美国儿科护士从业者协会第26届年会热点

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美国儿科护士从业者协会第26届年会热点

全国儿科护士从业者协会（NAPNAP）第26届年会摘要

2005年3月31日－ 4月3日

美国亚利桑那州非尼克斯

2005年3月31日至2005年4月3日，亚利桑那州凤凰城

脑膜炎球菌血症：令人恐惧的诊断Andrea M Kline，RN，MS，PCCNP，CPNP-AC，CCRN   脑膜炎球菌血症简介

脑膜炎双球菌血症对大多数医疗保健提供者而言都是令人恐惧的诊断。在最严重的形式下，它具有明显的特征。它是极少的感染之一，可在患者出现后不到24小时内使患者产生可怕的发病率和明显的死亡率。尽管医学取得了重大进展，但这种疾病继续对我们的孩子造成破坏性影响。

在得克萨斯州达拉斯的儿科重症监护护士从业者丽莎·米洛诺维奇（RNA，MSN，PCCNP，CCRN）主持的会议上，她讨论了当前的流行病学趋势，病理生理学，管理和脑膜炎球菌血症的预防。[1]

流行病学

由于控制了b型流感嗜血杆菌感染，脑膜炎奈瑟氏球菌已成为美国儿童和年轻人中脑膜炎的主要原因。[2]在1980年代美国很少爆发疫情，但自1991年以来，局部爆发的频率有所增加。[2]从1994年7月到1997年，据报道有42例脑膜炎球菌暴发，其中4例发生在大学校园内。      

脑膜炎球菌血症的发生率在婴儿中最高，青春期发病率再次上升，在15至24岁的人群中发病率达到最高。发病率估计为0.5-5 / 100,000 [3] ，10％至15％的病例是致命的。从这种感染中恢复的患者中，有10％至15％的患者有明显的发病率，包括永久性听力丧失，智力低下以及手指或四肢丧失。[1]

细菌学与传播

“脑膜炎球菌血症是一种潜在的破坏性感染，可导致全系统败血症，多器官衰竭和脑膜炎，”亚利桑那州凤凰城大学传染病主治医师医学博士Sean Elliott表示（个人通讯，2005年4月7日）。这种侵略性细菌感染是由脑膜炎奈瑟氏菌引起的，后者是一种封装的革兰氏阴性双球菌。[4]脑膜炎奈瑟氏球菌有多个血清群，其中B和C血清群在美国最常见。[3]这种细菌可能会产生孤立的脑膜炎或脑膜炎球菌血症。脑膜炎球菌血症表示体循环中存在N脑膜炎。[1]        

这种潮虫病的传播是通过直接接触鼻咽携带者的呼吸道分泌物来实现的。患此病的最高风险人群包括婴幼儿，难民，病例患者的家属，军人，住在宿舍的新生，微生物学家与脑膜炎奈瑟氏菌的分离株以及暴露于主动和被动吸烟的人群。[2]  

症状与管理

Milonovich女士接着指出，“最初的症状很模糊”，孩子可能出现发烧，呕吐，头痛，嗜睡和腹痛。它可以迅速发展成包括瘀点和紫癜，精神状态改变，脑膜炎和快速的血液动力学崩溃。[4]  Elliott博士说：“由于最初的脑膜炎球菌血症呈非特异性和流感样表现，因此医疗保健提供者需要保持高度的怀疑指数以识别和治疗这种感染。”（个人通讯，2005年4月7日） 。

米洛诺维奇说：“我们的目标很简单，恢复足够的氧气和底物向组织的输送。但是，达到这个目标并非易事。” N脑膜炎很容易用抗生素根除，但正在进行的病理生理学作用可能是不可逆的。脑膜炎球菌血症通常对青霉素G，头孢噻肟和头孢曲松敏感。[1]  

Milonovich解释说，服用抗生素后，由于内毒素释放，患者通常会变得更糟。她回顾了其他管理策略，包括液体管理，血液制品管理，正性肌力支持和血管内监测。小儿败血症中类固醇的作用尚不清楚。[1]还使用了 支持性技术，例如机械通气，局部疗法，皮肤移植和肾脏替代疗法。

新颖的研究/未来趋势

Milonovich还回顾了当前其他减少脑膜炎球菌血症影响的研究工作。这些措施包括肾脏替代疗法，以去除体液，去除内毒素和提供最佳营养。正在研究的其他策略是皮肤/肢体管理协议，细菌渗透性增加蛋白的给药和活化蛋白C（APC）的给药。由于不利的风险收益率，最近停止了多中心儿科APC试验。[1]

基因组学是对基因及其功能的研究，不仅在脑膜炎球菌血症方面而且在其他传染病领域都是令人兴奋的研究领域。细胞因子的释放在对脑膜炎奈瑟氏菌内毒素的炎症反应和浸润性脑膜炎球菌疾病的整体病理生理中起着重要作用。爱尔兰的一项研究表明，严重的脑膜炎球菌血症是多因素的。研究结果表明，遗传因素与脑膜炎球菌血症之间可能存在很强的联系，患者的预后可能取决于他们的遗传组成。[5]  

预防脑膜炎球菌病

直到最近，仅可获得脑膜炎球菌多糖疫苗（Menomune）。正如佐治亚州亚特兰大疾病控制和预防中心免疫服务部MPH的William L. Atkinson博士在题为“儿童免疫的新变化”的会议上所报道的。在使用这种疫苗的2岁以下的患者中，存在与年龄相关的免疫反应，并且免疫原性反应不一致。[6]

2004年9月，美国食品和药物管理局（FDA）的疫苗和相关生物产品咨询委员会一致投票建议对由Sanofi Pasteur开发的用于预防侵袭性脑膜炎球菌的结合疫苗进行许可。[7] 短短几个月后，FDA批准了Menactra疫苗。[8]这是在美国获得许可的首个可提供针对N型脑膜炎血清群A，C，Y和W-135的保护的四价结合疫苗。[8]正如Milonovich所讨论的，两种可用的疫苗均不能有效抵抗B型血清型，B型血清型是美国最常见的血清型之一。     

成功的结合疫苗的好处包括延长保护时间，诱导免疫记忆，加强免疫反应以及减少接受者鼻咽细菌的运输。[8] 美国疾病控制与预防中心的免疫实践咨询委员会已经成立了一个工作组，以更新关于控制脑膜炎球菌疾病以及为另外一个出生人群（例如11-12岁）进行常规脑膜炎球菌疫苗接种的建议和选定的大学生。[8]  [编者注：这些建议最近进行了更新，以包括针对11至12岁儿童的常规脑膜炎球菌疫苗接种。] [9]

“在美国，脑膜炎球菌感染每年影响数千人，青春期达到高峰。已批准将Menactra用于11至15岁的儿童，肯定应将其纳入免疫接种计划。我们正在进入新的疫苗接种阶段，这是针对青少​​年的目标；除了梅那曲之外，百日咳疫苗和针对乳头瘤病毒的疫苗还处于3期试验中，”伊利诺伊州芝加哥儿童纪念医院传染病主治医师医学博士Ben Katz（个人通讯，2005年4月8日）。     

脑膜炎球菌血症儿童的发病和死亡风险很高。医护人员在评估可疑症状患者时必须考虑此诊断，然后及时实施治疗。未来可能会提出针对这种致命疾病进行免疫接种的建议。

参考文献

• Milonovich L.流行病学，病理生理学和管理。全国儿科护士从业者协会第26届年度儿科医疗保健会议的程序和摘要；2005年3月31日至4月3日；亚利桑那州凤凰城。
• 疾病控制中心。预防和控制脑膜炎球菌病。免疫实践咨询委员会的建议。MMWR Morb Mortal Wkly Rep。2000; 49：1-10。抽象
• 疾病预防与控制中心。脑膜炎球菌病。可在以下网址获得：http : //www.cdc.gov/ncidod/diseases/submenus/sub_meningitis.htm。2005年6月6日访问。
• Kirsch EA，Barton RP，Kitchen L，Giroir BP。脑膜炎球菌血症的病理生理，治疗和结局：综述和最新经验。Pediatr Infect Dis J.1996； 15：967-979。抽象
• Balding J，Healy CM，Livingstone WJ等。脑膜炎球菌血症的爱尔兰人群中的基因组多态性谱：可以预测疾病的严重程度和结果吗？基因免疫。2003; 4：533-540。
• 阿特金森WL。儿童免疫接种有什么新变化？全国儿科护士从业者协会第26届年度儿科医疗保健会议的程序和摘要；2005年3月31日至4月3日；亚利桑那州凤凰城。
• FDA批准：Abraxane，Menactra，Extraneal。可在以下网址获得：http：//www.medscape.com/viewarticle/497987。2005年6月6日访问。
• FDA许可Menactra（TM）多糖白喉类毒素缀合物疫苗用于预防脑膜炎球菌疾病。可在以下网址获得：http：//www.menactra.com。2005年6月6日访问。
• 建议11至12岁儿童进行常规脑膜炎球菌疫苗接种。Medscape医学新闻。可在以下网址获得：http：//www.medscape.com/viewarticle/501887。2005年6月6日访问。
  

建议阅读

疾病控制中心。脑膜炎球菌病和大学生。免疫实践咨询委员会的建议。MMWR Morb Mortal Wkly Rep。2000; 49：11-20。

　

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呼吸道合胞病毒：小孩的大问题Andrea M Kline，RN，MS，PCCNP，CPNP-AC，CCRN   什么是RSV？

病毒性疾病，特别是呼吸道合胞病毒（RSV），在所有儿科环境中均很常见。尽管它通常是一种自限性疾病，主要是令人讨厌的疾病，但它可能导致婴儿和儿童的大量发病和死亡。

全国儿科护士从业者协会（NAPNAP）的年度会议着重介绍了当前的诊断，管理策略和预防技术。在Lauren Sorce，RN，MSN，CPNP，CCRN主持的会议上，[1] 伊利诺伊州芝加哥市儿童纪念医院的儿科重症监护室，儿科重症监护室，流行病学，危险因素，临床表现，管理和化学预防措施进行了讨论。

“ RSV是导致婴儿和幼儿呼吸系统疾病和发病率及死亡率的主要原因。尽管许多儿童已从与RSV相关的细支气管炎中完全康复，但高风险的患者人群却经历了更为严重的并发症和危及生命的疾病。”亚利桑那州图森市亚利桑那大学传染病主治医师医学博士Sean Elliott说（个人通讯，2005年4月7日）。

Sorce女士将RSV病毒描述为有包膜的单链RNA病毒。感染细胞需要两种糖基化的表面蛋白。RSV有2株，A组和B组。RSV在全球范围内都有分布，冬季则是季节性分布，以1月至3月为高峰月份。大多数孩子在达到第二个生日时受到了影响。在整个生命周期中都会发生再感染。[1]

约0.5％至2％的RSV儿童需要住院治疗。这导致在美国估计有125,000例次于RSV的儿科住院治疗。[1]

RSV的危险因素

Elliott博士解释说：“ RSV的高危患者人群包括“早产儿，患有慢性肺病的婴儿，先天性心脏病的婴儿和1岁以下的婴儿”（个人通讯，2005年4月7日）。

Sorce女士审查了RSV的危险因素清单，包括年龄较小，有早产史的婴儿，男性，社会经济地位较低，潜在的心肺疾病，潜在的免疫功能低下以及先天性神经或代谢性疾病。

临床体征和症状

Sorce女士说：“呼吸暂停通常是婴儿RSV的最初症状，并且经常是住院的原因。” 还有许多其他体征和症状，包括发烧，烦躁，不适，呼吸困难，呼吸增加，回缩，呼吸急促，厌食，咽炎，鼻漏，咳嗽，长时间的呼气相，罗勒，喘息和低氧。[1]

Checchia及其同事的一项研究[2]的发现 表明，通过使用市售肌钙蛋白测定法可以确定，进入RSV疾病的小儿重症监护病房的儿童中有很大一部分（54.5％）患有心肌损伤。另外，这些患者中的一些患者表现出临床上显着的损伤，从而导致心脏不稳定并需要正性肌力支持。[2]

RSV的传输/处理/管理策略

RSV是通过直接接触，接触病毒后进行自我接种或通过鼻子或眼睛进入而传播的。Sorce女士说：“不传播RSV可能很困难。” 她补充说：“ RSV如此强大，它可以在无孔表面上存活至少24小时，并且在听诊器上可以存活48小时。”  

没有其他危险因素的儿童估计死亡率约为1％。先天性心脏病（CHD）的儿童更容易受到伤害，与RSV相关的住院估计有2％至3％的死亡率。[3]

借助有关药物治疗的混合数据，管理由支持治疗驱动，包括氧气，双水平正压面罩通气，日光照射和有创通气。

预防RSV

Elliott博士指出：“不幸的是，目前尚无有效的抗病毒药物可治疗RSV，因此预防是目前可用的最佳治疗方法。” 他继续指出：“预防以抗帕金森病的单克隆抗体帕利珠单抗的形式发生，可以对符合AAP确立的高风险标准的患者以较高的安全性肌内注射。尽管该产品确实可以不能完全预防RSV毛细支气管炎，已证明可以降低接受者经历的细支气管炎发作的严重程度”（个人通讯，2005年4月7日）。

在演讲中，Sorce女士回顾了帕利珠单抗先天性心脏病研究，该研究评估了帕利珠单抗对2岁以下血液动力学显着CHD患儿的给药。她解释说，这表明帕利珠单抗接受者的住院风险降低了45％。[4]

美国儿科学会（AAP）在2003年提出了新建议，建议将具有血液动力学显着性冠心病的婴儿考虑用于帕利珠单抗治疗（表）。（Sorce女士鼓励所有与会者阅读AAP发布的有关帕利珠单抗使用指南的论文。[5,6]）

表。AAP关于帕利珠单抗管理的建议摘要[5,6]</= 2 years of age with chronic lung disease (CLD) who have required medical therapy (oxygen, diuretics, bronchodilators, etc) within 6 months before RSV season </= 28 weeks gestational age (with or without CLD) during RSV season 29-32 weeks gestational age if </= 6months old at start of RSV season 32-35 weeks gestational age if </= 6 months old at start of RSV season </= 2 years of age and hemodynamically significant CHD

"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).

The Future

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.

References

• Sorce LS. Respiratory syncytial virus: little bug, big problem. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference; March 31-April 3, 2005; Phoenix, Arizona.
• Checchia PA, Appel HJ, Kahn S, et al. Myocardial injury in children with respiratory syncytial virus infection. Pediatr Crit Care Med. 2000;1:146-150. Abstract
• Yount LE, Mahle WT. Economic analysis of palivizumab in infants with congenital heart disease. Pediatrics. 2004;114:1606-1611. Abstract
• Feltes TF, Cabalka AK, Meissner C, et al. Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. J Pediatr. 2003;143:532-540. Abstract
• American Academy of Pediatrics. Revised indications for the use of palivizumab and respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections. Pediatrics. 2003;112:1442-1446. Abstract
• American Academy of Pediatrics. Technical Report. Revised indications for the use of palivizumab and respiratory syncytial virus immunoglobulin intravenous for the prevention of respiratory syncytial virus. Pediatrics. 2003;112:1447-1552 Abstract
• Respiratory syncytial virus. MedImmune. Available at: http://www.medimmune.com. Accessed June 1, 2005.
  

Suggested Reading

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.

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Keeping Children Healthy and FitCarolyn Montoya, MSN, CPNP   Child Health and Fitness

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

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:

• Early identification of overweight;
• Developmental challenges;
• Parent/child communication;
• Nutrition essentials;
• Feeding and eating behaviors; and
• Physical activity.
  

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.)

Popular Culture, Diversity, and Obesity

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.

The New Female Triad: Polycystic Ovary Syndrome, Obesity, and Insulin Resistance

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.

Table. Criteria for the Metabolic SyndromeCriterion Adults Adolescents High triglyceride level, mg/dL >/= 150 >/= 110 Low HDL-C level, mg/dL
   Males
   Females
< 40
< 50
</= 40
</= 50 Abdominal obesity, waist circumference, cm
   Males
   Females
> 102
> 88
>/= 90th percentile
>/= 90th percentile High fasting glucose level, mg/dL >/= 110 >/= 110 High blood pressure, mm Hg >/= 130/85 >/= 90th Percentile

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.

References

• Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291:2847-2850. Abstract
• Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Advance Data. 2000;314:1-27. Available at: http://www.cdc.gov/nchs/data/ad/ad314.pdf. Accessed May 26, 2005.
• US Centers for Disease Control and Prevention (CDC). BMI is used differently with children than it is with adults, 2004. Available at: http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm. Accessed May 26, 2005.
• Gottesman MM, Brady M, Deloian B, et al. HeatSM Clinical Practice Guidelines. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference on Pediatric Health Care 2005; March 31-April 3, 2005; Phoenix, Arizona. Abstract 013.
• Story M, Stevens J, Himes J, et al. Obesity in American-Indian children: prevalence, consequences, and prevention. Prev Med. 2003;37:S3-S12. Abstract
• French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health. 2001;22:309-335. Abstract
• Danielson B. Popular culture, diversity, and obesity. Program and abstracts of the National Association of Pediatric Nurse Practitioners and Associates 26th Annual Conference on Pediatric Health Care; March 31-April 3, 2005; Phoenix, Arizona. Abstract 110.
• Brahan D, Bauchner H. Changes in reporting of race/ethnicity, socioeconomic status, gender, and age over 10 years. Pediatrics. 2005;115:e163-e166. Available at: http://www.pediatrics.org/cgi/doi/10.1542/peds.2004-1437. Accessed May 26, 2005.
• Walsh C, Ross LF. Are minority children under- or overrepresented in pediatric research? Pediatrics. 2003;112:890-895.
• Palaniappan LP, Carnethn MR, Footmann SP. Heterogeneity in the relationship between ethnicity, BMI, and fasting insulin. Diabetes Care. 2002;25:1351-1357. Abstract
• Young-Hyman D, Herman L, Dawnavan LS, Schlundt DG. Care-giver perception of children's obesity-related health risk: a study of African American families. Obesity Res. 2000;8:241-248.
• Young-Hyman D, Schlundt DG, Herman-Wenderoth L, Bozylinski K. Obesity, appearance, and psychosocial adaptation in young African American children. J Pediatr Psychol. 2003;28:463-472. Abstract
• Murray R. The new female triad: polycystic ovary syndrome, obesity and insulin resistance. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference on Pediatric Health Care; March 31-April 3, 2005; Phoenix, Arizona. Abstract 219.
• Stein IF, Leventahl ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol. 1935;29:181-191.
• Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. 2005;352:1223-1236. Abstract
• Murray R. Polycystic ovary syndrome, obesity and insulin resistance. The new female triad. Advance Nurse Pract. 2004;12:22. Available at: http://nurse-practitioners.advanceweb.com/common/. Accessed May 26, 2005.
• Weiss R, Dziura J, Burget TS, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362-2374. Abstract
• Reaven GM. Banting Lecture 1988: role of insulin resistance in human disease. Diabetes. 1988;37:1595-1607. Abstract
• Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497. Abstract
• Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents. Arch Pediatr Adolesc Med. 2003;157:821-827. Abstract
• Freemark M, Bursey D. The effects of metformin on body mass index and glucose tolerance in obese adolescents with fasting hyperinsulinemia and a family history of type 2 diabetes. Pediatrics. 2001;107:355. Available at: http://pediatrics.aappublications.org/cgi. Accessed May 26, 2005.
• Jones KL, Arslanian S, Peterokova VA, et al. Effect of metformin in pediatric patients with type 2 diabetes. A randomized controlled trial. Diabetes Care. 2002;25:89-94. Abstract
• Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005;352:1138-1145. Abstract
  

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Offering Guidance to Parents: Child Temperament, Managing Colic, and Youth Sport ParticipationTammy C. Tempfer, MSN, RN-C, PNP   

　 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.

Understanding Each Child's Unique Temperament

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.

Five Principles of Temperament

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.

Misconceptions About 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.

Dimensions of Temperament

A child's temperament includes 4 dimensions:

• Activity
• Approach/withdrawal
• Task perseverance
• Negative reactivity
  

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.

The Dynamic 4 -- Temperament Typology

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.

Developing a Discipline Plan and Using Behavioral Contracts

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.

Colic and Calming a Fussy Baby

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.

Cow's Milk/Soy Protein Allergy of Intolerance

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]

Immature Gastrointestinal System

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]

Immature Central Nervous System

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]

Difficult Infant Temperament

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]

An Intervention to Calm Crying Babies

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]

The Calming Reflex -- the 5 Ss

• 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.
  
  

An Experiment in Soothing Your Baby

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.

• Shhhh him softly. If that doesn't work, do it louder, right in his ear.
• Swaddle his arms to keep them from flailing. Do that while shhhing.
• Place your wrapped baby on his side or stomach and shush him again.
• Now use a quick, jiggly motion.
• Finally, on top of all of these, offer a pacifier or finger to suck on.
  

By this time, most fussy babies will usually be calmed.

A New Parent's Survival Guide: The Top 10 Survival Tips for Parents of New Babies

The speaker closed with this guidance for clinicians to share with parents:

• Trust yourself: you are the latest in the unbroken chain of the world's top parents
• Lower your expectations
• Accept all the help you can
• Get your priorities straight: should you take a break or do the dishes?
• Be flexible: it's much better to bend than to snap
• Know thyself: how do your baby's cries make you feel?
• Don't rock the cradle too hard: babies, frustration, and child abuse
• Keep your sense of humor handy
• Take care of your spouse (s/he just might come in handy someday)
• Don't ignore depression: the uninvited guest
  

Youth Sports Participation

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.

Parents' Responsibilities

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:

• Remain in the spectator area during games.
• Do not advise the coach on how to coach.
• Do not make derogatory comments to coaches, officials, or parents of either team.
• Do not try to coach your child during the contest.
• Do not drink alcohol at contests or come to a game after drinking too much.
• Cheer for your child's team.
• Show interest, enthusiasm, and support for your child.
• Be in control of your emotions.
• Help when asked by coaches or officials.
• Thank coaches, officials, and other volunteers who conduct the event.[14]
  

Preseason Conditioning and Training

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.

References

• McClowry SG. Child temperament: providing insights and strategies to parents. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference; March 31-April 2, 2005; Phoenix Arizona.
• McClowry SG. Your Child抯 Unique Temperament: Insights and Strategies for Responsive Parenting. Champaign, Ill: Research Press; 2003.
• Online temperament profile. Available at: http://education.nyu.edu/nursing/insights/survey.html. Accessed June 1, 2005.
• Ellett ML. What is known about infant colic? Gastroenterol Nurs. 2003;26:60-65.
• Oggero R, Garbo G, Savino F, Mostert M. Dietary modifications versus dicyclomine hydrochloride in the treatment of severe infantile colics. Acta Paediatr. 1994;83:222-225. Abstract
• Treem WR. Infant colic: a pediatric gastroenterologist's perspective. Pediatr Clin North Am. 1994;41:1121-1138. Abstract
• Keefe MR, Kotzer AM, Froese-Fretz A, Curtin M. A longitudinal comparison of irritable and nonirrritable infants. Nursing Res. 1996;45:4-9.
• Fox NA, Henderson HA, Marshall PJ. The biology of temperament: an integrative approach. The Handbook of Developmental Cognitive Neuroscience. Cambridge, Mass: MIT Press; 2001.
• Murray L, Stanley C, Hooper R, King F, Fiori-Cowley A. The role of infant factors in postnatal depression and mother-infant interactions. Dev Med Child Neurol. 1996;38:109-119. Abstract
• Karp H. The 4th trimester and calming reflex: an effective new approach to lessen crying and enhance sleep in early infancy. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference; March 31-April 2, 2005; Phoenix Arizona.
• Karp H. The Happiest Baby on the Block. New York, NY: Bantam Books; 2002. Available at: http://www.thehappiestbaby.com/. Accessed June 1, 2005.
• Metzl J. The young athlete. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference; March 31-April 2, 2005; Phoenix Arizona.
• Metzl J, Shookhoff C. The Young Athlete: A Sports Doctor's Complete Guide for Parents. Boston: Little Brown and Company; 2002.
• Sullivan JA, Anderson SJ. Care of the Young Athlete. American Academy of Orthopaedic Surgeons, American Academy of Pediatrics; 2000.
  

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Appendicitis: A Real Pain for ChildrenAndrea M Kline, RN,MS,PCCNP,CPNP-AC,CCRN   Abdominal Pain in Children

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.

Etiology, Incidence, and Presentation of Appendicitis

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.

Evaluating Suspected Appendicitis

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]

Management of Appendicitis

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]

Complications/Outcomes

"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]

Trends in Malpractice Suits

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.

References

• Rothrock SG, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med. 2000;36:39-51. Abstract
• Bolick B. Appendicitis in infants and children; the differential diagnosis of abdominal pain. Program and abstracts of the National Association of Pediatric Nurse Practitioners 26th Annual Conference on Pediatric Healthcare; March 31-April 3, 2005; Phoenix, Arizona.
• Kwok MY, Kim MK, Gorelick MH. Evidence-based approach to the diagnosis of appendicitis in children. Pediatr Emerg Care. 2004;20:690-698. Abstract
• Cardall T, Glasser J, Guss D. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med. 2004;11:1021-1027. Abstract
• Cappendijk VC, Hazebroek FW. The impact of diagnostic delay on the course of acute appendicitis. Arch Dis Child. 2000;83:64-66. Abstract
• Garcia-Pena BM, Mandl KD, Kraus SJ, et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA. 1999;15:1041-1046.
• Garcia-Pena, BM, Taylor, GA, Lund, DP, Mandl, K. Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics. 1999;104:440-446. Abstract
• Rothrock S, Skeoch G, Rush J, Johnson N. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med. 1991;20:45-50. Abstract
• Wolfe JM, Smithline HA, Phipen S, Montano G, Garb JL, Fiallo V. Does morphine change the physical examination in patients with acute appendicitis? Am J Emerg Med. 2004;22:280-285.
• El Ghoneimi A, Valla JS, Limonne B, et al. Laparoscopic appendectomy in children: report of 1,379 cases. J Pediatr Surg. 1994;29:786-789. Abstract
• Nelson DS, Bateman B, Bolte RG. Appendiceal perforation in children diagnosed in the emergency department. Pediatr Emerg Care. 2000;16:233-237. Abstract
• Flum DR, Koepsell T. The clinical and ecomonic correlates of misdiagnosed appendicitis. Nationwide analysis. Arch Surg. 2002;137:799-804. Abstract
• Selbst SM，Friedman MJ和Singh SB。美国急诊部门和急救中心涉及儿童的渎职诉讼的流行病学和病因学。儿科新兴护理。2005; 21：165-169。抽象