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美国儿科护士从业者协会第26届年会热点
Highlights of the National Association of Pediatric Nurse Practitioners (NAPNAP) 26th Annual Conference
2005年3月31日－4月3日
美国亚利桑那州非尼克斯
March 31, 2005 - April 3, 2005, Phoenix, Arizona
Meningococcemia is a frightening diagnosis for most healthcare providers. In its most severe forms, it possesses unmistakable characteristics. It is one of the few infections that can leave patients with gruesome morbidities and significant mortality in less than 24 hours after presentation. Despite major medical advances, this disease continues to cause devastating effects to our children.
At a session presented by Lisa Milonovich, RN, MSN, PCCNP, CCRN, Pediatric Critical Care Nurse Practitioner in Dallas, Texas, she discussed current epidemiologic trends, pathophysiology, management, and prevention of meningococcemia.[1]
As a result of the control of Haemophilus influenzae type b infections, Neisseria meningitidis has become the leading cause of meningitis in children and young adults in the United States.[2] Outbreaks were rare in the United States in the 1980s, but since 1991 the frequency of localized outbreaks has increased.[2] From July of 1994 to 1997, 42 meningococcal outbreaks were reported, 4 occurring on college campuses.
Rates for meningococcemia are highest in infants, with another rise in rate during adolescence, peaking in incidence among 15 to 24 year olds. Incidence is estimated at 0.5-5/100,000[3] and 10% to 15% of cases are fatal. Of patients who recover from this infection, 10% to 15% have significant morbidities including permanent hearing loss, mental retardation, and loss of digits or limbs.[1]
"Meningococcemia is a potentially devastating infection which can cause system wide sepsis, multi-organ failure, and meningitis," said Sean Elliott, MD, Infectious Diseases Attending Physician at the University of Phoenix in Arizona (personal communication, April 7, 2005). This aggressive bacterial infection is caused by N meningitidis, which is an encapsulated Gram-negative diplococcus.[4] There are multiple serogroups of N meningitidis, with serogroups B and C being most common in the United States.[3] This bacteria may produce an isolated meningitis or meningococcemia. Meningococcemia denoted presence of N meningitidis in the systemic circulation.[1]
Transmission of this meninogococcemia is via direct contact with respiratory secretions from a nasopharyngeal carrier. Highest-risk groups for acquiring this disease include infants and young children, refugees, household contacts of case patients, military recruits, freshmen college students living in dormitories, microbiologists working with isolates of N meningitidis, and people exposed to active and passive smoke.[2]
Ms. Milonovich went on to point out that "initial symptoms are vague," and children may present with fever, vomiting, headache, lethargy, and abdominal pain. This can quickly evolve to include petechiae and purpura, altered mental status, meningismus, and rapid hemodynamic collapse.[4] "Because the initial presentation of meningococcemia is non-specific and flu-like, healthcare providers need to maintain a high index of suspicion to recognize and treat this infection," said Dr. Elliott (personal communication, April 7, 2005).
"Our goal is simple," said Milonovich, "restoring adequate oxygen and substrate delivery to tissues. However, reaching that goal is not very simple." N meningiditis is easily eradicated with antibiotics, but the effects of the pathophysiology in progress can be irreversible. Meningococcemia is generally sensitive to penicillin G, cefotaxime, and ceftriaxone.[1]
Milonovich explained how patients often get worse initially after antibiotic administration due to endotoxin release. She reviewed other management strategies including fluid management, blood product administration, inotropic support, and intravascular monitoring. The role of steroids remains somewhat unclear in pediatric sepsis.[1] Supportive techniques such as mechanical ventilation, topical therapy, skin grafting, and renal replacement therapies are also utilized.
Milonovich also reviewed other current research efforts to decrease the effects of meningococcemia. These include renal replacement therapies for fluid removal, endotoxin removal, and the provision of optimal nutrition. Other strategies being investigated are skin/limb management protocols, administration of bacterial permeability increasing protein, and administration of activated protein C (APC). The multicenter pediatric APC trial was recently halted because of an unfavorable risk-benefit ratio.[1]
Genomics, the study of genes and their function, is an exciting area of research in not only meningococcemia, but also in other areas of infectious disease. Cytokine release plays an important role in the inflammatory response to the N meningitidis endotoxin and the body's overall pathophysiology of invasive meningococcal disease. An Irish study demonstrated that severe meningococcemia is multifactorial. Findings indicated that there may be a strong association between genetic factors and meningococcemia, and the outcome of patients may be dependent on their genetic composition.[5]
Until recently, only the meningococcal polysaccharide vaccine (Menomune) was available. As reported by William L. Atkinson MD, MPH, Immunizations Services Division, Centers for Disease Control and Prevention, Atlanta, Georgia, in a session entitled, "What's New in Childhood Immunization?" there is an age-related immune response and an inconsistent immunogenic response in those patients under 2 years of age with this vaccine.[6]
In September 2004, the Vaccines and Related Biological Products Advisory Committee of the US Food and Drug Administration (FDA) voted unanimously to recommend licensure of the conjugate vaccine developed by Sanofi Pasteur for prevention of invasive meningococcal disease.[7] A few short months later, the FDA licensed the Menactra vaccine.[8] This is the first quadrivalent conjugate vaccine licensed in the United States to provide protection against serogroups A, C, Y, and W-135 of N meningiditis.[8] As discussed by Milonovich, neither of the available vaccines is effective against serotype B, which is one of the most common serotypes in the United States.
The benefits of a successful conjugate vaccine include improved duration of protection, induction of immunologic memory, booster responses, and reduction in nasopharyngeal bacterial carriage for recipients.[8] The US Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has formed a working group to update recommendations on control of meningococcal disease as well as routine meningococcal vaccination for one of more birth cohorts (eg, 11-12 year olds) and of selected college pupils.[8] [Editor's note: These recommendations were recently updated to include routine meningococcal vaccination for 11- to 12-year-old children.][9]
"Meningococcal infections affect several thousand people a year in the United States, with a peak in adolescence. Menactra has been approved for children 11-15 years of age and should definitely be added to the immunization schedule. We are entering a new phase of vaccination, where adolescents will be targeted; besides Menactra, pertussis vaccination and a vaccination against papillomaviruses are in phase 3 trials," stated Ben Katz, MD, Infectious Diseases Attending Physician, Children's Memorial Hospital, Chicago, Illinois (personal communication, April 8, 2005).
Children with meningococcemia have significant risk for morbidity and mortality. It is imperative that healthcare providers consider this diagnosis when evaluating patients with suspicious symptomatology and then implement therapy promptly. The future likely holds recommendations for immunization against this deadly disease.
Centers for Disease Control. Meningococcal disease and college students. Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2000;49:11-20.
Viral illness, specifically respiratory syncytial virus (RSV), is commonly seen in all pediatric settings. While it is typically a self-limited disease that is primarily a nuisance, it can lead to significant morbidity and mortality in infants and children.
Current diagnosis, management strategies, and preventive techniques were highlighted at the annual conference of the National Association of Pediatric Nurse Practitioners (NAPNAP). At a session presented by Lauren Sorce, RN, MSN, CPNP, CCRN,[1] Pediatric Nurse Practitioner, Pediatric Critical Care, Children's Memorial Hospital, Chicago, Illinois, epidemiology, risk factors, clinical manifestations, management, and chemoprophylaxis were discussed.
"RSV is a leading cause of respiratory disease and morbidity and mortality in infants and young children. Although many children recover fully from RSV-associated bronchiolitis, a high-risk segment of the patient population experiences much more severe complications and life-threatening disease" said Sean Elliott, MD, Infectious Diseases Attending Physician at the University of Arizona in Tucson, Arizona (personal communication, April 7, 2005).
Ms. Sorce described the RSV virus as an enveloped single-stranded RNA virus. Two glycosylated surface proteins are required to infect cells. There are 2 strains of RSV, the A group and the B group. There is worldwide distribution of RSV with a seasonal distribution for winter, with January through March as the peak months. Most children have been affected by the time they reach their second birthday. Reinfection occurs throughout the life span.[1]
About 0.5% to 2% of children with RSV will require hospitalization. This leads to an estimate of 125,000 pediatric hospitalizations secondary to RSV in the United States.[1]
The high-risk patient population for RSV includes "premature infants, infants with chronic lung disease, infants with congenital heart disease, and infants less than 1 year of age," explained Dr. Elliott (personal communication, April 7, 2005).
Ms. Sorce reviewed the list of risk factors for RSV that includes younger age, infants with a history of prematurity, male gender, lower socioeconomic class, underlying cardiorespiratory disease, underlying immune dysfunction, and congenital neurologic or metabolic diseases.
"Apnea is often the first sign of RSV in infants and often the reason for hospitalization," Ms. Sorce stated. There are also many other signs and symptoms including fever, irritability, malaise, dyspnea, increased work of breathing, retractions, tachypnea, anorexia, pharyngitis, rhinorrhea, cough, prolonged expiratory phase, rales, wheezing, and hypoxia.[1]
Findings from a study by Checchia and colleagues[2] demonstrated that a large percentage (54.5%) of children admitted to the pediatric intensive care unit with RSV disease have myocardial damage as identified by the use of commercially available troponin assays. Additionally, some of these patients exhibited clinically significant damage leading to cardiac instability and need for inotropic support.[2]
RSV is transmitted from direct contact, self inoculation after contact with virus, or entry via nose or eyes. "It can be difficult to not spread RSV," stated Ms. Sorce. "RSV is so strong that it survives on nonporous surfaces for at least 24 hours and can survive on stethoscopes for 48 hours," she added.
Children without other risk factors have an estimated mortality rate of about 1%. Children with congenital heart disease (CHD) are more vulnerable, with an estimated risk for mortality of 2% to 3% for RSV-related hospitalizations.[3]
With mixed data on pharmacologic therapies, management is driven by supportive care including oxygen, bilevel positive pressure mask ventilation, heliox, and invasive ventilation.
"Unfortunately, no efficacious antiviral medications exist which treat RSV, so prevention is the best treatment currently available," pointed out Dr. Elliott. He went on to point out that, "Prevention occurs in the form of monoclonal antibody against RSV, called palivizumab, which can be injected intramuscularly with a fairly high degree of safety to patients meeting AAP-established criteria for high risk. Although this product does not completely prevent RSV bronchiolitis, it has been demonstrated to reduce the severity of bronchiolitis episodes experienced by recipients" (personal communication, April 7, 2005).
In her presentation, Ms. Sorce reviewed the Palivizumab Congenital Heart Disease Study that evaluated palivizumab administration to children less than 2 years of age with hemodynamically significant CHD. She explained that it demonstrated a 45% risk reduction in hospitalization for recipients of palivizumab.[4]
New recommendations by the American Academy of Pediatrics (AAP) in 2003 recommended that infants with hemodynamically significant CHD be considered for palivizumab administration (Table). (Ms. Sorce encouraged all attendees to read the papers published by the AAP on guidelines for palivizumab use.[5,6])
"Synagis has been beneficial in decreasing hospitalizations for RSV, but better, cheaper, and more convenient prophylaxis is needed. There are 'second generation' products in clinical trials, as well as vaccines. These may not be cheaper, but will certainly be more effective and convenient," said Ben Katz, MD, Infectious Diseases Attending Physician, Children's Memorial Hospital, Chicago, Illinois (personal communication, April 8, 2005).
MedImmune is developing a third generation anti-RSV molecule that may have significant benefits over palivizumab. In October 2003, it submitted an investigational new drug application to the FDA to evaluate this product, called Numax. This is currently in 2 phase 3 clinical trial stages that were started in November of 2004.[7]
RSV is a common virus that is ubiquitous in our environment. We are all reinfected with it many times throughout life. Infants and children, particularly those with other underlying medical problems, are at risk for a more protracted course, some requiring hospitalization leading to critical illness. Due to the virulence of this virus, prevention is our biggest ally in protecting the young from this disease.
The Impact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics. 1998;102:531-537.
A fitness theme was key at this year's conference, as NAPNAP released the first draft of clinical practice guidelines (CPGs) dealing with the identification of overweight and obesity prevention in children. The need for prevention strategies is evident due to the ever increasing prevalence of overweight children. Data collected from the National Health and Nutrition Examination Survey report that in 2001-2002, 16.5% of children aged 6-19 years were overweight compared with 15.0% in 1999-2000.[1] For children in this same age group, 31.5% were at risk for overweight compared with 29.9% in 1999-2000.[1] Perhaps even more alarming are the rates for younger aged children. The prevalence of overweight in children aged 2-5 years is 10.3% and the rate for children at risk for overweight in this age group is 22.6%.[1]
"At risk for overweight" in children is defined as a body mass index (BMI) at or above the 85th percentile but less than the 95th percentile of the sex-specific BMI for age on the Centers for Disease Control (CDC) Prevention Growth Charts.[2,3] Overweight is defined as at or above the 95th percentile of the sex-specific BMI-for-age growth chart.[2,3] BMI is calculated as weight in kilograms divided by the square of height in meters.[2,3]
The HEATSM (Healthy Eating and Activity Together) initiative was developed in the summer of 2003 with the formation of the Steering Work Group at NAPNAP.[4] The 8-member work group was divided into subgroups arranged by age groups (infancy, early childhood, school-age, and adolescence). In addition, subgroups were developed to focus on cultural diversity, research and evaluation, and advocacy.
Based on a review of the literature as well as clinical expertise of the participants, the Steering Work Group focused on 6 areas deemed critical for overweight prevention. The 6 areas include:
At this meeting, the draft of the guidelines was reviewed by approximately 75 participants who attended a special 4-hour session on the HEATSM initiative. The purpose of this session was to discuss the practice guidelines and encourage the attendees to provide feedback. In addition, the participants were given a "tool kit" developed by the HEATSM workgroup containing various handouts and resources related to the problem of overweight children. The attendees were asked to use both the new guidelines as well as the tool kit in their practices. They will then be asked to complete a survey regarding the guidelines and the tool kit after using them for a month. The feedback provided by these participants will help the workgroup to finalize the guidelines.
The CPGs developed by the HEATSM initiative are based on an extensive review of the literature and are intended to be evidence-based guidelines. In addition, the guidelines include several unique features not found in other practice guidelines. They include sections based on the 4 age groups of infancy, early childhood, school-age, and adolescence, with early identification and prevention strategies identified for each of the age groups. Each section also contains information on developmental challenges and parent-child communications specific to the age group being discussed. Two unique features that warrant further discussion are the inclusion of cultural and advocacy considerations for each age group.
The decision of the Steering Work Group to focus cultural considerations for only 3 different ethnic groups was based on the evidence of increasing rates of overweight in African American, Hispanic, and Native American cultural groups. The prevalence of overweight children aged 6-19 years in the black community is 20.5% and the rate for being at risk for overweight is 35.4%.[1] For Mexican American children aged 6-19 years, the risk of being overweight is 39.9% and the rate for those children who are overweight is 22.2%.[1] Rates vary among Native American tribes; however, estimates indicate that as many as 39% of Native American boys and 40% of Native American girls are overweight.[5] Specific strategies for working with children of different ages in these 3 ethnic groups can be found in each section of the guidelines.
The advocacy section was developed with the intent of making both children and their parents aware of the influences that the environment has on the problem of obesity.[6] In addition, the guidelines provide families with strategies to make changes in their communities that will help to prevent the problem of obesity.
As mentioned previously, the guidelines are currently in draft form. It is the intent of the Steering Work Group to revise the draft based on member input and then submit the guidelines to several external sources for review. The finished version of the guidelines is expected before the end of 2005. (Readers may want to check the NAPNAP Web site for this content in late 2005.)
The problem of overweight children disproportionably affects several minority groups. Benjamin Danielson, MD, Medical Director at the Odessa Brown Children's Clinic in Seattle, Washington, addressed the cultural influences that impact perceptions of diet, eating patterns, and other factors associated with being overweight.[7]
Dr. Danielson pointed out that there are several different definitions for race, ethnicity, and culture. Typically, race has been used to divide the human population based on distinguishing physical characteristics transmitted by genes. It has also been used to define a body of people united by a common history or nationality as well as define humanity as a whole (eg, "the human race").
Ethnicity typically relates to a racial, national, or cultural group while culture usually refers to the beliefs, customs, arts, and institutions of a particular society at a given time. Dr. Danielson believes these definitions to be flawed terms in that there is a high risk for overgeneralizing and discounting the individual.
Dr. Danielson maintains that few studies in medical research categorize people by ethnicity. Those that do include categories by ethnicity usually include only a small number of categories. For example, many studies use the ethnic category labeled "Hispanic." However, this term is very broad and does not differentiate between Hispanics of South American, Mexican, Spanish, or other Latino origin.
Dr. Denise Brahan and Dr. Howard Bauchner conducted a review of selected journals with research articles that focused on children and asthma to determine if race/ethnicity and socioeconomic statues (SES), in comparison with age and gender, were considered as part of the studies.[8] The authors reviewed 74 reports from 2000 to 2002. More reports described age (90.1%) and gender (78.2%) than SES (41.6%). Race and ethnicity were described 54.5% of the time in the studies reviewed. The coding of race and ethnicity was 78.7% white, 89.4% black, 55.3% Latino, and 14.9% Asian. Of note, ethnic subgroups for the Latino subjects were only included in 2 of the 31 articles that coded for Latinos, and none of the 8 articles that coded for Asians included Asian subgroups. Similar to Dr. Danielson, these authors maintain that not only more reporting of race and ethnicity data is necessary but also more reporting of ethnic subgroups.
A similar study was conducted by Catherine Walsh and Dr. Lainie Ross in 2003.[9] They reviewed 3 general pediatric journals between July 1999 and June 2000. A total of 192 studies were reviewed. Their conclusions were that black subjects were overrepresented, and white and Hispanic subjects were underrepresented. The authors did note that there were significant variations depending on the type of research conducted.
As noted in the HEATSM CPGs, children of black, Hispanic, or Native American heritage suffer disproportionately from being overweight or being at risk for overweight. As previously discussed, the definitions for overweight and at risk of overweight are based on the sex-specific BMI for age on the CDC Prevention Growth Charts.[2,3] Dr. Danielson maintains that the relationship between BMI and health outcomes is not always clear. A study conducted by Palaniappan and colleagues determined that blacks seem to have higher insulin levels at lean weights than whites or Mexican-Americans.[10] This same study found Mexican-American women to have higher fasting insulin at similar levels of adiposity in comparison to white women. Dr. Danielson suggested that optimal BMIs may be different for different cultures.
Body image is also a concept that is affected by culture and impacts the issue of obesity. For example, among African Americans, a larger body size may be acceptable.[11,12] Dr. Danielson maintains that, "Many ethnicities have much to teach the majority culture about appropriate body image as well as appreciation of body image."
Additionally, healthcare providers need to tailor their messages regarding meals and food consumption with a sensitivity that recognizes the meaning of food for different cultures. Too often, pointed out Dr. Danielson, the nutritional messages given by healthcare providers are not culturally appropriate and often denigrate the culture by "vilifying food."
One example of providing culturally sensitive care for overweight children is the Fit4You program established at the Odessa Brown Children's Clinic. Dr. Danielson is the medical director of this clinic, which is part of the Children's Hospital and Regional Medical Center in Seattle, Washington. According to Dr. Danielson, 90% of the clients at the Odessa Brown clinic are impoverished and two thirds of the clientele are African American.
The Fit4You program began by reaching out to the community through a process Dr. Danielson refers to as "respectful inquiry." Medical professionals engage the community in order to determine what strategies would work for a particular problem, such as the problem of overweight, in that community. Key features of the Fit4You program include incorporating lay health workers or cultural mediators into treatment programs, including the whole family, and finding a way to celebrate culture. Diet is not the primary focus of the program and food is not vilified. Motivational interviewing is incorporated into the program to help patients identify the need for change. Dr. Danielson also spoke about the "walking tours" conducted in the neighborhood. Children are encouraged to celebrate their heritage through these tours, and they get the benefit of exercise through walking.
Dr. Danielson's take-home messages are that overweight disproportionably affects minorities, and improved research methods are needed. Medical professionals need to enhance their appreciation of different cultures, find a way to enhance listening skills, and celebrate all forms of diversity.
As the prevalence of overweight children continues to rise in the United States, healthcare providers are now seeing more and more children with insulin resistance, obesity, and polycystic ovary syndrome (PCOS). Rebecca Murray, Family Nurse Practitioner and an Assistant Clinical Professor at Yale University School of Nursing, New Haven, Connecticut, addressed the challenge faced by providers in terms of treating "the new female triad" in children.[13]
One of the key features that providers need to keep in mind is that PCOS presents with a variety of symptoms. The term PCOS was originally described in 1935 by Dr. Irving F. Stein and Dr. Michael L. Leventhal to explain their findings in 7 women who presented with amenorrhea, hirsutism, obesity, and a polycystic appearance to their ovaries.[14] The cysts found on the ovaries (by x-ray) were originally thought to be the cause of the problem.
Ms. Murray stressed that PCOS is an endocrine disorder with a variety of presentations. A recent review of PCOS published in The New England Journal of Medicine by Dr. David Ehrmann discussed the criteria for diagnosis established by an international consensus group.[15] At least 2 of the following symptoms need to be present in order to make the diagnosis of PCOS:
Oligovulation or anovulation;
Elevated levels of circulating androgens or clinical manifestations of androgen excess; and
Polycystic ovaries (defined by ultrasound).
This article, as well as the speaker, stressed the fact that women who do not have polycystic ovaries can have PCOS, and the presence alone of polycystic ovaries does not make the diagnosis. Additionally, Ms. Murray indicated that many women suffering from dysfunctional uterine bleeding are in fact experiencing anovulation. Providers need to have a high index of suspicion and consider anovulation in young women who present with severe menstrual cramping and irregular bleeding.
Increased insulin levels, called hyperinsulinemia, contribute to the hyperandrogenism of PCOS by stimulating ovarian androgen production.[16] Ms. Murray maintains that "increased insulin does not have this effect in all women." Women who have hormonal imbalances that are associated with increased insulin levels most probably have a genetic predisposition or mutation that makes them more prone to having the symptoms of PCOS.
The ultimate goal of treatment for PCOS is to suppress insulin-androgen production. Nonpharmacologic treatment includes exercise and nutritional interventions. Pharmacologic strategies include the use of oral contraceptives, progesterone, antiandrogens, and insulin-sensitizing agents.[15,16]
Obesity is associated with PCOS and is the most common cause of insulin resistance in children.[17,18] The term "metabolic syndrome" was first described in 1988 by Dr. Gerald Reaven to explain the connection between insulin resistance (hyperinsulinemia), hypertension and dyslipidema, and type 2 diabetes.[18] Criteria for the metabolic syndrome in adults has been established by the National Cholesterol Education Program (NCEP, or Adult Treatment Panel III [ATP III]).[19]
Although no formal criteria have been established for children, one study by Dr. Cook and colleagues modified the ATP III adult criteria for adolescents aged 12 to 19 years using pediatric reference data (see Table).[20] In this study, Dr. Cook and his colleagues analyzed data from 2430 adolescents aged 12 to 19 years who participated in the Third National Health and Nutrition Examination Survey (1988-1994). They concluded that nearly 30% of overweight adolescents and as many as 4% of all adolescents in the United States meet the criteria for metabolic syndrome.
HDL-C = high-density lipoprotein cholesterol
Like the treatment for PCOS, treatment for metabolic syndrome in children involves nutritional and exercise interventions. In addition, Ms. Murray advocates the use of an insulin sensitizing agent such as metformin to lower insulin levels. A study by Dr. Michael Freemark and Dr. Deborah Bursey found metformin effective in reducing fasting blood glucose and fasting insulin levels.[21] Twenty-nine white and black adolescents aged 12 to 19 years with BMIs exceeding 30 kg/m2 were enrolled in the study. Patients were randomized to receive metformin at dosages of 500 mg twice daily or a placebo for 6 months. Reported side effects in this study included abdominal discomfort, diarrhea, and nausea. The authors noted that there is a risk of lactic acidosis in type 2 diabetic patients treated with metformin. Therefore, patients with ketosis-prone diabetes or those with underlying renal, hepatic, or cardiopulmonary disease should not be given the medication. Certainly one of the limitations of this study is the small sample size, and the results would need to be repeated with a larger sample.
A double-blind, placebo-controlled study by Dr. Jones and colleagues found metformin to be safe and effective for the treatment of type 2 diabetes in pediatric patients.[22] There were 82 subjects aged 10-16 years. The children enrolled in the study came from different sites in the United States as well as from 4 other countries. Children in the group receiving metformin were given dosages of less than 2000 mg/day over a 16-week period. Improvement in fasting plasma glucose was noted for both males and females as well as in all race subgroups. The most commonly reported side effects were abdominal pain, diarrhea, nausea, vomiting, and headache.
PCOS, obesity, and insulin resistance have the potential to cause major complications in patients including type 2 diabetes, infertility, endometrial hyperplasia, endometrial cancer, and cardiovascular disease.[15,16] A recent article by S. Jay Olshansky, PhD, and colleagues in The New England Journal of Medicine examined the potential decline in life expectancy in the United States due to the increasing prevalence of obesity.[23] Dr. Olshansky and his colleagues concluded that life expectancy may decline as much as 2 to 5 years or more in the coming decades due to the effects of obesity. Ms. Murray stressed the need for healthcare providers to identify the symptoms of this triad early so that interventions can be started in order to prevent the long-term medical and psychological ramifications. Failure to address these issues may mean that today's young people could be living shorter and less healthy lives than their parents.
A significant portion of each office visit can and should be designated for anticipatory guidance and discussion of parents' concerns. As practitioners, we need to be versed in a myriad of topics beyond nutrition and safety. Three presenters offered valuable insights into the important topics of children's temperament, calming fussy colicky babies, and sport participation.
Sandee Graham McClowry, PhD, RN, FAAN,[1] Professor, New York University, Division of Nursing, New York, NY, presented her expertise in child's temperament. McClowry has studied the topic and published her findings in her book entitled, Your Child's Unique Temperament, Insights and Strategies for Responsive Parenting.[2] Temperament is a social information processing system through which children view and interact with the world, altering the responses of others and contributing to their own development. Temperament is also a way through which individuals see their world. Children's perception of their world influences how they will react to a given situation. One child can interpret an unexpected wait in line as an opportunity to socialize, whereas another child may complain constantly. Each child is unique and is endowed with attributes that have the potential to blossom in a nurturing environment.
Principle 1: Children are born with a unique temperament.
Our inborn temperament influences the way we act and react in any given situation. Temperament involves the intrinsic and stylistic parts of ourselves that contribute toward making us the unique individuals that we are. Parents often become believers when they have a second child. Strategies that worked for the first child may be counterproductive with the second child. Whereas the first baby may have laughed when jostled, the sibling may be overstimulated by such activity and would rather be held quietly and securely.
Principle 2: Temperament influences behavior and emotional reactions.
Temperament is more than behavior. It also involves our internal reactions to situations. Temperament influences how individuals perceive other people and events. It has major implications for how we remember and interpret experiences. People often differ in their description of the same situation, and temperament contributes to their diverse perceptions.
Principle 3: Temperament is easy to see in situations that involve change and stress.
Temperament is a powerful predictor of children's reaction to change. Children differ on which circumstances they find stressful. Change can be stressful even when it involves a positive event like going on a vacation or anticipation of a holiday like Christmas. Every day, multiple situations occur that are likely to elicit reactions that differ depending on the child's temperament.
Principle 4: Temperament does not change easily.
Attempting to change a child's temperament is futile. Because temperament is inborn and partly hereditary, it is highly resistant to change. Efforts to change a child's temperament are frustrating for both the parent and child and are likely to be counterproductive. Such strategies undermine the child's self-esteem.
Principle 5: Goodness of fit.
"Goodness of fit" refers to the match of the child's temperament to the demands, expectations, and opportunities of the child's environment. A child's adjustment is enhanced through "goodness of fit." When goodness of fit occurs, positive development can be anticipated. On the other hand, when there is mismatch between the child's temperament and the environment, behavior problems can develop.
Effective parents adjust the environment in their home to achieve goodness of fit for their children. However, goodness of fit must be evaluated within the context of the family environment. It can be further complicated if the temperament of siblings are widely different. Enhancing goodness of fit entails implementing the 3 Rs of temperament parenting: recognize, reframe, and respond. The first step is to recognize your child's temperament.
Temperament is not a synonym for "temper" or temper tantrum. However, temperament refers to a normal variance in individual characteristics. Children with all types of temperament have strengths and related tendencies that cause parental concerns. Another misconception is that childhood temperament is the same as adult personality. Most temperament researchers view adult personality as more complex than childhood temperament. A final myth is that you will become a permissive parent if you take into account your child's temperament. On the contrary, temperament-based parenting doesn't mean that you accept a child's behavior that violates your values and is disrespectful. Parents are responsible for socializing their children.
A child's temperament includes 4 dimensions:
Activity refers to motor activity. Children who are high in activity are constantly in motion, even when they are supposed to be still. Children who are low in activity can sit quietly for long periods of time.
Approach/withdrawal is evident in the child's first reaction to new people and situations. Children who are high in approach are usually excited about meeting new people or having an opportunity to experience a novel situation. Children who are low in approach and high in withdrawal appear to be shy.
Task perseverance is the child's tendency to stick with a task until it is done, even if he or she is interrupted. Children who are high in task perseverance can complete their schoolwork or other activities with ease. Children who are low in task persistence have difficulty finishing homework.
Negative reactivity is the child's tendency to have negative reactions to life situations. A child who is high in negative reactivity will have an intense, immediate reaction to a minor inconvenience. The child may exhibit high negative reactivity through facial expressions, body language, and tone of voice or statements of distress or displeasure. The child who is low in negative reactivity is generally pleasant and mild in his or her reactions to situational changes.
McClowry described 4 different temperament typologies. They are Freddy the Friendly, who is social and eager to try; Coretta the Cautious, who is cautious and slow to warm-up; Hilary the Hard Worker, who is industrious; and Gregory the Grumpy, whose temperament is high maintenance.
Parents can complete a profile of their child's temperament by accessing McClowry's Web site.[3]
Once a parent recognizes their child's temperament, they can reframe their perceptions. Reframing is a powerful temperament-based parenting strategy that enhances goodness of fit. It allows parents to appreciate their child's strengths while simultaneously acknowledging child temperament-related problems or concerns.
Almost daily, situations occur that require parents to respond to a child's behavior or request. Some parental responses are more effective than others but can generally be viewed as counterproductive, adequate, or optimal. Optimal responses relay parental warmth while still conveying expectations for mature behavior. These responses encourage the child to problem solve, acknowledging that parents have heard the child's wishes, while allowing for circumstances that require the parent deny the child's request.
Affection communicates a desire to be connected with another and can be expressed in a multitude of ways. When a parent attempts to communicate affection, all of the verbal and nonverbal components should relay positive sentiment to avoid sending the child mixed messages. Paying attention to a child requires empathy and the dedication of time. One facet of empathy is being sensitive to the subtleties that make an individual unique. It is important to affirm a child's goodness and talents. Warm parental messages can foster children's independence by providing them with a sense of competence and self-worth.
McClowry recommended parents think of a discipline plan as a ladder with a different management strategy on each rung, with the simplest strategy on the lowest rung. Ideally, parents should exert the least amount of authority necessary to redirect their children's behavior. The purpose of designing a discipline plan is to foster a child's development, reduce family strife, and enhance family warmth and cohesion. A harmonious relationship between a parent and child is an ongoing process to which every family can aspire.
Behavior contracts are recommended for changing repetitive, frustrating behavior problems. A child's behavior can be redirected by establishing specific guidelines and appropriate reinforcement. Implementing a contract can be advantageous to avoid painful battles of wills.
Select one reasonable goal
State the goal in a positive way
Negotiate child and parent (and teacher, if appropriate) responsibilities
Decide together on a reinforcement -- it can be a privilege or small item
The parent and child (and teacher) should sign the contract
Check the goal at the specific time. If achieved, place a sticker on a tally sheet; otherwise, leave the space blank
Give no warnings
Acknowledge the child when he or she meets the goal. Use optimal statements whenever possible
Be sure to provide the child with the reinforcement when the contract is completed
Temperament-based parenting treats each child as an individual with his or her unique gifts and talents. Parents can develop strategies that are responsive to each child's temperament.
Persistent crying, diminished soothability, and restlessness in an otherwise healthy, well-fed infant characterize infant colic. The classic definition of infant colic, often used in research studies, is paroxysms of irritability lasting for a total of more than 3 hours per day and occurring on more than 3 days per week for 3 weeks in an otherwise healthy infant. Colic occurs in approximately 20% of all infants and is unrelated to sex, race, or socioeconomic status. Caring for a colicky infant is very stressful for parents, and in high-risk families, colic may have a lasting effect on the parent-infant relationship. The onset of colic is frequently the first 3 weeks of life. Infants usually recover by 3-4 months of age.[4]
A major problem in relation to infant colic is that the cause is unknown. There are at least 5 possible explanations for infant colic -- cow's milk/soy protein allergy or intolerance, immaturity of the gastrointestinal (GI) system, immaturity of the central nervous system, difficult infant temperament, and parent-infant interaction problems consisting of the transfer of parent anxiety to the infant and the inability of the infant to give clear clues about the needs to the caregiver.
Food intolerance of protein and carbohydrates is implicated as a contributing factor in the development of infant colic. Numerous studies have been conducted to determine the relationship between diet and crying. It was found that breast-fed infants were as likely to be colicky as bottle-fed infants. Intolerance to either cow's milk or soy protein or both are temporary and result in the intact protein being absorbed as a result of increased mucosal permeability in the infant's GI tract. A few infants are truly allergic to cow's milk and with repeated exposure will eventually develop common allergic symptoms such as hives or eczema. A true allergy to cow's milk may be temporary or lifelong. Whether the problem is intolerance or an allergy to cow's milk or soy protein from the infant's or breast-feeding mother's diet, a change in diet will result in immediate improvement in 10% to 35% of colicky infants.[5]
The word "colic" originates from the Greek word "kolikos," meaning "of the colon," suggesting that the Greeks thought persistent infant crying resulted from GI pain. Proposed GI causes of infant colic have generally been categorized into 4 main groups -- excessive gas, bowel distention and spasm, abnormal intestinal motility, and gastroesophageal reflux (GER). GER may be a significant causative factor in about 5% of infants with colic, particularly those with vomiting and food refusal. The acid reflux would have to lead to esophagitis to cause pain resulting in colic.[6]
Irritable infants have been found to be more disorganized at birth, causing them to be easily stimulated. Crying during the first 3 months may be a byproduct of the major reorganization of the human brain systems that take place during this period. The central nervous system gradually matures over the first 3-4 months of life. It is likely that neurologically mediated individual differences in reactivity to stimulation are at least part of the reason for variations in crying behavior.[7]
It has been suggested that infants who "present with a temperamental disposition toward irritability and negative affect may display characteristic behavior that can persist for years. The type of care giving such children receive may modulate, at least in part, the degree to which early infant irritability predicts later social withdrawal."[8]
The amount of concern generated by crying infants often depends on the experience, anxiety level, and general personalities of the caregivers. The aversive crying of the colicky infant is hard to soothe effectively and occurs for no apparent reason. In the face of their inability to control or explain such behavior in their infants, parents feel helpless and inadequate and may become anxious and even depressed over time.[9]
Colic is likely due to multifactorial causes. Harvey Karp, MD,[10] Assistant Clinical Professor of Pediatrics, University of California School of Medicine, Department of Pediatrics, Los Angeles, California, presented an intervention that he has found successful. Karp stated, "Unlike baby horses, able to run on the first day of life, our newborns are extremely immature...more fetuses than infants. One might argue that after 9 months of gestation they are still not ready for the world, however they must be 'evicted' from the uterus because their heads are so big they can barely fit through the cervix. Inside the womb, fetuses are constantly enveloped by several powerful sensations (tight confinement, frequent jiggly motion, and white noise louder than a vacuum cleaner). These all trigger a previously unknown reflex...the calming reflex."
Karp explained that most babies can handle being born too soon because they have mild temperaments and good self-calming abilities. Despite being exposed to waves of overstimulation and understimulation, they can soothe themselves. Colicky babies, on the other hand, have trouble with self-calming. They live through the same experiences as calm babies, but rather than taking them in stride, they overreact dramatically. These infants desperately need the sensations of the womb to help then turn on their calming reflex. Karp's book, The Happiest Baby on the Block, explains methods to calm fussy babies. The basis for the cuddle cure is the 5 "Ss."[11]
Swaddling -- the cornerstone of the calming technique. Wrapping makes the baby feel magically returned to the womb and satisfies her longing for the continuous touching and tight fit of the uterus. This "S" doesn't actually trigger the calming reflex but it keeps the baby from flailing and helps her pay attention to the other "Ss," which do activate the reflex. For wrapping to be successful, keep the arms snugly restrained at the sides. Use the "DUDU" wrap -- Down-Up-Down (1/2 way) then Up and across the belt. Babies should be swaddled snugly without loose blankets because of the risk of SIDS. Also, they should be checked to make sure they are not overheated because of the possible association between SIDS and overheating.
Side/Stomach -- supine is the safest position for sleeping; however, the side/stomach is the best position for calming a crying baby. The side and stomach positions work well because they trigger the calming reflex by imitating the baby's position in the uterus. Some infants are so sensitive to position that just rolling them from their sides slightly over toward the stomach calms them, rolling them a tiny bit from their sides toward their backs makes them panic. The side position also allows truncal flexion (fetal position), which is a position of calm.
Shhhhh -- for a new baby, the sound of calm and tranquility is the loud shushing sound of the uterine and placental blood flow. The sound inside the uterus is loud (80-90 db), harsh (high pitched whooshing), rhythmic, and constant. When you first try shhhhing, the baby should quiet within a minute or two. Once the fussy baby settles, she will probably need continuing, moderate white noise to keep her from returning to crying.
Swinging -- rhythmic movements imitate the uterine experience. When babies are fussy, these movements need to be small and vigorous (like a shiver.) Don't restrict the head from jiggling. It should quiver like Jell-O on a plate. Babies who are really wailing need to be jiggled at 120 per minute for a few seconds or minutes until they begin to calm. There is no risk of "Shaken Baby Syndrome" when the movements are tiny (excursions of only 1-2 inches) and the head stays in line with the body. However, this movement should not be done when a parent is angry.
Sucking -- the last "S" requires the baby's cooperation and is introduced when she calms down. It allows a baby to bring to play her own self-calming ability. Sucking (on a breast, bottle, or pacifier) comforts the baby and allows her to recover from the intensely upsetting experience of screaming.
The clinician should advise the parent that to find their baby's favorite calming technique, they should place him on his back when he's a little fussy. One by one, add another "S" and see how many it takes to settle him down.
By this time, most fussy babies will usually be calmed.
The speaker closed with this guidance for clinicians to share with parents:
Jordan D. Metzl, MD,[12] Medical Director. Sports Medicine Institute for Young Athletes at the Hospital for Special Surgery, New York, NY, explained the benefits of youth sports. Currently, more than 30 million children and teens under the age of 18 participate in some form of organized sports, and the number keeps rising. The past 15 years have seen a youth sports explosion in the United States. Metzl's book, The Young Athlete, A Sports Doctor's Complete Guide for Parents, discusses the benefits and many aspects of sports participation.[13]
The physical benefits of youth sports include fitness, stress relief, skill mastery, and development of healthy habits. Kids who play sports develop general physical fitness and can establish lifelong habits for good health. Sports allow kids to clear their minds of academic and social pressures, to literally run off tension. Sports give kids a satisfying, enjoyable way to develop their own talents. The process of repetition teaches the athlete how to master a move and also how to experiment with different approaches to improve a skill.
Personal benefits include valuing preparation, resilience, attitude control, leadership opportunities, identity and balance, time management, and long-term thinking. Sports increase self-discipline and the awareness of the value of preparation because kids can see the difference in their performance. Sports provide an unparalleled model for dealing with disappointment and misfortune. Young athletes learn to handle adversity, whether it's picking themselves up after losing a big game or not getting as many minutes of playing time as they wanted. Older teens learn that a confident attitude improves their performance, and that they have some control over their attitude.
Team sports offer kids a rare opportunity to serve as leaders. Being part of a group is inordinately important to kids, and sports make kids feel like they belong. Young athletes learn to manage their time productively to get homework completed on time. Athletes learn the fundamental lesson of sacrificing immediate gratification for long-term gain.
Social benefits include relationships with other kids, teamwork, diversity, building relationships with adults, and participating in a community. Athletes develop relationships with their teammates and, for boys, sports are a primary way of socializing with others. On a team, kids learn about cooperation, camaraderie, and give-and-take. Organized sports sponsored by clubs or youth leagues offer players an opportunity to meet a variety of kids from different backgrounds. Sports give kids an opportunity to spend ongoing periods of time with an adult in a shared endeavor. To thrive, kids need to be with adults who want them to do well in a variety of endeavors, who notice their improvements and hard work, who manifest sound values, and who don't pay attention to them solely because of their contribution to the win column.
The clinician can offer these guidelines to parents:
Encourage your children to play sports, but do not exert undue pressure. Allow you child to choose to play, and to quit, if he or she wants.
Understand what your child wants from sports and provide a supportive atmosphere for achieving his or her goals.
Set limits on your child's participation in sports. You need to determine when your child is physically and emotionally ready to play and to ensure that the conditions for playing are safe.
Ensure that the coach is qualified to guide your child through the sports experience.
Keep winning in perspective, and help your child do the same.
Help your child set realistic performance goals.
Help your child understand the valuable lessons sports can teach.
Help you child meet the responsibilities to the team and the coach.
Discipline your child appropriately when necessary.
Allow the coaches to do the coaching.
Supply the coach with information about any injuries or other medical conditions your child may have. Ensure that your child takes any necessary medications to games and practices.
An appropriate code of conduct for parents of children participating in sports is to:
Young athletes can benefit from effective preseason conditioning: getting into shape for the sports season, starting about 6 weeks before the first practice. For athletes of any age, but particularly young athletes, this can make a tremendous difference in performance and injury prevention. Preseason conditioning can be divided into 2 types: cardiovascular, designed to enhance the heart and lungs, and muscular, designed to increase muscle strength and bone density. Both types are important and, if done properly, can improve performance and safety.
Cardiovascular conditioning can take any form and is best accomplished by letting kids be kids. The key is to encourage them to develop a consistent activity pattern, usually 4 to 5 days of vigorous exercise a week. When figure skaters play basketball or football players swim, they not only increase their cardiovascular fitness and work different muscles, they also develop different skill sets, and it's fun as well.
Strength training increases muscle power, improves bone density, and is generally helpful for all athletes. Strength training is repetitive lifting of light weights, designed to increase baseline strength by developing more muscle fiber. Power lifting is heavy lifting designed to maximize muscle bulk. Strength training is safe for kids; power lifting is not. The bones of children and teens end in open growth plates made of cartilage, and power lifting is potentially dangerous to growth plates. Strength training programs employ multiple repetitions of combination of resistance activities (weights, push-ups, and so on) to increase baseline strength, which is essential to all sports.
Children and their parents can enjoy the benefits of sports participation together. Clearly and above all, youth sports should be about having fun and being physically fit.
Abdominal pain is a frequent presenting complaint in children. Most often, the cause does not require surgical intervention. Difficulty often lies in attempting to decipher benign stomach pain from pathologic etiologies. Appendicitis is the most common atraumatic surgical emergency in the pediatric population.[1]
At a session presented by Beth Bolick, RN, MS, PCCNP, CPNP-AC,[2] Nurse Practitioner and Graduate Nursing Professor, Rush University, Chicago, Illinois, the etiology of appendicitis, common presentations, evaluation, diagnostic work up, management, and complications of this disease were discussed.
The appendix is a 4.5-9.5 cm long diverticulum of the cecum.[1] The function of the appendix is unknown.[2] The precursor to appendicitis is luminal obstruction from lymphoid hyperplasia, fecaliths, foreign bodies, or parasites.[1] After the lumen is obstructed, blood flow to the area is impaired, leading to bacterial invasion and local inflammation.
Appendicitis is diagnosed in 1% to 8% of children presenting to the emergency department with the complaint of abdominal pain, and incidence increases with age.[3] It most often presents in the second decade of life, with lifetime risk for males of 8.6% and 6.7% in females.[3]
In adults, the first symptom of appendicitis is periumbilical pain, followed by nausea, right lower quadrant pain, and later nausea and vomiting. Ms. Bolick stressed, however, that, "there really is no 'classic presentation' in young children."
In neonates, nonspecific symptoms of abdominal distention and vomiting dominate.[3] In children between the ages of 2 and 5 years, abdominal pain predates vomiting and is associated with fever and anorexia in the majority of cases. School-age children are better able to report their symptoms. The school-age child's pain is often described as constant and worse with movement or coughing (cat's eye symptom).[3] School-age children may also have vomiting, nausea, anorexia, diarrhea, constipation, or dysuria.
History and physical. The history and physical are the foundation of the diagnosis, but due to the imprecision of these findings, adjunctive diagnostics are often needed.[4] "Family history is often likely to be positive for appendicitis," stated Ms. Bolick.
White blood cell count and fever. Cardall and colleagues examined the value of white blood cell count (WBC) and fever in patients with suspected appendicitis. They cautioned against relying on WBC count when evaluating a patient with suspected appendicitis.[4] Body temperature was also not found to be a useful discriminator in patients in the emergency department with suspected appendicitis.[4]
C-reactive protein. This measure is more likely to be elevated with appendiceal perforation.
Kidney, ureter, and bladder x-ray (KUB). There is limited value in obtaining a KUB in a patient with suspected appendicitis, explained Ms. Bolick. It may be useful in aiding in the diagnoses of nonappendiceal causes of abdominal pain, which can include lower lobe pneumonia, bowel obstruction, free peritoneal air, calcified fecalith, localized ileus, or a soft tissue mass.
Ultrasonography and computed tomography (CT). Ms. Bolick also discussed the utility of ultrasound and CT radiographic techniques. Ultrasonography is noninvasive and does not require exposure to radiation. It can be useful when the appendiceal diameter is greater than 6 cm, can identify noncompressible distention or obstruction of the appendiceal lumen, and can demonstrate highly echogenic areas surrounding the appendix.[5] There are technique variants in the ultrasonographers.
CT scan can reveal fat streaking, appendiceal diameters > 6 cm, fluid collections, and focal or cecal apical thickening. This technique provides more performer consistency, but requires exposure to radiation.
A prospective cohort study by Garcia-Pena and colleagues found that CT following negative or equivocal ultrasound results is highly accurate in the diagnosis of appendicitis in pediatric patients.[6] Another study by Garcia-Pena demonstrated that diagnostic studies using CT could reduce costs and improve diagnosis in children with appendicitis.[7]
Missed diagnosis. Missed or delayed diagnosis can lead to increased rates of appendiceal perforation, morbidity, and unnecessary appendectomy.[4] A study by Rothrock and colleagues reviewed common misdiagnosis of appendicitis in children. They noted that 42% of the children misdiagnosed with appendicitis were diagnosed with gastroenteritis, with upper respiratory tract infections in second place.[8]
Observation may be required in patients in whom examination findings are equivocal. If there is concern about compliance or follow-up, Ms. Bolick recommended transfer to a short-stay unit. If a child is sent home, parents should have clear instructions on when to return, and staff should arrange for follow-up and educate the family on the difficulty in making the diagnosis.[2]
When the diagnosis is made and surgery is planned, Ms. Bolick emphasized the importance of optimizing volume status and initiating appropriate antibiotics in the preoperative phase of management. Antibiotic coverage should include coverage for common organisms (eg, Escherichia coli and Bacteroides fragilis), as well as for less common organisms (eg, Pseudomonas aeruginosa and Enterococcus faecalis).
She also discussed historical beliefs that pain control in appendicitis may mask the physical examination in these patients. She reviewed findings by Wolfe and colleagues in a small study that demonstrated that judicious dosing of morphine resulted in significant improvement in pain without changes in their physical examination.[9]
Historically, appendectomies were performed via open laparotomy. More recently, laparoscopic techniques have been developed and evaluated in pediatric patients. One study performed in France demonstrated benefits of laparoscopic appendectomy to include ease of procedure, reduced scarring, shorter hospital stays, and earlier return to normal activities. The benefits were demonstrated while proving to be safe and effective.[10]
"Early diagnosis and operative intervention is imperative to prevent the morbidity associated with a perforated appendix," stated Sarah Martin, RN, MSN, PCCNP, Pediatric Surgery Nurse Practitioner at Children's Memorial Hospital in Chicago, Illinois, an attendee at the session (personal communication, April 8, 2005). Perforation often occurs within 48 hours, leading to bacterial invasion and local inflammation. Peritonitis and systemic infection can ensue.
One study by Nelson and colleagues reported the overall appendiceal perforation rate to be 47%.[11] Patients with perforation had a significantly lower median age, longer duration of illness, and greater incidence of vomiting and fever. Incidence of appendiceal perforation is highest in infancy, with a range of 70% to 95%. This risk decreases 10% to 20% in adolescents.[3]
Complications of appendiceal perforation were discussed by Ms. Bolick. These include wound or intra-abdominal abcess, sepsis, enterocutaneous fistula, peritonitis, intestinal dysfunction, and bowel obstruction.[2,3]
In 1997, a nationwide survey by Flum and associates reported that 15.3% of appendectomies were unnecessary, resulting in $741.5 million of potentially avoidable medical costs. They also reported that patients with a negative appendectomy had higher mortality rates, likely due to delayed diagnosis of the actual presenting symptoms.[12]
Selbst and colleagues evaluated the epidemiology and etiology of malpractice suits involving children accessing US emergency departments and urgent care centers. Most cases (47%) involved children less than 2 years of age. Appendicitis was the second most common diagnosis involved in pediatric emergency medicine malpractice claims, second only to meningitis. Diagnostic error was identified in accounting for 39% of the claims.[13]
Diagnosis of appendicitis can be difficult in children as there is no classic presentation in children. Appropriate diagnosis, management, and intervention will improve outcomes and decrease incidence of litigation.