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|Monday, May 24, 2010
|Painless IVs in the ER: Kids Love It!
|by Pediatric Perspectives at 10:42 AM
John D. Hoyle, Jr., MD
Emergency Care Specialists PC
Helen DeVos Children's Hospital
One of the most anxiety-provoking events for a child is getting a shot or undergoing a procedure that requires a needle. Unfortunately, in our practice as pediatric emergency physicians much of what we do requires the insertion of an intravenous line. Like most pediatric emergency departments and children's hospitals, we've used anesthetic cream to numb the child's skin before inserting the IV.
However, it takes at least 30 minutes for the cream to take effect, significantly slowing down busy EDs like ours. The cream can also result in vasoconstriction, making IV insertion more difficult.
Then we found the J-Tip syringe. Now, neither my colleagues nor I have any financial interest in this device! We just love using it.
The J-Tip is an FDA-approved needleless syringe that uses high pressure from a compressed carbon dioxide gas cartridge to deliver medication through the skin. It was originally approved to deliver insulin. It didn't take long, however, for pediatric specialists to discover it. When we heard about it, I was so skeptical that it was painless that I actually tested it on myself. And yes, it was completely painless.
Today, we use the J-Tip on all children we see in the ED who require an IV, lumbar puncture, or other painful procedure involving needles. Our nursing staff is, quite literally, "over the moon" about it. Children who are old enough to rate their pain on a 1-10 scale overwhelmingly rate the pain from a post-J-Tip IV start as low; many who are admitted refuse an IV start or change without the "popper," as we call it.
The most telling sign of its success, however, comes from parents. When asked to compare their child's pain from an IV start before the J-Tip and after, about 80 percent rated the post-J-Tip experience as either a 0 or 1 on the 10-point scale. The nurses also scored it very favorably.
Although I don't have the data to prove it yet, my gut tells me the J-Tip is also financially beneficial because it makes us more efficient. Our nurses just take a J-Tip with them when they go to start an IV and can complete the procedure without leaving the room.
A few studies have appeared in the literature. In one, staff at Children's Hospital and Regional Medical Center in Seattle randomized 116 children to receive either 0.25 mL of 1% buffered lidocaine with the J-Tip or 2.5 grams of the topical anesthetic (EMLA) prior to IV cannulation. The mean time until IV insertion was 1.8 minutes in the J-Tip group and 69 minutes in the EMLA group, with no significant difference in ease of cannulation. In addition, pain ratings at the time of insertion were significantly lower in the J-Tip group (P=0.0013). The J-Tip also cost less: $2.10 per use compared to $2.80 for EMLA.
Have you been using the J-Tip in your hospital? Share your experience!
John D. Hoyle, Jr., MD is a pediatric emergency physician at Helen DeVos Children's Hospital in Grand Rapids, Michigan.
|Tuesday, May 18, 2010
|Clues to Child Abuse May Be Found in Parents
|by Pediatric Perspectives at 02:27 PM
N. Debra Simms, MD
Director, Center for Child Protection
Helen DeVos Children's Hospital
Broken bones, bruises, underweight children-they are all potential indications of child abuse. But what about mom's broken arm or black eye? A recent report from the American Academy of Pediatrics found that one of the most effective ways to prevent child abuse may be for pediatricians to identify domestic violence against a child's caregiver. That's because numerous studies document the co-occurrence of child abuse and intimate partner violence, finding between 30% and 60% of child abuse co-occurs with intimate partner abuse.
As the Pediatrics article noted, intimate partner violence "has been called the leading precursor of child maltreatment."
The thing is, you have to look for signs of domestic abuse or intimate partner violence; the patient's caregiver is unlikely to volunteer it. This is part of the hidden life and hidden secrets that people do not feel comfortable sharing, even with a physician.
Here are some tips to get you started:
• Listen carefully to what the caregiver says and doesn't say. For instance, if mom mentions that she's worried her husband will be angry that the child is sick or needs medication, that's a clue. If she is fearful about her boyfriend's reaction to the diagnosis or cost of care, that's a clue.
When I was a resident, the mother of one of my patients often came in with bruises and other injuries. At first, she claimed they were related to her job. But the bruises continued even after she lost her job. When there was enough trust between us, she admitted that she was in abusive relationship with her boyfriend.
• Don't fall prey to stereotypes. Intimate partner violence can be perpetrated against men and it occurs in homosexual relationships as well as heterosexual.
• Look for subtle signs. While a broken arm or black eye is obvious clues to violence, the signs are likely to be far subtler. As Thackery et al describe in their article, depression, anxiety, failure to keep medical appointments, reluctance to answer questions about discipline in the home, or frequent office visits for complaints not borne out by the medical evaluation of the child may be signs of intimate partner violence. However, they noted, "most of the time, indicators of abuse are absent altogether."
Even if the child has not yet been abused, children in homes in which violence occurs are in danger. When you have adults who are out of control you have children who are not safe. The children are at risk not only of physical abuse, but of psychosocial abuse and the long-term consequences that can result from exposure to continual trauma.
Having said all that, before you begin screening your patients' caregivers for intimate partner violence make sure you know what to do if you do pick up on potential abuse. Who will you tell them to call? Where will you send them? Do you have a list of resources in your community? Of course, if the child is in imminent danger you have to alert authorities.
I hope this blog helps you think more about the issue of intimate partner violence and the potential implications for your patients. Feel free to post any questions you may have and I promise I'll respond.
Click "Add Comment" below to contribute to the conversation.
1. Thackeray JD, Hibbard R, Dowd MD; Committee on Child Abuse and Neglect; Committee on Injury, Intimate partner violence: the role of the pediatrician.Pediatrics. 2010 May;125(5):1094-100.
2. Violence, and Poison Prevention. Rivara FP, Anderson ML, Fishman P, et al. Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics. 2007;120(6):1270-1277[Abstract/Free Full Text]
3. Edleson J. The overlap between child maltreatment and women battering. Violence Against Women. 1999;5(2):134-154[Abstract/Free Full Text]
4. McGuigan W, Pratt C. The predictive impact of domestic violence on three types of child maltreatment. Child Abuse Negl. 2001;25(7):869-883[CrossRef][Web of Science][Medline]
5. Christian C, Scribano P, Seidl T, Pinto-Martin J. Pediatric injury resulting from family violence. Pediatrics. 1997;99(2). Available at: www.pediatrics.org/cgi/content/full/99/2/e8
|Tuesday, May 04, 2010
|Screening for Obesity Risks in Your Patients—Simple, Easy, Validated and Free
|by Pediatric Perspectives at 09:08 AM
Joe C. Eisenmann, PhD, Lead Researcher
Helen DeVos Children's Hospital Healthy Weight Center
If we really want to attack the obesity epidemic in our children and adolescents, we need to start before kids become overweight. As with any health preventive approach, we first have to identify significant risk factors and determine how they interact to create an overall risk. Once these risk factors are identified they can be used to develop a screening tool or algorithm to identify children in the highest risk groups. If every child is screened and counseled effectively we have an opportunity to implement evidence-based prevention to, hopefully, interrupt the BMI trajectory towards obesity.
Such a tool now exists: the Family Nutrition and Physical Activity (FNPA) screening tool, available free online at www.myfnpa.org. I assisted in the creation of the tool, which was developed in collaboration with the American Dietetic Association. We are currently using it to screen children referred to Helen DeVos Children's Hospital's new Healthy Weight Center.
The tool consists of 10 questions in 10 domains, as well as data on the child's gender and age, the parent's gender and age, and the family's socioeconomic status. It has been scientifically validated, with a recent study published in the Annals of Behavioral Medicine in August 2009 that showed the FNPA total score was predictive of a child's BMI change one year after baseline screening.
Questions focus on the home environment because we know that parents play a critical role in the creation of or prevention of an obesigenic environment. Thus, areas assessed in the survey include whether the child eats breakfast, has family dinners, eats meals in front of the television, has a television in their room, primarily eats prepared or fresh foods, and plays on any sports teams, among other physical activity and nutritionally-related questions.
I strongly encourage community pediatricians to begin using the FNPA on all patients to determine if they are at risk of obesity. The responses to the questions can help pinpoint areas of concern and provide a starting place for a conversation about changing family habits and environment to begin down the path to prevention. It can also be used to monitor these key behaviors over time.
Several important research questions remain to be answered, so if you are interested in helping facilitate the use of the FNPA in clinical practice, please contact me.
Joe C. Eisenmann, PhD is the lead researcher at the Helen DeVos Children's Hospital's Healthy Weight Center, and assistant professor in the departments of Kinesiology and Pediatrics and Human Development at Michigan State University in East Lansing. He can be reached at email@example.com and more about his work viewed at his web site at http://eisenmann.wiki.educ.msu.edu/