children under 5 years of age, some of whom had experienced an unintentional child poisoning incident. Results: A range of knowledge based, environmental, and behavioral barriers to comprehensive parental uptake of poison safety practices were identified. As a result there tended to be only partial implementation of safety initiatives in the home. Selection of safety practices was often guided by the interests and behaviors of the child. This made the child vulnerable to changes in the home environment, inadequate supervision, and/or shifts in their own behavior and developmental ability. Personal or vicarious exposure of a parent to a child poisoning incident was a significant motivator for parental review of safety practices. Conclusion: Environmental measures targeting child resistant containers, warning labels, and lockable poisons cupboards will support parents’ efforts to maintain poison safety. Additional education campaigns using stories of actual poisoning incidents may help to increase awareness of risk and encourage increased uptake.

Randomized Clinical Trial of Rapid Versus 24-Hour Rehydration for Children With Acute Gastroenteritis

In 2001, a nationwide study revealed deficiencies in the emergency care of seriously ill and injured children in Vietnam. In response, a project was initiated to conduct the Advanced Paediatric Life Support course in Vietnam and ascertain whether this course would provide a practical and sustainable method of improving the knowledge and skills of medical and nursing staff in this area. After approval to use the course was secured and funding obtained, the project commenced in 2003. Key Vietnamese personnel travelled to Australia to complete the course, undertake instructor training and gain organizational experience. Teaching materials were translated, reviewed and modified to account for local diseases and clinical practices while maintaining the fundamental principles of the parent course. Commencing in March 2004, 10 courses were conducted by Australian and Vietnamese instructors, training 239 doctors and nurses from a wide variety of clinical backgrounds. Additionally, three instructor courses were conducted, training 52 new instructors. As the skill and confidence of the Vietnamese instructors grew, the number and responsibilities of the international faculty reduced. The infrastructure now exists for the course to operate in a sustainable fashion within Vietnam. We believe that this project demonstrates that the course can be successfully modified to provide teaching in paediatric emergency care in a developing country.

DOES MATURE HINDMILK TASTE CALM CRYING INFANTS? |[dagger]| 79

OBJECTIVE: To compare the efficacy of 2 nasogastric rehydration regimens for children with acute viral gastroenteritis. METHODS: Children 6 to 72 months of age with acute viral gastroenteritis and moderate dehydration were recruited from emergency departments (EDs) at 2 metropolitan, pediatric, teaching hospitals. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either standard nasogastric rehydration (SNR) over 24 hours in the hospital ward or rapid nasogastric rehydration (RNR) over 4 hours in the ED. Primary (>2% weight loss, compared with the admission weight) and secondary treatment failures were assessed. RESULTS: Of 9331 children with acute gastroenteritis who were screened, 254 children were assigned randomly to receive either RNR (n = 132 [52.0%]) or SNR (n = 122 [48.0%]). Baseline characteristics for the 2 groups were similar. All patients made a full recovery without severe adverse events. The primary failure rates were similar for RNR (11.8% [95% confidence interval [CI]: 6.0%–17.6%]) and SNR (9.2% [95% CI: 3.7%–14.7%]; P = .52). Secondary treatment failure was more common in the SNR group (44% [95% CI: 34.6%–53.4%]) than in the RNR group (30.3% [95% CI: 22.5%–38.8%]; P = .03). Discharge from the ED after RNR failed for 27 patients (22.7%), and another 9 (7.6%) were readmitted to the hospital within 24 hours. CONCLUSIONS: Primary treatment failure and clinical outcomes were similar for RNR and SNR. Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients.

A Typical Feeding Enhances Memory for Spoken Words in Healthy 2- to 3-Day-Old Newborns

In human newborns, sucrose taste arrests crying and increases mouthing and hand-mouth contact, but colostrum and mature foremilk does not. To determine if mature hindmilk taste has similar effects, 20 normal 10 day old infants who were crying spontaneously for ≥ 15 consecutive seconds were randomized to receive 250 ul of their mothers hindmilk X 5 at 30 second intervals by pipette to the midline anterior tongue prior to one feed and water prior to another. Per cent time crying, mouthing, and hand-mouth contact were calculated for baseline (used as a covariate), administration intervals and up to three minutes following administration. Crying reduction was similar for both liquids during administration (67 vs. 63%), remained less in each minute following breast milk (74, 74, 71%), but increased (73, 83, 89%) following water (solution X period interaction: F[6, 114]=2.5;P=.03). Mouthing was elevated during administration (29% for both), but returned to baseline (< 13%) within two minutes (period effect F[5,90]=2.9;P=.02). There was no change in hand-mouth contact.