Archivos para 30 octubre 2007

Immunization Schedule Updated for Children and Teens

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News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD

Disclosures

Release Date: January 9, 2007Valid for credit through January 9, 2008

Credits Available

Physicians – maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians;
Family Physicians – up to 0.25 AAFP Prescribed credit(s) for physicians;
Nurses – 0.25 nursing contact hours (0.25 contact hours are in the area of pharmacology)


January 9, 2006 — The American Academy of Pediatrics, the Advisory Committee on Immunization Practices (ACIP), and the American Family of Physicians have updated the immunization schedule for children and teens. The revised guidelines appear in the January 5 issue of the Morbidity & Mortality Weekly Report.

Recommended Immunization Schedules for Persons Aged 0 to 18 Years — United States, 2007

“The Advisory Committee on Immunization Practices (ACIP) periodically reviews the recommended immunization schedule for persons aged 0 – 18 years to ensure that the schedule is current with changes in vaccine formulations and reflects revised recommendations for the use of licensed vaccines, including those newly licensed,” the ACIP authors write.

The new guidelines recommend the following changes from the previous childhood and adolescent immunization schedule, published in January 2006:

  • The new rotavirus vaccine (Rota, Merck & Co) should be given in a 3-dose schedule at ages 2, 4, and 6 months. The first dose should be administered from ages 6 weeks through 12 weeks, and subsequent doses should be given at 4- to 10-week intervals. Rotavirus vaccination should not be started in infants older than 12 weeks and should not be given after age 32 weeks.
  • All children aged 6 to 59 months should receive the influenza vaccine.
  • According to the updated recommendations for varicella vaccine, the first dose should be given at age 12 to 15 months, and a newly recommended second dose should be given at age 4 to 6 years.
  • The new human papillomavirus (HPV) vaccine should be given in a 3-dose schedule, with the second and third doses given 2 and 6 months after the first dose. Girls aged 11 to 12 years should be routinely vaccinated with HPV vaccine, but this vaccination series can be started in girls as young as age 9 years. A catch-up vaccination is recommended for females aged 13 to 26 years who have not been vaccinated previously or who have not completed the full vaccine series.
  • The new guidelines divide the recommendations into 2 schedules: 1 for children aged 0 to 6 years, and another for persons aged 7 to 18 years. Purple bars indicate special populations, and bold, capitalized fonts in the title highlight the 11- to 12-year evaluation. The catch-up immunization schedule incorporates the rotavirus, HPV, and varicella vaccines.

“The National Childhood Vaccine Injury Act requires that health-care providers provide parents or patients with copies of Vaccine Information Statements before administering each dose of the vaccines listed in the schedule,” the authors write. “Detailed recommendations for using vaccines are available from package inserts, ACIP statements on specific vaccines, and the 2003 Red Book.”

Individual ACIP statements for each recommended childhood vaccine are also available from the US Centers for Disease Control and Prevention, and guidance for obtaining and completing a Vaccine Adverse Event Reporting System form is available from the Department of Human Health Services.

The ACIP, the American Academy of Pediatrics, and the American Academy of Family Physicians have approved the recommended immunization schedules for persons aged 0 to 18 years and the catch-up immunization schedule for 2007.

MMWR Morb Mortal Wkly Rep. 2007;55:Q1-Q4.

Clinical Context

Recommendations for childhood and adolescent immunizations for 2007 have been reviewed and released by the ACIP. The main change to the format of the schedule is the division of the recommendation into 2 schedules: 1 for persons aged 0 to 6 years and another for persons aged 7 to 18 years.

In this report, it discloses the changes to the previous childhood and adolescent immunization schedule published in January 2006.

Study Highlights

  • The new rotavirus vaccine is recommended in a 3-dose schedule at ages 2, 4, and 6 months.
  • The first dose should be administered at ages 6 weeks through 12 weeks with subsequent doses administered at 4- to 10-week intervals.
  • Rotavirus vaccination should not be initiated for infants older than 12 weeks and should not be administered after age 32 weeks.
  • The influenza vaccine is now recommended for all children aged 6 to 59 months.
  • Varicella vaccine recommendations are updated. The first dose should be administered at age 12 to 15 months, and a newly recommended second dose should be administered at age 4 to 6 years.
  • The new HPV vaccine is recommended in a 3-dose schedule, with the second and third doses administered 2 and 6 months after the first dose.
  • Routine vaccination with HPV vaccine is recommended for girls aged 11 and 12 years; the vaccination series can be started in girls as young as age 9 years, and a catch-up vaccination is recommended for females aged 13 to 26 years who have not been vaccinated previously or who have not completed the full vaccine series.
  • Rotavirus, HPV, and varicella vaccines are incorporated in the catch-up immunization schedule.

Pearls for Practice

  • In the 2007 ACIP vaccination guidelines for children and adolescents, changes to the previous guidelines include the extension of the influenza vaccine to all children aged 6 to 59 months, the second dose of varicella at age 4 to 6 years, and the introduction of the rotavirus and HPV vaccines.
  • The new vaccinations include the 3-dose rotavirus vaccine at ages 2, 4, and 6 months and the 3-dose HPV vaccine, with the second and third doses administered 2 and 6 months after the first dose.

 

1. According to the 2007 ACIP immunization schedule, all of the following are changes to the 2006 guidelines, except:  (Required for credit)

 

2. According to the 2007 ACIP immunization schedule, which of the following statements is not correct regarding the updated vaccine information?  (Required for credit)

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Hepatitis A & B Vaccines

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http://www.medscape.com/viewprogram/7956?src=mp

http://aapredbook.aappublications.org/week/iotw052305.shtml

Les comparto este par de LINK referente al tema de Vacunas de Hepatitis A y B

DR. LUIS RUIZ

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Patient-Physician Email Communication May Be Effective

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News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD

Disclosures

Release Date: October 3, 2007Valid for credit through October 3, 2008

Credits Available

Physicians – maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians;
Family Physicians – up to 0.25 AAFP Prescribed credit(s) for physicians


October 3, 2007 — Patients prefer patient-physician email communication, which takes less time for physicians than does telephone messaging, according to the results of a survey reported in the October issue of Pediatrics.

“The 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century called for care that is based on continuous healing relationships,” write Paul Rosen, MD, MPH, MMM, and C. Kent Kwoh, MD, from the University of Pittsburgh School of Medicine in Pennsylvania, and colleagues. “In its first rule on redesign, the IOM report stated, ‘Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health care system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits.'”

The goals of this study were to evaluate the patterns of patients using a patient-physician email service, to measure physician time required to answer a patient question via email vs via telephone, and to assess the satisfaction of families who were provided email access to their child’s rheumatologist.

During a 2-year period, a consecutive series of the families of pediatric patients were offered email access, and the investigators collected data on patient email use. Studied parameters included urgency, subject matter, and volume of the message; time of day of messaging; and timed duration with use of a stopwatch of the pediatric rheumatologist’s email interactions and telephone interactions with patients. After 1 year of enrollment in the patient-physician email service, families were mailed a 12-item satisfaction survey concerning their email experience.

Of 328 families who were offered patient-physician email access, 306 enrolled, and 121 used the service. Of all patient emails sent, 40% were sent during nonbusiness hours, and 5.7% were urgent (notification of disease flare or of new symptoms or parent expectation of same-day response). Only 0.002% of the emails to the physician required emergent attention.

On average, the physician received 1.2 emails per day from patients. For the physician, answering patient questions by email was 57% faster than by telephone. Families who responded to the survey reported that patient-physician email improved access to the physician as well as quality of care, and they did not believe that patient-physician email distanced them from the pediatrician.

“Patient-physician e-mail is a service that patients will use given the opportunity,” the study authors write. “The e-mail service enables physicians to answer medical questions with less time spent compared with telephone messaging. In our experience in an academic pediatric subspecialty practice, patients reported enhanced communication and access with the e-mail service.”

Limitations of the study include lack of generalizability to practices in other pediatric subspecialties or in general pediatrics; lack of measurement of the impact of the email service on the number of telephone calls to the office; survey instrument used to evaluate patient satisfaction not being a validated tool; and only 41% of surveys returned, introducing sampling bias.

“For some physician practices, a staff-based triage system may be more efficient than a non–triage-based system,” the study authors conclude. “However, the comments of the families who used the service demonstrate that PPEM [patient-physician email] is one method of improving communication and providing consumer-driven health care…. Given the nature of family-centered care for pediatric patients, pediatricians and pediatric subspecialists are well positioned to transform health care delivery.”

The Children’s Arthritis Network supported this study. The authors have disclosed no relevant financial relationships.

Pediatrics. 2007;120:701-706.

Clinical Context

The 2001 IOM report mandates care based on continuous healing relationships, which implies that patients should have access to care whenever they need it and not only through in-person visits. Email communication may be a low cost, yet effective, method to respond to patient concerns, and 90% of patients surveyed stated that they would like the ability to email their physician.

Although pediatricians are more likely than other physicians to use email communication with their patients, only 30% of pediatricians are using patient-physician email at present. In addition, 37% of patients who use email reported that they would pay out of pocket for the ability to email their physician, and one third reported that they would change their physician to get patient-physician email.

The objective of this study was to assess patient use of patient-physician email as well as physician time spent and patient satisfaction.

Study Highlights

  • The goals of this study were to evaluate a patient-physician email service used to provide patient access to 1 pediatric rheumatologist.
  • During a 2-year period, a consecutive series of 328 families of this pediatrician’s patients were offered email access; 21 declined enrollment (10 because they had no email access, 9 because they preferred to always use the telephone).
  • Informed consent noted that email should not be used for an emergency or time-sensitive situation; should be concise, may be forwarded to other members of the healthcare team involved with the child’s care, will become part of the child’s medical chart, response will be sent within 72 hours, and private healthcare information sent through the Internet may be intercepted by hackers.
  • Measured outcomes included urgency, subject matter, and volume of the email message; time of day of messaging; and timed duration (with use of a stopwatch) of the physician’s email interactions and telephone interactions with patients.
  • After 1 year of enrollment in the patient-physician email service, families were mailed an anonymous 12-item satisfaction survey concerning their email experience.
  • Of 328 families who were offered patient-physician email access, 306 enrolled, and 121 used the service.
  • Families who responded to the survey reported that patient-physician email improved access to the physician as well as quality of care. They also believed that email facilitated understanding of medical tests, and they did not believe that patient-physician email distanced them from the pediatrician.
  • Of all patient emails sent, 40% were sent during nonbusiness hours, and 5.7% were urgent (notification of disease flare or of new symptoms, or parent expectation of same-day response).
  • Despite informed consent warning families not to use email to report emergencies, 0.002% (2/848 emails) sent to the physician required emergent attention. Both emails were sent by the same family.
  • On average, the physician received 1.2 emails per day from patients. Although the consent form indicated that email responses would be sent within 72 hours, almost all physician responses were sent within 24 hours, and many responses during regular business hours were sent within 2 hours.
  • For the physician, answering patient questions by email was 57% faster than by telephone (mean, 132.1 vs 309.2 seconds; P < .0001).
  • The email service in this study did not provide for security with encryption technology, which is recommended by the Health Insurance Portability and Accountability Act (HIPAA) policy statement. Patients were reminded through informed consent of the risk for stolen private health information.
  • The routing process for the telephone triage system used in this practice could take several hours, depending on the workload of each staff member involved. The email process bypassed the support staff and left physician response time as the only delay.
  • Although physicians may be concerned about increased liability regarding email communication with their patients, the investigators concluded that anything that enhances physician-patient communication should decrease the risk for misunderstanding, preventable injury, and liability. They also note that reimbursement for email communication with patients is not widespread, but that the email serves as documentation of the encounter and a copy can be saved to the medical record.

Pearls for Practice

  • Families who used a patient-physician email service reported that patient-physician email improved access to the physician as well as quality of care. They also believed that email facilitated understanding of medical tests, and they did not believe that patient-physician email distanced them from the pediatrician.
  • Only 0.002% of emails sent to the physician required emergent attention. Almost all physician responses were sent within 24 hours. For the physician, answering patient questions by email was 57% faster than by telephone.

 

1. Based on the study by Rosen and Kwoh, which of the following statements about patient family satisfaction with a patient-physician email service is correct?  (Required for credit)

 

2. Based on the study by Rosen and Kwoh, which of the following statements about physician concerns and benefits regarding patient-physician email is not correct?  (Required for credit)

Medscape Medical News 2007. ©2007 Medscape

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The material presented here does not necessarily reflect the views of Medscape or companies that support educational programming on http://www.medscape.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in

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LA ORACIÓN EN LOS NIÑOS

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Muchas personas hoy en día consideran que cada persona es libre de pensar y creer en lo que quiera. La mayoría de veces los resultados son inéditos y no ajsutados a las realidades que hoy vivimos. Por el contrario, llevan a nuestros jóvenes a comprender el mundo de una manera muy superflua, a no responsabilizarse, a perder el interés por vivir, a ser oprimidos por la angustia de pertenecer a una sociedad de consumo, sin Valores ni Principios morales. Carecen de modelos a seguir, y pueden llevar a conductas inadecuadas, que afectan a nuestras sociedades.

Cualquiera que sea tu Religión, considera importante que el estar en contacto con Dios es vital, para sentirte hijo, y por ende necesitado de ese Amor. Tus Actos serán fruto de esa vivencia personal.

 Todos los días los padres de nuestros pacientes, nos permiten compartir con ellos unos 20 a 30 minutos por mes. Que ese encuentro con ellos, en salud o en enfermedad, conlleve el sello de tu Fe, y recuerda que significas mucho para cada paciente, eres un MODELO  a seguir. Inculca buenas constumbres que le hagan crecer no unicamente en lo físico, sino en lo espiritual.

DR LUIS ALFREDO RUIZ CRUZ

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LEVOFLOXACIN EFFICACY IN PNEUMONIA COMMUNITY (CAP)

Bradley JS, Arguedas A, Blumer JL, Sáez-Llorens X, Melkote R, Noel GJ.

From the *Childrenʼs Hospital and Health Center, San Diego, CA; †Instituto de Atención Pediátrica, Neeman-ICIC, Universidad de Ciencias Médicas, San José, Costa Rica; ‡Case Western Reserve University, Rainbow Babies Hospital and Childrenʼs Hospital, Cleveland, OH; §Hospital del Niño, Ciudad de Panamá, Panamá; and ∥Johnson and Johnson Pharmaceutical Research and Development, L.L.C., Raritan, NJ.

BACKGROUND:: Levofloxacin has established efficacy and safety in the treatment of community-acquired pneumonia (CAP) in adults, and its use as an alternative therapy for children with CAP has been proposed.

OBJECTIVE:: Assess the clinical efficacy and safety of levofloxacin compared with standard of care antibiotic therapy in the treatment of CAP in children aged 6 months to 16 years.

METHODS:: In an open-label, multicenter, noninferiority trial, children with CAP were randomized 3:1 to receive levofloxacin or comparator antimicrobial therapy (0.5 to <5 years: amoxicillin/clavulanate or ceftriaxone; >/=5 years: clarithromycin or ceftriaxone with clarithromycin or erythromycin lactobinate) for 10 days. The primary outcome was cure rates at the test-of-cure visit (10-17 days after completing treatment) as determined by symptoms, physical examination, and chest radiography.

RESULTS:: Seven hundred and thirty-eight children were enrolled and 539 (405 levofloxacin-treated, 134 comparator-treated) were clinically evaluable at test-of-cure visit. Clinical cure rates were 94.3% (382 of 405) in levofloxacin-treated and 94.0% (126 of 134) in comparator-treated children. Cure rates were also similar for levofloxacin and comparator for each age group (<5 years, 92.2% versus 90.8%; >/=5 years, 96.5% versus 97.1%; respectively) and for children categorized as being at higher risk for severe disease. Mycoplasma pneumoniae was the most frequently identified cause of pneumonia (230 children). Levofloxacin was as well tolerated as comparators, with similar type and incidence of adverse events.

CONCLUSIONS:: Levofloxacin was as well tolerated and effective as standard-of-care antibiotics for the treatment of CAP in infants and children.

DR. BYRON HERRERA NO COMPARTE ESTE ABSTRAC DE UN ARTICULO INTERESANTE

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CASO INTERESANTE OCTUBRE

A Case of Tot Maltreatment

Posted 09/26/2007

Sarah A. Martin, RN, MS, CPNP-PC/AC, CCRN; Terea Giannetta, MSN, RN, CPNP; Karin Reuter-Rice, PhD, RN, CPNP
Author Information

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Clinical Insights In The Treatment of ADHD
Learn more about ADHD prevalence and treatment, recent data on ADHD and SUD comorbidity, important conventions in 2007, and more. Read expert interviews from key opinion leaders in ADHD.

Case Study

History of Present Illness

A.N. is a previously healthy 2-year-old African American girl who was admitted to a pediatric trauma center after being evaluated in the emergency department at an outside hospital and transferred for an acute abdomen. Her mother reported she had a 1-day history of bilious emesis, a green stool with bloody flecks, and abdominal pain at the outside hospital. Her mother and mother’s paramour reported that she fell over several times while sitting in her “time-out” chair as she kicked the wall until the chair fell over backwards. There was no report of any other trauma. At the outside hospital, an episode of bilious emesis and bright red rectal bleeding occurred. In route to the pediatric trauma center, A.N. received a 60 mL/kg fluid bolus with normal saline solution and a dose of ampicillin and gentamicin to cover a possible “abdominal catastrophe.”

History

A.N. is a previously healthy toddler with no medical or surgical history. She has no known medication or dietary allergies. Her family history is noncontributory to her current illness. Her immunizations are reported to be up to date per her mother’s verbal report. A.N.’s review of systems revealed no recent respiratory or gastrointestinal illnesses, with no previous bowel issues.

Physical Examination in the Emergency Department

A.N.’s weight is 10 kg (5th to 10th percentile), her height is 82 cm (10th percentile), and her temperature is 37.3° Celsius tympanic. Her heart rate is 143 beats per minute, her respiratory rate is 26 breaths per minute, and her blood pressure initially was 84/palpation, and 30 minutes after a fluid bolus, her blood pressure was 95/44 mm Hg. The general impression is of a lethargic, grunting toddler lying supine; no family members are present at the bedside at the time of the examination.

Results of a head, ears, eyes, nose, and throat examination reveal a hematoma measuring 1 by 1.5 cm on her right forehead and a 2-mm laceration on her nasal bridge. An examination of tympanic membranes is normal, and no ear or nasal discharge is appreciated. Her oral mucous membranes are moist and clear, with intact dentition.

A cardiopulmonary examination reveals no murmur; she is tachypneic, although her breath sounds are clear and equal. She has no retractions or accessory muscle use. Her extremities are cool peripherally, with a capillary refill time of 5 seconds. Her radial and pedal pulses are easily palpable bilaterally.

Examination of her abdominal reveals a distended, firm abdomen with hypoactive bowel sounds. There is diffuse rebound tenderness; however, no bruising or discoloration is appreciated. Bright red blood is present in her diaper, and a rectal examination was deferred. A neurologic examination reveals a lethargic, fearful toddler with a Glasgow Coma Scale score of 14. She moves all extremities symmetrically, and motor strength is 5/5 in all extremities.

Case Study Questions

  1. What laboratory tests are ordered initially, and what is your interpretation of the laboratory results?
  2. What are the most appropriate radiographic studies to order for a child suspected of sustaining an abdominal trauma?
  3. What common abdominal injuries occur with nonaccidental trauma, and what is the usual treatment?
  4. What risk factors for child abuse were identified? Who was the perpetrator of this injury?
  5. What are considerations for follow-up, and what initiatives exist for the prevention of child maltreatment?

Questions and Answers

What Laboratory Tests Are Ordered Initially, and What is Your Interpretation of the Laboratory Results?

In the emergency department, the following laboratory tests were ordered: a comprehensive metabolic panel (electrolytes, liver transaminases, blood urea nitrogen, and a creatinine level), amylase, lipase, complete blood cell count (CBC), type and cross for packed red blood cells, and urinalysis. A.N.’s electrolytes were within reference range except for a CO2 level of 16 mEq/L (reference range, 24-30 mEq/L). This depletion of carbon dioxide reflects a metabolic acidosis and may indicate some degree of dehydration, hydrogen chloride loss from vomiting, and ischemic and or necrotic bowel.

Her hemoglobin in the emergency room was 7.2 g/dL (reference range, 12-16), and this reading, with a previous measure of 8.2 g/dL at the outside hospital, raised concern for internal bleeding. A type and cross for packed red blood cells was ordered. A.N. has a leukocytosis of 27 thou/µL (reference range, 5-20), and this elevation can reflect stress, infection, or inflammation. Her liver transaminases were elevated with an alanine aminotransferase of 628 IU/L and an aspartate aminotransferase of 1,227 IU/L, which indicates some trauma to the liver. Her amylase and lipase values were normal. Her urinalysis was unremarkable.

A.N.’s physical examination and laboratory values support an intra-abdominal injury with signs of diffuse peritonitis. It is interesting to note that in a quarter of children with abdominal injuries from nonaccidental trauma, there is no sign of external bruising (Vandeven & Newton, 2006). Because she is showing signs of hypovolemic shock (tachycardia, hypotension, and poor perfusion) and fluid boluses of greater than 60 mL/Kg have been administered, packed red blood cells are ordered to be transfused.

What are the Most Appropriate Radiographic Studies to Order for A Child Suspected of Sustaining an Abdominal Trauma?

When an intra-abdominal injury is suspected, radiographic evaluation includes a cervical spine, chest x-ray, and pelvic radiograph to evaluate for concomitant injuries. A flat plate of A.N.’s abdomen revealed a pneumoperitoneum (with right subphrenic air present), which is suggestive of a hollow organ injury with presumed perforation. Although an abdominal computed axial tomography (CAT) scan is highly sensitive and specific for solid organ injuries, the study has not been shown to be diagnostic for hollow viscus injuries. Given her instability and existing x-ray findings, a CAT scan was not done because urgent operative intervention was needed.

Although the majority of pediatric abdominal traumatic injuries are managed nonoperatively, because a viscus perforation was suspected, A.N. was prepared for an exploratory laparotomy. Consent was obtained from her mother. Because the specific injury or injuries were not known, the consent was comprehensive and included exploration, possible bowel resection, possible bowel diversion, and central line placement. Harris and Stylianos (2001) describe the operative procedure for an exploratory laparotomy for a child in detail.

Case Update With Operative Findings. Operative findings included a duodenal hematoma, small bowel perforation, avulsion of the small bowel mesentery, and a right kidney contusion. An exploratory laparotomy was performed with repair of the ileal perforation, repair of the small bowel mesentery, exploration of the duodenum and right kidney, and drainage of a hematoma. The ileum was noted to be blue to purple in color; however, Doppler pulses were present, and the intestine was not resected. There was a hematoma in the duodenal wall and a serosal tear and a hematoma in the right colon.

At the time of this initial operation, a decision was made to bring the child back to the operating room in 24 hours to assess bowel viability; therefore, the abdomen was left open and packed with moist sponges, and a drain was placed. The child was transferred to the pediatric intensive care unit on mechanical ventilation with sedation and neuromuscular blockade. A Protective Services Team (PST) consult was initiated for presumed child maltreatment.

What Common Abdominal Injuries Occur with Nonaccidental Trauma, and What is the Usual Treatment?

For the pediatric trauma victim, blunt trauma occurs in 90% of the cases versus 10% for penetrating injuries (Gaines & Ford, 2002). Blunt abdominal trauma is the etiology for most abdominal injuries, and the most commonly injured organs are the spleen, liver, and kidneys. The most common mechanisms for injury are motor vehicle collisions, falls, and child abuse. Unfortunately, in 2004, child maltreatment was the etiology for as many as 1,490 fatalities (Child Welfare Information Gateway, 2006).

The injuries this child sustained could not be explained by the history offered by her family, and inconsistencies between the history and physical findings are key in diagnosing physical abuse. Injury to the gastrointestinal tract in a child who sustains blunt trauma is uncommon and occurs in less than 1% of the cases (Canty, Canty, & Brown, 1999). Roaten et al. (2005) reported that in children sustaining nonaccidental trauma, 50% of the children in their series had hollow viscus injuries. Roaten et al. found in 265 cases of nonaccidental trauma that the most frequently injured solid organ was the liver (33%), followed by the spleen (21%), and for hollow organs, the jejunum and ileum (29%) were most frequently injured, followed by the duodenum (25%) and the stomach (4%).

Injury to the duodenum is unusual and occurs in less than 5% of pediatric trauma victims, because the organ in children is protected in the retroperitoneal space (Gaines, Shultz, Morrison, & Ford, 2004). In a series of children who had sustained duodenal injuries, the most common etiology was found to be motor vehicle crashes, followed by child abuse (Gaines et al.). Clendenon, Meyers, Nance, and Scaife (2004) reported on duodenal injuries from two pediatric trauma centers over a 10-year period and found the most common etiology of these injuries to be child abuse. In addition, it was found that for children younger than 4 years, all of the duodenal injuries could be attributed to child abuse (Gaines et al.). Other injuries found in children who had duodenal injuries from child abuse included multiple contusions, rib fractures, other intestinal injuries, long bone fracture, pancreatic injury, and head injury (Gaines et al.).

Because nonaccidental trauma was presumed in this case, additional diagnostic testing was done and included a head CAT scan, skeletal survey, and an ophthalmology consult. Results of the head CAT scan were reported as normal, no abnormalities were noted on the skeletal survey, and the ophthalmology examination revealed no retinal hemorrhages. According to the American Academy of Pediatrics (2000), an initial negative skeletal survey should be repeated in 2 weeks for an increased diagnostic yield and may allow for a more precise age of individual injuries and may determine initial findings to be normal anatomic variants.

Management of duodenal injuries involving intestine rupture is operative with primary repair, and for hematomas, observation with the administration of parenteral nutrition is appropriate. Unfortunately, duodenal hematomas can contribute to a significant gastric outlet obstruction, and often lengthy hospitalizations of a month or longer for parenteral nutrition is necessary because enteral nutrition is not tolerated.

The Second Look Operation. A.N. remained mechanically ventilated and hemodynamically stable following her first operation. She was tachycardic, with a heart rate of 140 beats per minute, and she was febrile (38.8° Celsius rectal). Fresh frozen plasma and vitamin K was administered for a presumed consumptive coagulopathy. Total parenteral nutrition was started as a prolonged “nothing by mouth” status was anticipated. Upon return to the operating room a segment of her small bowel was necrotic and 20 cm of the ileum was resected. Her abdomen was closed, and she was readmitted to the PICU.

What Risk Factors for Child Abuse Were Identified? Who Was the Perpetrator of This Injury?

An extensive interview with the social worker and the mother and a separate interview with the mother’s boyfriend revealed several parental risk factors for abuse. In addition to the PST consult, detectives from the police department and, in accordance with mandated reporting, the Department of Children and Family Services were notified and involved. Identified risk factors included single parenthood, substance abuse, mental illness (maternal depression), and a history of neglect for the mother when she was a child.

Pediatric nurse practitioners are mandated reporters; however, there often is reluctance to report, and additional education and research is needed. Flaherty (2006) reported that physicians have expressed fears related to reporting, including losing families as patients, subsequent litigation for reporting suspected abuse, and concern they will have to testify in court. Prior to reporting a family, consider conferring with the child’s attending physician and parent(s) prior to making a report. The PST fulfilled the mandated reporting obligation of child abuse to the Department of Children and Family Services.

The history ascertained from PST included a detailed timeline of events surrounding the time frame the injury was thought to have occurred. This child’s family sought care after the mother had completed a work shift, and the history reflects that mother had been working and that the mother’s boyfriend had been caring for the child. Although no confession was obtained, the injuries were consistent with child maltreatment, and the Department of Children and Family Services took protective custody of A.N. Efforts to identify foster care for A.N.’s discharge was initiated by the PST.

What Are Considerations for Follow-up, and What Initiatives Exist for the Prevention of Child Maltreatment?

A number of programs have been developed to aid with the prevention of child abuse. The National Association of Pediatric Nurse Practitioners (2007) Position Statement contends that pediatric nurse practitioners are in a strategic position to assess for risk and protective factors as well as provide primary prevention. It is known that if it happens once and is not diagnosed, it will happen again, with the increased likelihood of more severe injury.

A number of programs exist for the prevention of child abuse. Because crying is known to be the number one trigger, the National Center on Shaken Baby Syndrome has a program Period of PURPLE crying, with the goal of educating parents about infant crying. Readers are referred to Vandeven and Newton (2006) and Walls (2006) for additional educational resources.

On hospital day 64, A.N. was discharged to a foster mother; she was tolerating enteral feeds after having her ileostomy taken down. Fortunately, this child had recovered from her injuries, and despite some morbidity, was discharged with a functional gastrointestinal tract. This child was seen in the pediatric surgery clinic 10 days after discharge and was doing well. A.N. was to be followed by the multidisciplinary PST on an ongoing basis. At the time of her discharge from the pediatric surgery clinic, there were no specific recommendations for long-term follow-up. As with any child who undergoes an abdominal surgery, A.N. is at lifelong risk for a bowel obstruction. Symptoms of concern that would warrant evaluation include abdominal distension, abdominal pain, and bilious emesis.

Fortunately, no deaths from intra-abdominal injury due to nonaccidental trauma were reported in the literature, with all deaths related to concomitant head injuries. A confession for this injury was never obtained, and thus there was no criminal prosecution. This case supports further investigation when there is suspicion for child maltreatment or when the history is inconsistent with the injury.

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ORGULLO DE SER CHAPIN

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