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PEDIATRIC PAIN: A NETWORK’S APPROACH TO
EDUCATION
SM Moss, MT Johnson, KE Hayward Murray, JM Trypuc, S Alidina
Child Health Network of Greater Toronto, Toronto, Ontario
BACKGROUND: The Child Health Network for the Greater Toronto
Area (CHN) is a partnership among 20 hospitals that provide
maternal/newborn and paediatric services, and 10 Community Care
Access Centres that manage home-based services.
OBJECTIVE: Using pain management education, this article explores
whether a network approach to education has merit and influences practice changes.
METHODS: An Education Framework was developed to promote and
support educational initiatives across the network. Pain management was
identified as a hospital priority, whereby improvements were needed in
clinicians’ awareness, understanding and clinical practices about procedural,
post-operative, peri-operative and traumatic pain in neonates, infants,
children and youth. Best practice standards and education modules were
developed on paediatric pain assessment and management, and a train-thetrainer approach was used for education.
RESULTS: CHN’s paediatric pain management initiative had positive
impacts. Changes in clinical practice were evident in 10 out of 12 hospitals. Eight hospitals instituted developmentally appropriate pain assessment tools for children, seven hospitals for youth, one hospital for
neonates and one for infants. As a network, the CHN hospital collective
worked collaboratively to develop best practice standards, and a methodological and comprehensive education approach. Resource constraints,
lack of buy-in and competing priorities impacted on more wide-scale
implementation of the pain management standards and best practices.
CONCLUSIONS: Networks can play an important role influencing
change and promoting best practice standards. CHN’s pain management
initiative suggests that a network approach to education has definite merit
and can influence changes in practice.
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A STRUCTURED ORAL EXAMINATION FOR
NEONATAL-PERINATAL MEDICINE
A Jefferies, B Simmons, E Ng, M Skidmore
Neonatal-Perinatal Fellowship Progam, Department of Paediatrics,
University of Toronto, Toronto, Ontario
Traditional oral examinations have low reliability, although face validity
may be acceptable. Often, candidates do not perceive them as a fair means
of assessment. The structured oral examination (SOE) is a method that
standardizes the examination process.
OBJECTIVE: To evaluate a SOE as an assessment tool in a neonatalperinatal medicine subspecialty training program.
METHODS: A 1-hour SOE, consisting of 8 predetermined clinical
scenarios (4 for first year candidates and 4 for second year), was administered to 13 neonatal-perinatal medicine trainees at the University of
Toronto. Each scenario had 2-7 standardized questions, designed to assess
several physician competencies (CanMEDS roles), as well as factual
knowledge. Questions included expected responses and a specific marking scheme. Scenarios, questions and marking scheme were developed by
3 neonatal faculty, then reviewed by 3 other neonatologists from the
same program and by 2 external neonatal faculty. 15 minutes was allotted per scenario. Two faculty examiners assigned scores independently
for each scenario and also completed a 7-point process global rating to
evaluate overall performance in each scenario. The intraclass correlation
coefficient (ICC) was calculated to determine inter-rater reliability. SOE
scores were compared with scores from an objective structured clinical
examination (OSCE) administered 6 months previously to assess criterion
validity.
RESULTS: Mean percentage score was 64±10 (sd) for the 6 first year
trainees and 66±13 for 7 second year trainees. Global ratings were similar for
the 2 years (4.6±0.8 vs 4.8±1.1, p>0.05). Scenario scores and global ratings
were significantly correlated (r=0.81, p<0.001). There was moderate interstation reliability for the global ratings (Cronbach’s alpha=0.48 for 1st year
Paediatr Child Health Vol 9 Suppl A May/June 2004
and 0.53 for 2nd year). Inter-rater reliability was substantial (ICC>0.61) for
65% of the stations. Correlations between SOE and OSCE scores and
between SOE and OSCE overall global ratings were significant (r=0.58,
p=0.04 and r=0.63, p=0.02 respectively). 92% of candidates and 83% of
examiners indicated that the SOE was a fair and standardized means of evaluation. Administration costs associated with the SOE were minimal.
CONCLUSIONS: Reliability of the SOE was appropriate for a training
program assessment tool. The SOE was well accepted by trainees and
faculty and was economical to administer. The SOE, therefore, may be a
useful method for assessing subspecialty trainees.
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USE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE
FOR CHILDREN WITH AUTISTIC SPECTRUM DISORDERS
WB Gibbard, BJ Kaplan, ME Clarke, MJ Verhoef
The University of Calgary, Calgary, Alberta
OBJECTIVE: The aim of this study was to identify the types of complementary and alternative medicine (CAM) being used for children with
autistic spectrum disorders (ASD) in southern Alberta, and the reasons
reported for use in this population.
METHOD: This was a cross-sectional survey with a study population of
children diagnosed with any ASD in the previous 10-years in southern
Alberta. Identification of these children was accomplished through a number of overlapping patient recruitment sites. Data was collected through
the use of a self-report questionnaire developed for this study concerning
the use of CAM, which was piloted initially with three families. Data were
collected via mail-out of 500 questionnaires on two separate occasions, to
an expected target population of 400.
RESULTS: 183 questionnaires were returned with a response rate of
approximately 46%. The overall rate of use of any type of CAM for children with ASD was 94%. The median number of therapies used was 7, and
the range was from 1 to 80. Preliminary analysis showed that the most
common types of CAM used were mind-body therapies such as sensory
integration (43.8%), music therapy (33%), and auditory integration
(19.9%), the most common spiritual therapy was prayer (36%), the most
common body therapy was massage (28%), the most common dietary or
nutritional therapies were gluten-free diets (22.2%), casein-free diets
(21.6%), low sugar diets (18.8%), Lactobacillus supplements (18.2%),
vitamin C (15.3%), omega-3-fatty acids (15.9%), magnesium (14.8%),
and dimethylglycine (13.1%). The most common reasons reported for the
use of CAM in this population were to improve the child’s autistic symptoms (44%), to improve the child’s mental and emotional well being
(39%), and to improve the child’s general health (37%). Other common
reasons cited for CAM use were a belief that it could not hurt their child
(29%), because conventional medicine did not have any answers or treatment options (23%), to take charge of the health of their child (21%), and
a belief in a holistic approach to health (21%).
CONCLUSION: Results from this study indicate that CAM use in children with ASD is common. Further research is needed with respect to the
safety and efficacy of these treatments. Future research should be guided, in
part, by the treatment priorities identified by this study.
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OUTCOME OF NEONATES LESS THAN 30 WEEKS WITH
HISTOLOGICAL CHORIOAMNIONITIS
E Dempsey, K Barrington, MF Chen, T Kokottis, R Usher
Royal Victoria, Montreal, Quebec
OBJECTIVE: To determine the short term outcome of newborns less
than 30 weeks gestation when there is definite placental histological
chorioamnionitis.
METHODS: Retrospective analysis of records of all neonates delivered at
our institution from Jan 1989 through to Jan 1999. This information was
retrieved from our perinatal database and pathology database. The population was stratified according to the presence or absence of histological
chorioamnionitis. Statistical analysis was performed using Student’s t test
and Mann Whitney. Logistic regression was used to control for potential
confounding variables.
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RESULTS: There were 392 neonates less than 30 weeks delivered during
this time period. Complete placental histology was available on
342 patients (87.4%). Histological chorioamnionitis was identified in
140 (40.9%) cases. Those with histological chorioamnionitis delivered
sooner (26.3 weeks versus 27.5 weeks), were of lower birth weight (920.1
grams versus 1029.8 grams ) and had lower 5 min apgars.
Neonatal septicaemia and pneumonia were strongly associated with underlying histological chorioamnionitis. Neonatal septicaemia occurred in
10.7% of live births where there was a diagnosis of severe histological
chorioamnionitis (versus 1.5% without p<0.05). The organisms most commonly isolated were group B strep, E. coli and Candida albicans. All cases of
septicaemia had received antepartum antibiotics. There was a significant
reduction in the odds of developing RDS ( OR 0.43, p value 0.001) and
odds of dying in the neonatal period (OR 0.38 , p value 0.001) when
histological chorioamnionitis was present.
CONCLUSIONS: Severe histological chorioamnionitis increases the risk
of premature delivery and is strongly associated with neonatal sepsis. There
is a significant reduction in the incidence of RDS and neonatal mortality
in patients with histological chorioamnionitis .
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RESPONSE TO IRON SUPPLEMENTATION IN CHILDREN
WITH AUTISM SPECTRUM DISORDER
CF Dosman, IE Drmic, JA Brian, MM Harford, W Sharieff, R Smith,
H Moldofsky, S Zlotkin, W Roberts
The Hospital for Sick Children, University of Toronto, Toronto, Ontario
Our main objective was to determine the change in serum ferritin level in
response to iron supplementation in children with Autism Spectrum
Disorder (ASD) seen at a tertiary level center. Our secondary objective
was to document the relationship between low ferritin and low dietary
iron. An open-label treatment trial was conducted with children who had
previously demonstrated low serum ferritin measured during clinical diagnostic evaluations for ASD between 1998 and 2003. Diagnostic measures
included the Autism Diagnostic Interview-Revised (ADI-R), Autism
Diagnostic Observation Schedule (ADOS), and clinical evaluation. All
children were prescribed 8 weeks of oral iron suspension or sprinkles.
Dietary intake, compliance and side effects were tracked using a 3-day
Food Record Form and a Nutritional Supplement Log. Serum ferritin and
blood indices, including mean corpuscular volume (MCV) and hemoglobin (Hb) were measured at baseline and after 8 weeks of treatment. Thirtythree children completed the study (mean age 6 years 3 months, 35 males,
8 females); 85% had ferritin <22 µg/L and 30% had ferritin <12 µg/L.
There were significantly more preschoolers with ferritin <12 µg/L
(Chi2=6.9, p=.018), but there were no gender differences. Fifty-two percent of the sample had insufficient dietary iron intake; over half of these
were preschoolers. Dietary sufficiency was not correlated with serum ferritin levels. Mean ferritin level increased significantly from 16 µg/L to
29 µg/L with a mean of 7 weeks of treatment (T=–5.02, p<.000). Ferritin
level in 6 out of 8 preschoolers remained <12 µg/L despite treatment. At
baseline, MCV was low in 42%, and Hb was below expected range for age
in 9%. Mean MCV levels improved significantly with the treatment
(T=–3.38, p=.002). No association was found between low ferritin and
autistic symptomatology based on ADI-R or ADOS scores.
Low serum ferritin is common in children with ASD. Signs of iron-deficient erythropoeisis were common, representing a more advanced stage of
iron deficiency. Although mean ferritin levels increased overall with iron
supplementation, the iron stores of a minority of children (all preschoolers) remained depleted following treatment. MCV improvement suggests
some benefit from the treatment; this subset may require prolonged treatment to replete iron stores. These findings emphasize the importance of
recognizing and treating iron deficiency in children with ASD.
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SEDATION AND ANALGESIA FOR INCARCERATED INGUINAL
HERNIA IN THE PAEDIATRIC EMERGENCY DEPARTMENT
RD Goldman, P Wales, S Balasubramanian, S Mace
Division of Paediatric Emergency Medicine and the Division of
General Surgery, The Hospital for Sick Children, Department of
Paediatrics and Surgery, University of Toronto, Ontario, and School
of Medicine, Queen’s University, Kingston, Ontario
INTRODUCTION: Ten percent of children with inguinal hernia will
experience incarceration and a reduction procedure will be required. The
procedure involves pain and discomfort in most cases. No recommendations on the level of sedation or analgesia for children exist.
METHODS: We conducted a formal mail survey among paediatric emergency physicians (131) and paediatric surgeons (45) in eight centers across
Canada. The survey consisted of multiple choice questions to determine the
use of sedation or analgesia for incarcerated hernia reduction and the length
of the trials. Up to 3 surveys were sent. Data was entered into Microsoft Excel
software and descriptive statistics were done with the SPSS program.
RESULTS: A total of 118 (67%) of the physicians responded. Eighty four
(71%) stated that they would perform the first reduction trial with no
sedation or analgesia. If another trial was needed, 74 (62%) would have
given sedation or analgesia, mostly through the intravenous route.
Fentanyl and Midazolam were the most frequently prescribed medications.
The first attempt at reduction would last 5±5 minutes (range 1-30); waiting between trials was suggested to be on average 14±10 minutes long
(range 1-45) and the number of attempts the responders would carry out
was on average 2±1 trials (range 0-3).
CONCLUSION: Paediatric emergency physicians and paediatric surgeons do not use a unified protocol for reduction of incarcerated hernia in
the paediatric emergency department and significant practice variation
exists. Effort should be made to create and disseminate a protocol for sedation and/or analgesia during this urgent procedure.
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INTERNATIONALLY ADOPTED CHILDREN;
THE EDMONTON CLINIC EXPERIENCE
CI Baxter, ME Lang
Royal Alexandra Hospital, Child Health Ambulatory Clinic,
Edmonton, Alberta
One of the services of the Adoption Clinic in Edmonton, Alberta, is to
address the unique medical and social health concerns for internationally
adopted children and their families. To our knowledge, this is the only service in Western Canada, and only one of three of its kind in Canada. Through
a retrospective chart review, we report our early experience with this clinic.
The charts of 43 internationally adopted children (28 girls and 15 boys)
were reviewed for epidemiological data, including prenatal and birth
history, place of birth, age at adoption, orphanage placement, and any
known past medical history. In addition, at the time of initial assessment in
the adoption clinic, significant findings on initial physical examination and
laboratory investigations were documented. The majority of children were
adopted from China (n=15, of whom 14 were girls). Haiti was the next most
common country from which to adopt (n=11). Other children were adopted
from Romania (n=5), the Phillipines (n=3), Malawi (n=3), and individual
children were adopted from Kazakhstan, Brazil, St. Vincent, Vietnam,
Ukraine, and Lithuania. In the majority of cases there was no prenatal, birth
or family history available. The average age of the adopted children was
27.2 months (±3.7 months) with the majority (30 children) having spent
most of their lives in an orphanage. Although several children had a history
of diarrhea and malnutrition, by the time of their first clinic visit only 2 met
the criteria of failure to thrive. Ten children had abnormal stools, Giardia
lamblia and Blastocystis hominis being the most common organisms. At initial
consultation, only three children had an abnormal physical exam, siblings
with splenomegaly, which was later determined to be caused by malaria.
Single cases each of rickets, hepatitis B, hepatitis C, lead toxicity and alphaand beta-thalassemia trait, hypothyroidism and iron-deficiency anemia were
found on routine screening tests. Developmental delay was evident in 32 of
the 43 children; of these 26 were from an orphanage. Psychiatric disorders
Paediatr Child Health Vol 9 Suppl A May/June 2004