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.

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.

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References:

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