Pediatric NP/PA - October 2010, Vol 1, No 1 by Sean Walsh

OCTOBER 2010

WWW.PEDIATRICNPPA.COM

VOL 1, NO 1

THE OFFICAL NEWSPAPER FOR THE PEDIATRIC/ADOLESCENT NURSE AND ADVANCED PRACTITIONER CONFERENCE COVERAGE

PROFILE

Rady Children’s Hospital, San Diego, California

HAART Reduces Risk of Cardiac Dysfunction After Perinatal HIV Infection By Daniel M. Keller, PhD

he use of highly active antiretroviral therapy (HAART) reduces the incidence of cardiac dysfunction among children perinatally infected with HIV. But the risk rises if children are older at the time of HAART initiation, if they have poor immune status, or had prior use of ddC (zalcitabine). Epidemiologist Kunjal Patel, PhD, of the Harvard School of Public Health in

Boston reported these results at AIDS 2010: XVIII International AIDS Conference, held in July in Vienna, Austria. Dr Patel and colleagues enrolled 3107 children perinatally infected with HIV in a multicenter prospective cohort study and observed them for cardiac dysfunction between 1993 and 2007. Cardiac dysfuncton was defined as a new diagnosis of cardiomyopathy or initiation Continued on page 4

VACCINES

H1N1 in Children: Lessons From the 2009 Pandemic Scott Turner, NP The Children’s Hospital and Senior Instructor of Pediatrics and Neurology at the University of Colorado, Denver Health Sciences Center, Aurora, Colorado

Cardiac nurses from Rady Children's NICU.

ady Children’s Hospital officially opened its doors to receive its first 12 patients in August of 1954. Since then, nearly 2 million sick and injured children have been treated. Consistently recognized as one of the top children’s hospitals in the nation by U.S. News and World Report, Rady Children’s receives many parents and their children from across the country. The new Acute Care Pavilion is opening this month, and that will help ensure that a child will never be turned away for lack of space. Pediatric NP/PA was able to catch up with Mary J. Fagan, Vice President, Patient Care Services and Chief Nursing Officer, and Sue Shepard, RN, Pediatric Cardiology Nurse, from Rady Children’s Hospital to talk about their institution’s success, its outreach program, and life as a pediatric cardiology nurse. PNPPA: What is your hospital doing that is different from other children’s hospitals? Ms Fagan: For nearly 15 years Rady Children’s has focused on the continuContinued on page 22

n April 2009 a novel “swine flu” with serological markers of H1N1 first appeared in 2 patients within the United States. By June 2009, the World Health Organization had declared H1N1 to be pandemic.1 What Makes H1N1 Infection Unique? The H1N1 virus is a novel influenza virus. The protein markers on the surface of infected cells are similar to those seen in the “swine flu” pandemic of 1918. Since most of the population alive today has never been exposed to these antigens, most people lack a significant level of immunity to this type of flu. As a result, a significantly larger number of people

were expected to contract the flu in 2009 than in a typical flu season.2 Who Is Hardest Hit? With the seasonal flu, healthcare providers know to watch out for the wellbeing of the very young and the very old. Seniors aged 65 years and older account for more than 60% of the flu-related hospitalizations and more than 90% of the flu-related deaths in the US each year.3 But the H1N1 virus seems to target a much younger population. According to the CDC and others, 95% of those hospitalized with H1N1-related illness in 2009 were younger than 65 years, with the median age being 21. Nearly half of these Continued on page 19

Inside From the Board

Complimentary CE Credit 3

A Day in the Life

Nursing in the Pediatric Cardiac Catheterization Laboratory

A Journal Is Born!

Pulmonary Hypertension in Infants and Children

The Growth Chart News for the Ages

24 25

Recognizing those providing bright futures for kids To honor the noble profession of pediatric advanced practice, Pediatric NP/PA will recognize the people and practices that have made a difference in the care of children.

Nurse Practitioner of the Year Physician Assistant of the Year

Pediatric Institution of the Year Treatment Advance of the Year

All awardees will be nominated and voted on by you, our reading community, and will receive the distinct recognition for making a bright future for a child. You will have the opportunity to make nominations in each category and provide a description of how the nominee helped to spread a little sunshine.

Editorial Board Patti Batchelder, RN, MSN, PNPBC

Shannon Fitzgerald, MSN, ARNP

The Children's Hospital University of Colorado at Denver Aurora, CO

Seattle Children's Hospital Seattle, WA

Cris Ann Bowman-Harvey, RN, MSN, CPNP

Alison G. Grisso, PharmD

Advanced Pediatric Associates Aurora, CO

Michelle Brei, CPNP, APRN Yale Health New Haven, CT

Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville, TN

Erica Monasterio, RN, MN, FNP

Scott B. Turner, MSN, APRN-BC

University of California, San Francisco San Francisco, CA

The Children's Hospital University of Colorado Denver Aurora, CO

Janette H. Prokop, MSN, APRN-C, CPEN

Deborah Walter, BSN, MSN, ACNP

The Children’s Hospital Aurora, CO

Rady Children’s Hospital San Diego, CA

Maureen S. Haugen, RN, MS, CPNP, CPON

Sharon SablesBaus, PhD, RN, PCNS-BC

Children’s Memorial Hospital Chicago, IL

University of Colorado, Denver Aurora, CO

Sara Gerrie, RN, MSN, CPNP Center for Cancer and Blood Disorders Littleton, CO

Kathleen Ryan, MSN, FNP San Diego Unified School District San Diego, CA

Karyn Brundige, MSN, CPNP Seattle Children’s Hospital Seattle, WA

Bernadette McCormick, RN, BSN

Sue Shepard, RN, BSN

Rady Children’s Hospital San Diego, CA

Nathalie Cleveland, MSN, RN, CPNP

Shirley Becton McKenzie, MS, PNP-BC, AE-C

Jacqueline Marie Toia, RN, MS, DNP

The Children's Hospital Aurora, CO

Children's Memorial Hospital Chicago, IL

Now Accepting Nominations for Editorial Board Positions The Editorial Board is instrumental in determining the content and direction of Pediatric NP/PA. If you are interested in serving on the Pediatric NP/PA Editorial Board, or would like to nominate a colleague, please e-mail the candidate’s resume to kristin@novellushc.com.

www.PediatricNPPa.com

october 2010 I VoL 1, No 1

CONTENTS october 2010 • VoL 1, No 1

THE OFFICAL NEWSPAPER FOR THE PEDIATRIC/ADOLESCENT NURSE AND ADVANCED PRACTITIONER

PUBLISHING STAFF Directors, Client Services Russell Hennessy russell@novellushc.com Mark Timko mark@novellushc.com Jack Iannaccone jack@novellushc.com Editorial Director Kristin Lee Siyahian Copy Editor Bjarne Hansen Contributing Editors Rosemary Hansen Bonnie Nickel Production Manager Marie R.S. Borrelli Business Manager Blanche Marchitto blanche@greenhillhc.com Executive Administrator Andrea Boylston Circulation Department circulation@novellushc.com Editorial Contact: Telephone: 732-992-1891 Fax: 732-656-7938

Novellus Healthcare Communications, LLC 241 Forsgate Drive, Suite 205D Monroe Twp, NJ 08831 EDITORIAL CORRESPONDENCE should be addressed to EDITORIAL DIRECTOR, Pediatric NP/PA™, 241 Forsgate Drive, Suite 205D, Monroe Township, NJ 08831. E-mail: kristin@novellushc.com. YEARLY SUBSCRIPTION RATES: United States and possessions: individuals, $105.00; institutions, $135.00; single issues, $17.00. Orders will be billed at individual rate until proof of status is confirmed. Prices are subject to change without notice. Correspondence regarding permission to reprint all or part of any article published in this journal should be addressed to REPRINT PERMISSIONS DEPARTMENT, Novellus Healthcare Communications, LLC, 241 Forsgate Drive, Suite 205D, Monroe Township, NJ 08831. The ideas and opinions expressed in Pediatric NP/PA™ do not necessarily reflect those of the editorial board, the Editorial Director, or the Publisher. Publication of an advertisement or other product mention in Pediatric NP/PA™ should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturer with questions about the features or limitations of the products mentioned. Neither the Editorial Board nor the Publisher assumes any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material contained in the periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosage, the method and duration of administration, or contraindications. It is the responsibility of the treating physician or other healthcare professional, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Every effort has been made to check generic and trade names, and to verify dosages. The ultimate responsibility, however, lies with the prescribing physician or healthcare provider. Please convey any errors to the Editorial Director. ISSN 2155-1529 (print); ISSN 21551553 (online) Pediatric NP/PA is published 6 times a year by Novellus Healthcare Communications, LLC, 241 Forsgate Drive, Suite 205D, Monroe Township, NJ 08831. Telephone: 732.656.7935. Fax: 732.656.7938. Copyright ©2010 by Novellus Healthcare Communications, LLC. All rights reserved. Pediatric NP/PA™ logo is a trademark of Novellus Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the Publisher. Printed in the United States of America. ™

october 2010 I VoL 1, No 1

FEATURES 7 Conference Coverage: 26th Annual Pediatric Nursing Conference • Pediatric Vaccine Issues Go Beyond Just When to Give Them • “Connect With Each Kid” to Detect Autism Spectrum Disorders Early • Every Nurse Can Be a Researcher • Cardiac Nurse Explains the Basics of ECG Evaluation at Pediatric Conference 9 Primary Care The Pediatric Medical Home: Pediatric Nurse Practitioner and Physician Assistant Responsibilities and Opportunities Barbara J. Deloian, PhD, RN, CPNP 14 Continuing Education Pulmonary Hypertension in Infants and Children: Pathophysiology and Diagnostic Workup Deborah Walter, BSN, MSN, ACNP 18 Dermatology Childhood Eczema: The Most Common Chronic Skin Disorder Rosemary Hansen 23 Pulmonology Update: Cystic Fibrosis Ruth S. DeVoogd, MSN, RN, PNP-AC/PC DEPARTMENTS 24 A Day in the Life Nursing in the Pediatric Cardiac Catheterization Laboratory Cyndi Murphy, RN, BSN 25 The Growth Chart: News for the Ages

WANT TO HEAR FROM YOU!

Out Mouths of Babes of the

Artwork Month of the

page 20

page 22

As a tribute to your relationship with patients, we will feature special moments, comical quotes, and artwork from your patients.

Submit your stories, patient quotes, and artwork by visiting www.pediatricNPPA.com or e-mailing kristin@novellushc.com.

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From the Board

A Journal Is Born! Born on October 2, 2010 Circulation: a hefty 34,000 pediatric healthcare providers Dear Colleague,

t is with great pleasure and excitement that I introduce Pediatric NP/PA to the pediatric healthcare community. Our goal is to present information that addresses the professional life of the pediatric nurse and advanced practitioner.

Nathalie Cleveland MSN, RN, CPNP Pediatric Oncology The Children’s Hospital, Aurora, CO

Within our pages and on our Web site, we offer our reading community NP/PAauthored articles on various topics, continuing education opportunities, and news updates from conferences, as well as interviews and profiles of pediatric providers and their institutions.

We recognize that pediatric providers are unique in that our precious patients require not only our medical skill and knowledge but also our nurturing. In recognition of the special relationships we cultivate with our patients, Pediatric NP/PA offers information to support our knowledge of their care, as well as a venue to share our special connection with them. Look for regular departments such as “Out of the Mouths of Babes” (page 20) and “Artwork of the Month” (page 22). I encourage you to contribute your experiences. We strongly believe in supporting and promoting our careers and profession. To that end, we will sponsor annual awards honoring nurse practitioners, physician assistants, pediatric institutions, and treatment advances. Nominations will be made by, who else, our pediatric NP/PA community! Please see our nominating information on the inside front cover.

On behalf of our editorial board and staff, I’d like to welcome you to Pediatric NP/PA. We promise to support and promote the role of the pediatric nurse and physician assistant with timely and insightful information and thereby support your ability to provide bright futures for your patients. With best regards,

www.PediatricNPPa.com

october 2010 I VoL 1, No 1

Conference Coverage HAART Reduces Risk...continued from cover of digoxin or dobutamine therapy. Children with a history of cardiac dysfunction, diabetes, or cardiotoxic chemotherapy were excluded from the study. Studies in the pre-HAART era gave conflicting results about cardiac dysfunction. “The goal of [this] study was to assess the long-term effects of HIV infection and in utero and postnatal exposure to antiretroviral therapy,” Dr Patel said. HAART was defined as the use of 3 or more drugs from at least 2 different classes of anti-HIV drugs. Dr Patel said that the use of HAART regimens was associated with a 60% decrease in the risk of cardiac dysfunction compared with the use of nonHAART regimens (hazard ratio, 0.40; 95% confidence interval, 0.3-0.7; P=.002). Over the course of the study, 102 cases of cardiac dysfunction occurred, giving an incidence rate of 5.7 cases per 1000 person-years. The median age at diagnosis was 9.5 years. Thirty-eight deaths occurred among the incident cases, a mortality rate of 37%. In multivariable analyses, factors associated with increased risk of cardiac dysfunction were birth prior to 1990, Hispanic ethnicity, a low CD4+ cell count at baseline, ddC use, and Centers for Disease Control and Prevention category C disease at baseline (defined as the presence of one or more AIDS-indicator conditions regardless of CD4+ cell count). Among children receiving HAART, older age at HAART initiation, a low CD4+ cell count before or after HAART initiation, and use of ddC before receiving HAART were independent risk factors for cardiac dysfunction.

A limitation of the study is that it involved a survivor cohort, so not all children were followed from birth. “Our calculated incidence rate, therefore, may not be generalizable to the underlying incidence rate in the pediatric perinatally infected population,” Dr

Patel noted. Another limitation is the lack of viral load data for most children in the early years of the study, so it could not be addressed as a confounder for HAART use. “I think we still need to maintain vigilance in looking for cardiac dysfunction

in the HAART era, especially among children with poor immune status either before or after HAART initiation, prior ddC exposure, and if HAART was started at an older age,” she concluded.

With all 4 doses, she’s good to grow Give her proven protection with the only DTaP-IPV/Hiba vaccine.1-4 Keep her growing strong with all the recommended childhood immunizations. Help protect with all 4 doses of Pentacel vaccine and help enhance compliance The 2008 National Immunization Survey shows that by 24 months of age, 1 in every 5 children did not receive all 4 recommended doses of DTaP vaccine.5 According to the AAPb, administering a combination vaccine may enhance timeliness and compliance.6,7

Pentacel vaccine:

Visit www.pediatricNPPA.com to connect with us! In addition to Web-only exclusives, news coverage, and journal articles, you’ll have the opportunity to submit patient quotes and artwork, and make nominations for the Sunshine Awards.

october 2010 I VoL 1, No 1

• Contains a Hib component, so it fits easily into the primary series at 2, 4, 6, and 15-18 months of age1,8

• Can save a shot at the crowded toddler visit 8 Four doses of Pentacel vaccine constitute a primary pertussis immunization series.1 Children should receive a fifth dose of DTaP at 4-6 years of age.1

To learn more about the efficacy, convenience, and safety of Pentacel vaccine, please visit pentacel.com. To order Pentacel vaccine, log onto VaccineShoppe.com® or call 1-800-VACCINE (1-800-822-2463).

www.PediatricNPPa.com

Pediatric NP/PA

Coming soon! Pediatric NP/PA presents conference coverage from the Annual Meeting of the American Academy of Pediatrics. Rely on us to bring you updates from the conferences that directly impact your practice.

Indication Pentacel vaccine is indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis, and invasive disease due to Haemophilus influenzae type b. Pentacel vaccine is approved for use as a 4-dose series in children 6 weeks through 4 years of age (prior to fifth birthday).

Safety Information The most common local and systemic adverse reactions to Pentacel vaccine include injection site redness, swelling, and tenderness; fever, fussiness, and crying. Other adverse reactions may occur. Known systemic hypersensitivity reaction to any component of Pentacel vaccine or a life-threatening reaction after previous administration of the vaccine or a vaccine containing the same substances are contraindications to vaccination. The decision to give Pentacel vaccine should be based on the potential benefits and risks; if Guillain-Barré syndrome has occurred within 6 weeks of receipt of a prior vaccine containing tetanus toxoid; or if adverse events have occurred in temporal relation to receipt of pertussis-containing vaccine. Encephalopathy within 7 days of administration of a previous dose of a pertussis-containing vaccine or a progressive neurologic disorder is a contraindication. Vaccination with Pentacel vaccine may not protect all individuals. Before administering Pentacel vaccine, please see accompanying brief summary of full Prescribing Information. CPT®c Code: 90698 a DTaP = Diphtheria, tetanus, and acellular pertussis; IPV = Inactivated poliovirus; Hib = Haemophilus influenzae type b. b AAP = American Academy of Pediatrics. c CPT = Current Procedural Terminology is a registered trademark of the American Medical Association.

Pentacel vaccine is manufactured by Sanofi Pasteur Limited and Sanofi Pasteur SA and distributed by Sanofi Pasteur Inc. References: 1. Pentacel vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2009. 2. Decker MD, Edwards KM, Bradley R, Palmer P. Comparative trial in infants of four conjugate Haemophilus influenzae type b vaccines. J Pediatr. 1992;120:184-189. 3. Granoff DM, Anderson EL, Osterholm MT, et al. Differences in the immunogenicity of three Haemophilus influenzae type b conjugate vaccines in infants. J Pediatr. 1992;121:187-194. 4. Greenberg DP, Lieberman JM, Marcy SM, et al. Enhanced antibody responses in infants given different sequences of heterogeneous Haemophilus influenzae type b conjugate vaccines. J Pediatr. 1995;126:206-211. 5. Centers for Disease Control and Prevention (CDC). Estimated vaccination coverage with individual vaccines and selected vaccination series before 24 months of age by state and local area US, National Immunization Survey, 2008. http://www2a.cdc.gov/nip/coverage/nis/nis_iap2.asp?fmt=v&rpt=tab09_24mo_iap&qtr=Q1/2008-Q4/2008. Accessed April 15, 2010. 6. Food and Drug Administration. Pentacel®: DTaP-IPV/Hib Combined (diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus and Haemophilus b conjugate [tetanus toxoid conjugate] vaccine combined). VRBPAC Briefing Document. http://www.fda.gov/ohrms/dockets/ac/07/briefing/2007-4275B1-01.pdf. Accessed April 8, 2010. 7. American Academy of Pediatrics. Combination vaccines for childhood immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Pediatrics. 1999;103:1064-1077. 8. CDC. Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010. MMWR. 2010;58(51&52):1-4.

sanofi pasteur. Discovery Drive. Swiftwater, Pennsylvania 18370. www.sanofipasteur.us MKT20015-1

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Printed in USA

october 2010 I VoL 1, No 1

Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) Vaccine Pentacel® $ only Brief Summary: Please see package insert for full prescribing information. INDICATIONS AND USAGE Pentacel® is a vaccine indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis and invasive disease due to Haemophilus influenzae type b. Pentacel vaccine is approved for use as a four dose series in children 6 weeks through 4 years of age (prior to fifth birthday). DOSAGE AND ADMINISTRATION Immunization Series Pentacel vaccine is to be administered as a 4 dose series at 2, 4, 6 and 15-18 months of age. The first dose may be given as early as 6 weeks of age. Four doses of Pentacel vaccine constitute a primary immunization course against pertussis. Three doses of Pentacel vaccine constitute a primary immunization course against diphtheria, tetanus, H influenzae type b invasive disease, and poliomyelitis; the fourth dose is a booster for diphtheria, tetanus, H influenzae type b invasive disease, and poliomyelitis immunizations. Mixed Sequences of Pentacel Vaccine and DTaP Vaccine While Pentacel and DAPTACEL (Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed [DTaP], Sanofi Pasteur Limited) vaccines contain the same pertussis antigens, manufactured by the same process, Pentacel vaccine contains twice the amount of detoxified pertussis toxin (PT) and four times the amount of filamentous hemagglutinin (FHA) as DAPTACEL vaccine. Pentacel vaccine may be used to complete the first 4 doses of the 5-dose DTaP series in infants and children who have received 1 or more doses of DAPTACEL vaccine and are also scheduled to receive the other antigens of Pentacel vaccine. Children who have completed a 4-dose series with Pentacel vaccine should receive a fifth dose of DTaP vaccine using DAPTACEL at 4-6 years of age. However, data are not available on the safety and immunogenicity of mixed sequences of Pentacel vaccine and DAPTACEL vaccine for successive doses of the DTaP series. Administration Just before use, thoroughly but gently shake the vial of DTaP-IPV component, withdraw the entire liquid content and inject into the vial of the lyophilized ActHIB vaccine component. Shake the vial now containing Pentacel vaccine thoroughly until a cloudy, uniform, white to off-white (yellow tinge) suspension results. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If these conditions exist, Pentacel vaccine should not be administered. Withdraw and administer a 0.5 mL dose of Pentacel vaccine intramuscularly. Pentacel vaccine should be used immediately after reconstitution. CONTRAINDICATIONS Hypersensitivity A severe allergic reaction (eg, anaphylaxis) after a previous dose of Pentacel vaccine or any other diphtheria toxoid, tetanus toxoid, or pertussis-containing vaccine, inactivated poliovirus vaccine or H influenzae type b vaccine, or any ingredient of this vaccine is a contraindication to administration of Pentacel vaccine. Encephalopathy Encephalopathy (eg, coma, decreased level of consciousness, prolonged seizures) within 7 days of a previous dose of a pertussis-containing vaccine that is not attributable to another identifiable cause is a contraindication to administration of any pertussis-containing vaccine, including Pentacel vaccine. Progressive Neurologic Disorder Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, or progressive encephalopathy is a contraindication to administration of any pertussis-containing vaccine including Pentacel vaccine. Pertussis vaccine should not be administered to individuals with such conditions until a treatment regimen has been established and the condition has stabilized. WARNINGS AND PRECAUTIONS Management of Acute Allergic Reactions Epinephrine hydrochloride solution (1:1,000) and other appropriate agents and equipment must be available for immediate use in case an anaphylactic or acute hypersensitivity reaction occurs. Adverse Reactions Following Prior Pertussis Vaccination If any of the following events occur within the specifi ed period after administration of a pertussis vaccine, the decision to administer Pentacel vaccine should be based on careful consideration of potential benefits and possible risks. • Temperature of ≥40.5°C (≥105°F) within 48 hours, not attributable to another identifiable cause. • Collapse or shock-like state (hypotonic-hyporesponsive episode (HHE)) within 48 hours. • Persistent, inconsolable crying lasting ≥3 hours within 48 hours. • Seizures with or without fever within 3 days. Guillain-Barré Syndrome and Brachial Neuritis A review by the Institute of Medicine (IOM) found evidence for a causal relation between tetanus toxoid and both brachial neuritis and Guillain-Barré syndrome. (1) If Guillain-Barré syndrome occurred within 6 weeks of receipt of prior vaccine containing tetanus toxoid, the decision to give Pentacel vaccine or any vaccine containing tetanus toxoid should be based on careful consideration of the potential benefits and possible risks. Infants and Children with a History of Previous Seizures For infants or children with a history of previous seizures, an appropriate antipyretic may be administered (in the dosage recommended in its prescribing information) at the time of vaccination with a vaccine containing acellular pertussis antigens (including Pentacel vaccine) and for the following 24 hours, to reduce the possibility of post-vaccination fever. Limitations of Vaccine Effectiveness Vaccination with Pentacel vaccine may not protect all individuals. Altered Immunocompetence If Pentacel vaccine is administered to immunocompromised persons, including persons receiving immunosuppressive therapy, the expected immune response may not be obtained. ADVERSE REACTIONS Data from Clinical Studies Rates of adverse reactions varied by dose number. The most frequent (>50% of participants) systemic reactions following any dose were fussiness/irritability and inconsolable crying. The most frequent (>30% of participants) injection site reactions following any dose were tenderness and increased circumference of the injected arm. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a vaccine cannot be directly compared to rates in the clinical trials of another vaccine and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to vaccine use and for approximating rates of those events. The safety of Pentacel vaccine was evaluated in four clinical studies in which a total of 5,980 participants received at least one dose of Pentacel vaccine. In three of the studies, conducted in the US, a total of 4,198 participants were enrolled to receive four consecutive doses of Pentacel vaccine. In the fourth study, conducted in Canada, 1,782 participants previously vaccinated with three doses of Pentacel vaccine received a fourth dose. The vaccination schedules of Pentacel vaccine, Control vaccines, and concomitantly administered vaccines used in these studies are provided in Table 1. Across the four studies, 50.8% of participants were female. Among participants in the three US studies, 64.5% were Caucasian, 9.2% were Black, 12.9% were Hispanic, 3.9% were Asian, and 9.5% were of other racial/ethnic groups. In the two controlled studies, the racial/ethnic distribution of participants who received Pentacel and Control vaccines was similar. In the Canadian fourth dose study, 86.0% of participants were Caucasian, 1.9% were Black, 0.8% were Hispanic, 4.3% were Asian, 2.0% were East Indian, 0.5% were Native Indian, and 4.5% were of other racial/ethnic groups. Table 1: Clinical Safety Studies of Pentacel Vaccine: Vaccination Schedules Study 494-01

P3T06 494-03

Pentacel 2, 4, 6, and 15 months

Control Vaccines HCPDT + POLIOVAX + ActHIB at 2, 4, 6, and 15 months

Concomitantly Administered Vaccines 7-valent pneumococcal conjugate vaccine* (PCV7) at 2, 4, and 6 months in a subset of participants†

Hepatitis B vaccine at 2 and 6 months‡ 2, 4, 6, and 15-16 months DAPTACEL + IPOL + ActHIB at 2, 4, and 6 PCV7* at 2, 4, and 6 months months; and DAPTACEL + ActHIB at Hepatitis B vaccine at 2 and 6 months‡ 15-16 months 2, 4, 6, and 15-16 months None PCV7* at 2, 4, and 6 months in all participants; and at 15 months in a random subset of participants Hepatitis B vaccine at 2 and 6 months (if a dose was previously administered)‡ or at 2, 4, and 6 months (if no previous dose) Measles, mumps, rubella vaccine§ (MMR) and varicella§ vaccine at 12 or 15 months in random subsets of participants None

None

5A9908 15-18 months**

HCPDT: non-US licensed DTaP vaccine that is identical to the DTaP component of Pentacel vaccine. POLIOVAX: US licensed Poliovirus Vaccine Inactivated, Sanofi Pasteur Limited. IPOL: US licensed Poliovirus Vaccine Inactivated, Sanofi Pasteur SA. * PCV7 manufactured by Wyeth Laboratories. † PCV7 was introduced after the study was initiated, and thus, administered concomitantly with Pentacel vaccine in a subset of participants. ‡ The first dose of hepatitis B vaccine (manufacturer not specified) was administered prior to study initiation, from birth to 21 days of age. Subsequent doses were with hepatitis B vaccine manufactured by Merck and Co. § MMR and varicella vaccines were both manufactured by Merck and Co. ** Study participants previously had received three doses of Pentacel vaccine by 8 months of age. Solicited Adverse Reactions The incidence and severity of selected solicited injection site and systemic adverse reactions that occurred within 3 days following each dose of Pentacel or Control vaccines in Study P3T06 is shown in Table 2. Information on these reactions was recorded daily by parents or guardians on diary cards. In Table 2, injection site reactions are reported for the Pentacel vaccine and DAPTACEL vaccine injection sites. Table 2: Number (Percentage) of Children with Selected Solicited Adverse Reactions by Severity Occurring within 0-3 days of Pentacel Vaccine or Control Vaccines in Study P3T06

Injection Site Reactions Redness >5 mm >25 mm >50 mm Swelling >5 mm >25 mm >50 mm Tenderness* Any Moderate or Severe Severe Increase in Arm Circumference >5 mm >20 mm >40 mm

Dose 1 N=465-467 %

Pentacel Vaccine Dose 2 Dose 3 N=451 N=438-440 % %

DAPTACEL Vaccine Dose 4 Dose 1 Dose 2 Dose 3 Dose 4 N=387-396 N=1,400-1,404 N=1,358-1,359 N=1,311-1,312 N=376-380 % % % % %

7.1 2.8 0.6

8.4 1.8 0.2

8.7 1.8 0.0

17.3 9.2 2.3

6.2 1.0 0.4

7.1 0.6 0.1

9.6 1.9 0.0

16.4 7.9 2.4

7.5 3.0 0.9

7.3 2.0 0.0

5.0 1.6 0.0

9.7 3.8 0.8

4.0 1.6 0.4

4.0 0.7 0.1

6.5 1.1 0.1

10.3 4.0 1.3

47.5 19.6 5.4

39.2 10.6 1.6

42.7 11.6 1.4

56.1 16.7 3.3

48.8 20.7 4.1

38.2 12.2 2.3

40.9 12.3 1.7

51.1 15.8 2.4

—

33.6 4.7 0.5

—

30.6 6.9 0.8

Pentacel Vaccine Systemic Reactions

DAPTACEL + ActHIB Vaccines Dose 1 Dose 2 Dose 3 Dose 4 N=1,390-1,406 N=1,346-1,360 N=1,301-1,312 N=379-381 % % % % DAPTACEL + IPOL + ActHIB Vaccines

Dose 1 N=466-467 %

Dose 2 N=451-452 %

Dose 3 N=435-440 %

Dose 4 N=389-398 %

Fever†‡ ≥38.0˚ C >38.5˚ C >39.5˚ C

5.8 1.3 0.4

10.9 2.4 0.0

16.3 4.4 0.7

13.4 5.1 0.3

9.3 1.6 0.1

16.1 4.3 0.4

15.8 5.1 0.3

8.7 3.2 0.8

Decreased Activity/ Lethargy§ Any Moderate or Severe Severe

45.8 22.9 2.1

32.7 12.4 0.7

32.5 12.7 0.2

24.1 9.8 2.5

51.1 24.3 1.2

37.4 15.8 1.4

33.2 12.7 0.6

24.1 9.2 0.3

Inconsolable Crying Any ≥1 hour >3 hours

59.3 19.7 1.9

49.8 10.6 0.9

47.3 13.6 1.1

35.9 11.8 2.3

58.5 16.4 2.2

51.4 16.0 3.4

47.9 12.2 1.4

36.2 10.5 1.8

Fussiness/Irritability Any ≥1 hour >3 hours

76.9 34.5 4.3

71.2 27.0 4.0

68.0 26.4 5.0

53.5 23.6 5.3

75.8 33.3 5.6

70.7 30.5 5.5

67.1 26.2 4.3

53.8 19.4 4.5

* Any: Mild, Moderate or Severe; Mild: subject whimpers when site is touched; Moderate: subject cries when site is touched; Severe: subject cries when leg or arm is moved. † Fever is based upon actual temperatures recorded with no adjustments to the measurement route. ‡ Following Doses 1-3 combined, the proportion of temperature measurements that were taken by axillary, rectal or other routes, or not recorded were 46.0%, 53.0%, 1.0%, and 0% respectively, for Pentacel vaccine and 44.8%, 54.0%, 1.0%, and 0.1%, respectively, for DAPTACEL + IPOL + ActHIB vaccines. Following Dose 4, the proportion of temperature measurements that were taken by axillary, rectal or other routes, or not recorded were 62.7%, 34.4%, 2.4% and 0.5%, respectively, for Pentacel vaccine, and 61.1%, 36.6%, 1.7% and 0.5%, respectively, for DAPTACEL + ActHIB vaccines. § Moderate: interferes with or limits usual daily activity; Severe: disabling, not interested in usual daily activity. Hypotonic Hyporesponsive Episodes In Study P3T06, the diary cards included questions pertaining to HHEs. In Studies 494-01, 494-03, and 5A9908, a question about the occurrence of fainting or change in mental status was asked during post-vaccination phone calls. Across these 4 studies, no HHEs, as defined in a report of a US Public Health Service workshop (2) were reported among participants who received Pentacel vaccine (N = 5,979), separately administered HCPDT + POLIOVAX + ActHIB vaccines (N = 1,032) or separately administered DAPTACEL + IPOL + ActHIB vaccines (N = 1,455). Hypotonia not fulfilling HHE criteria within 7 days following vaccination was reported in 4 participants after the administration of Pentacel vaccine (1 on the same day as the 1st dose; 3 on the same day as the 3rd dose) and in 1 participant after the administration of DAPTACEL + IPOL + ActHIB vaccines (4 days following the 1st dose). Seizures Across Studies 494-01, 494-03, 5A9908 and P3T06, a total of 8 participants experienced a seizure within 7 days following either Pentacel vaccine (4 participants; N = 4,197 for at least one of Doses 1-3; N = 5,033 for Dose 4), separately administered HCPDT + POLIOVAX + ActHIB vaccines (3 participants; N = 1,032 for at least one of Doses 1-3, N = 739 for Dose 4), separately administered DAPTACEL + IPOL + ActHIB vaccines (1 participant; N = 1,455 for at least one of Doses 1-3), or separately administered DAPTACEL + ActHIB vaccines (0 participants; N = 418 for Dose 4). Among the four participants who experienced a seizure within 7 days following Pentacel vaccine, one participant in Study 494-01 had an afebrile seizure 6 days after the first dose, one participant in Study 494-01 had a possible seizure the same day as the third dose, and two participants in Study 5A9908 had a febrile seizure 2 and 4 days, respectively, after the fourth dose. Among the four participants who experienced a seizure within 7 days following Control vaccines, one participant had an afebrile seizure the same day as the first dose of DAPTACEL + IPOL + ActHIB vaccines, one participant had an afebrile seizure the same day as the second dose of HCPDT + POLIOVAX + ActHIB vaccines, and two participants had a febrile seizure 6 and 7 days, respectively, after the fourth dose of HCPDT + POLIOVAX + ActHIB vaccines. Serious Adverse Events In Study P3T06, within 30 days following any of Doses 1-3 of Pentacel or Control vaccines, 19 of 484 (3.9%) participants who received Pentacel vaccine and 50 of 1,455 (3.4%) participants who received DAPTACEL + IPOL + ActHIB vaccines experienced a serious adverse event. Within 30 days following Dose 4 of Pentacel or Control vaccines, 5 of 431 (1.2%) participants who received Pentacel vaccine and 4 of 418 (1.0%) participants who received DAPTACEL + ActHIB vaccines experienced a serious adverse event. In Study 494-01, within 30 days following any of Doses 1-3 of Pentacel or Control vaccines, 23 of 2,506 (0.9%) participants who received Pentacel vaccine and 11 of 1,032 (1.1%) participants who received HCPDT + POLIOVAX + ActHIB vaccines experienced a serious adverse event. Within 30 days following Dose 4 of Pentacel or Control vaccines, 6 of 1,862 (0.3%) participants who received Pentacel vaccine and 2 of 739 (0.3%) participants who received HCPDT + POLIOVAX + ActHIB vaccines experienced a serious adverse event. Across Studies 494-01, 494-03 and P3T06, within 30 days following any of Doses 1-3 of Pentacel or Control vaccines, overall, the most frequently reported serious adverse events were bronchiolitis, dehydration, pneumonia and gastroenteritis. Across Studies 494-01, 494-03, 5A9908 and P3T06, within 30 days following Dose 4 of Pentacel or Control vaccines, overall, the most frequently reported serious adverse events were dehydration, gastroenteritis, asthma, and pneumonia. Across Studies 494-01, 49403, 5A9908 and P3T06, two cases of encephalopathy were reported, both in participants who had received Pentacel vaccine (N = 5,979). One case occurred 30 days post-vaccination and was secondary to cardiac arrest following cardiac surgery. One infant who had onset of neurologic symptoms 8 days post-vaccination was subsequently found to have structural cerebral abnormalities and was diagnosed with congenital encephalopathy. A total of 5 deaths occurred during Studies 494-01, 494-03, 5A9908 and P3T06: 4 in children who had received Pentacel vaccine (N = 5,979) and one in a participant who had received DAPTACEL + IPOL + ActHIB vaccines (N = 1,455). There were no deaths reported in children who received HCPDT + POLIOVAX + ActHIB vaccines (N = 1,032). Causes of death among children who received Pentacel vaccine were asphyxia due to suffocation, head trauma, Sudden Infant Death syndrome, and neuroblastoma (8, 23, 52 and 256 days post-vaccination, respectively). One participant with ependymoma died secondary to aspiration 222 days following DAPTACEL + IPOL + ActHIB vaccines. Data from Post-Marketing Experience The following additional adverse events have been spontaneously reported during the post marketing use of Pentacel vaccine worldwide, since 1997. Between 1997 and 2007, Pentacel vaccine was primarily used in Canada. Because these events are reported voluntarily from a population of uncertain size, it may not be possible to reliably estimate their frequency or establish a causal relationship to vaccine exposure. The following adverse events were included based on one or more of the following factors: severity, frequency of reporting, or strength of evidence for a causal relationship to Pentacel vaccine. Cardiac disorders (cyanosis); gastrointestinal disorders (vomiting, diarrhea); general disorders and administration site conditions (injection site reactions [including inflammation, mass, abscess and sterile abscess], extensive swelling of the injected limb [including swelling that involved adjacent joints], vaccination failure/therapeutic response decreased (invasive H influenzae type b disease); immune system disorders (hypersensitivity, such as rash and urticaria); infections and infestations (meningitis, rhinitis, viral infection); metabolism and nutrition disorders (decreased appetite); nervous system disorders (somnolence, HHE, depressed level of consciousness); psychiatric disorders (screaming); respiratory, thoracic and mediastinal disorders (apnea, cough); skin and subcutaneous tissue disorders (erythema, skin discoloration); vascular disorders (pallor). DRUG INTERACTIONS Concomitant Administration with Other Vaccines In clinical trials, Pentacel vaccine was administered concomitantly with one or more of the following US licensed vaccines: hepatitis B vaccine, 7-valent pneumococcal conjugate vaccine, MMR and varicella vaccines. When Pentacel vaccine is given at the same time as another injectable vaccine(s), the vaccine(s) should be administered with different syringes and at different injection sites. STORAGE AND HANDLING Pentacel vaccine should be stored at 2° to 8°C (35° to 46°F). Do not freeze. Product which has been exposed to freezing should not be used. Do not use after expiration date shown on the label. PATIENT COUNSELING INFORMATION Before administration of Pentacel vaccine, health-care personnel should inform the parent or guardian of the benefits and risks of the vaccine and the importance of completing the immunization series unless a contraindication to further immunization exists. The health-care provider should inform the parent or guardian about the potential for adverse reactions that have been temporally associated with Pentacel vaccine or other vaccines containing similar ingredients. The health-care provider should provide the Vaccine Information Statements (VIS) which are required by the National Childhood Vaccine Injury Act of 1986 to be given with each immunization. The parent or guardian should be instructed to report adverse reactions to their health-care provider. REFERENCES 1. Stratton KR, et al. editors. Adverse events associated with childhood vaccines; evidence bearing on causality. Washington, DC: National Academy Press; 1994. p. 67-117. 2. Braun MM. Report of a US Public Health Service workshop on hypotonic-hyporesponsive episode (HHE) after pertussis immunization. Pediatrics 1998;102(5)1-5.

Product information as of December 2009. Manufactured by: Sanofi Pasteur Limited Toronto Ontario Canada and Sanofi Pasteur SA Lyon France Distributed by: Sanofi Pasteur Inc. Swiftwater PA 18370 USA

Pentacel® is a registered trademark of the sanofi pasteur group, and its subsidiaries. MKT20183

R1-1209 USA 2027314-242

Conference Coverage News From the 26th Annual Pediatric Nursing Conference, Philadelphia, Pennsylvania, July 16-18, 2010.

Pediatric Vaccine Issues Go Beyond Just When to Give Them By Daniel M. Keller, PhD

n a presentation on childhood immunizations, Donna Weaver, RN, MN, of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC) in Atlanta, discussed several current issues on the topic and presented the usual vaccine schedule recommendations. First, she said the Advisory Committee on Immunization Practices (ACIP) now maintains a general preference for the use of combination vaccines. Combinations minimize the number of injections and healthcare visits, provide timely coverage, and avoid the costs of stocking and administering separate vaccines. Disadvantages are higher costs, unnecessary doses, and potential adverse events. Ms Weaver said ACIP also provides criteria by which providers might choose singlecomponent products.

There are two licensed rotavirus vaccines on the market. In March, the CDC became aware of the presence of porcine circovirus or portions of it in both vaccines. “These viruses are not known to cause any infection or illness in people,” Ms Weaver said, and the Food and Drug Administration has determined that it is appropriate to use these vaccines based on their proven benefits and strong safety records. However, both are now contraindicated in infants diagnosed with severe combined immunodeficiency because of the risk of vaccine-acquired rotavirus infection. Vaccination against human papillomavirus is now recommended for boys as well as girls. ACIP provisional recommendations for girls are routine immunization at 11 or 12 years (or beginning the 3-dose series as early as 9 years of age), and also for females up to 26 years if they have not completed the full

series. ACIP recommends only the quadrivalent vaccine (Gardasil®, Merck) for administration to males between 9 and 26 years, ideally before their first sexual contact, to reduce the risk of acquiring genital warts. One troubling trend that Ms Weaver noted is the need for longer needles to administer vaccines because of the rise in obesity. A study by Middleman et al (Pediatrics. 2010;125[3]:e508-e512) using 1- or 1.5-inch needles to administer hepatitis B vaccine in the deltoid muscle to obese adolescents showed that the antibody response was almost halved with the shorter needles. Proper needle length is important for an optimum immune response as well as to minimize local adverse reactions. “Use of longer needles has been associated with less redness and swelling than occurs with shorter needles because of injection into deeper muscle mass,” Ms

Weaver said. “Appropriate needle length depends on age and body mass.” Finally, for the 2010-2011 influenza season, recommendations are that the annual vaccine be administered to everyone 6 months of age and older. For certain children 6 months to 8 years (eg, those with unknown vaccination status or those who have never received seasonal flu vaccine, etc), 2 doses are recommended at least 4 weeks apart. Ms Weaver said ACIP recommends that vaccination efforts begin as soon as the current vaccines become available and continue through the influenza season. Ms Weaver’s handout from the conference is available at www.pediatricnurs ing.net/conf/handouts/2010/Session_101_ Weaver.pdf.

“Connect With Each Kid” to Detect Autism Spectrum Disorders Early By Daniel M. Keller, PhD

arly intervention in children with autism spectrum disorders (ASD) can produce long-lasting benefits, so early recognition of problems is critical. The key to recognizing children with ASD is “to embrace development” – to know what are age-appropriate behaviors and developmental milestones and thus be able to recognize a child with potential ASD. Margaret Souders, PhD, CRNP, assistant professor at the University of Pennsylvania School of Nursing and a member of the Clinical Genetics Center at Children’s Hospital of Philadelphia, advised attendees to carefully observe their young patients and to screen them at prescribed intervals. As delineated by the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders IV, text revision), ASD comprises autism disorder, Rett disorder, childhood disintegrative disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise

specified. They all share a triad of core deficits: qualitative impairment in socialization, deficits in communication, and repetitive/stereotypic behavior.

helps to pick up any regression “where you have [skills] but then you actually lose them, and about 30 percent of kids with autism spectrum disorder actually

The key to recognizing children with ASD is “to embrace development” – to know what are ageappropriate behaviors and developmental milestones. Dr Souders said the American Academy of Pediatrics recommends developmental surveillance at every well-child visit, formal screening at 9, 18, and 30 months or whenever there is a concern, and formal autism screening at 18 and 24 months. “Usually by 18 months there can be some classic signs of autism spectrum disorder that you can pick up with a quick screener,” she said. “One of them is the child does not point things out in his environment and brings you into that to share the moment.” The 24-month screening

go through regression,” she explained. A specific screener for use at 18 and 24 months, the Modified Checklist for Autism in Toddlers (M-CHAT), is available free on the Internet. Besides the screeners, Dr Souders urged pediatric practitioners to “really spend time to understand where the child’s developmental level is and to really get good at looking at normal…so that when you may come across a child that has differences it’s easier for you to identify.” She advised them to “emotionally and socially connect with each kid.”

She said that early diagnosis and intensive, tailored programs of speech and occupational, developmental, and physical therapy can produce lasting benefits. One hypothesis is that the interactions help to “shape the brain” by eliciting the production of neurotransmitters. “These interactions create a chemical bath, and this chemical bath then creates connections and dendrites to form in the brain that may not have been there if they didn’t have the intense interventions,” she explained. The idea is that neurons interact to stimulate adjacent neurons “like when you’re in physics lab, if you’re with a partner who knows what to do you tend to know what to do,” Dr Souders said.

Dr Souders’ slides from the meeting can be viewed at www.pediatricnursing. net/conf/handouts/2010/Session_214_Sou ders.pdf. Conference Coverage continued on page 8

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october 2010 I VoL 1, No 1

Conference Coverage

Every Nurse Can Be a Researcher By Daniel M. Keller, PhD

vidence-based practice is a critical component in the delivery of modern high-quality and costeffective nursing care, and every nurse can add to that evidence base by participating in research. Michele Prior, RN, MSN, MSEd, Pediatric Advanced Practice Nurse at Allegheny General Hospital in Pittsburgh, Pennsylvania, showed the audience how any nurse can become a researcher. Nursing research, she said, is valuable because it can lead to evaluating current practice, designing and testing new practices based on evidence rather than tradition, and advancing the practice of nursing. A research project is indicated when there is insufficient or conflicting evidence to make a recommendation for practice, when questions arise from a quality improvement study, or when one considers implementing an evidence-based practice standard with a new patient population. “Librarians should be our best friends when it comes to nursing research…to help us to search for research articles [and] evidence-based practice articles,” Ms Prior said. If no librarian is available, she suggested to “find a friend who’s good on the computer and go for it.” Some good sites are Medline (www.pubmed.gov), Cumulative Index to Nursing and Allied Health Literature (CINAHL; www.cinahl.com), the

Cochrane Collaboration (www.coch rane.org), and Mosby’s Nursing Consult (www.nursingconsult.com). Nurses generally have positive attitudes toward research but may feel they lack the knowledge to use research, interpret studies, or engage in research themselves. However, Ms Prior said a useful research project can be as simple as taking oral temperatures at timed intervals after someone has ingested hot or cold foods or beverages to see when the temperatures return to baseline. A journal club is a good way to become comfortable with research studies and how to analyze them. “It’s probably a beginning way to spark the interest of research,” Ms Prior said, helping

nurses to question their practices and ensure they are evidence-based, as well as demystifying research. A good way to select articles for review is to get ideas from staff on what topics, clinical issues, and components of nursing care could be done better. Pediatric nursing is rich with research opportunities, but ethical considerations are especially important with children. “It is a very fine line between including children in research and excluding them from research,” Ms Prior said. One reason to include them is that the majority of medications used in children have been tested only in adults, and extrapolation may be difficult. But “we don’t want to ever put

children at an unnecessary harm or risk by having them participate in research trials,” she warned. Starting around age 7, most children who are developmentally appropriate should be asked for their assent to participate in research, and they have the right to decline unless an intervention is so important and urgent that it is highly indicated regardless, such as a new chemotherapy regimen for a child with a stage IV cancer. Ms Prior’s slides from the conference are available at www.pediatricnursing.net/conf /handouts/2010/Session_223_Prior.pdf.

Cardiac Nurse Explains the Basics of ECG Evaluation at Pediatric Conference By Daniel M. Keller, PhD

ood clinical skills go a long way in helping the noncardiac nurse or physician assistant evaluate electrocardiogram (ECG) irregularities. Thorough patient assessment is one key to figuring out why a child is having an abnormal rhythm. Amy Jo Lisanti, MSN, RN, CCRN, CCNS, Clinical Nurse Specialist in the Cardiac Intensive Care Unit at the Children’s Hospital of Philadelphia, gave an overview of the anatomy and conduction system of the heart, cardiac cycle, cardiac electrophysiology, and ECG. The rates of normal sinus rhythms vary by age. The fastest rates are for newborns and infants up to age 12 months, at 100 to 180 beats per minute, decreasing with age until age 8, when they are 60 to 110 beats per minute. Knowledge of normal ranges is

october 2010 I VoL 1, No 1

critical for recognizing sinus bradycardia and tachycardia. Ms Lisanti reviewed the elements of a normal ECG tracing, showing the individual waves, PR interval, QRS duration, and ST segment. ECG analysis begins with determining if the rhythm is regular or irregular, identifying the waveforms, determining if there is a P wave before every QRS complex, and looking at the T wave morphology and ST segment. Next, measurements of the PR interval, QRS duration, and QT/QTc intervals should be done. ECG analysis involves the whole patient and even the equipment and not just looking at the tracing. Waveform changes can result from problems in performing the ECG or from true physiologic changes in the patient. ECG artifact can occur if the

patient moves, the electrodes are loose, there is improper grounding, or the monitor is faulty. Patient conditions of hypoxia, cardiac ischemia, cardiac hypertrophy, electrolyte imbalances (eg, potassium, calcium, magnesium) as well as medications or cardiac surgery can all cause ECG changes. Ms Lisanti showed examples of various atrial and ventricular arrhythmias and explained prolonged QT and QTc intervals, which raise the risk of sudden death. Since the QT interval changes with heart rate, QTc, the “corrected” QT interval, is adjusted for the heart rate. She explained that the rate is determined from the R-R interval, the time duration between 2 consecutive R waves in the ECG. Prolonged QT interval is considered a QTc greater than 0.42 seconds in men and

greater than 0.44 seconds in women. She reviewed the most common arrhythmias in children. Bradycardia is commonly related to hypoxia, and asystole can follow if the bradycardia is left untreated. Another common problem of concern is supraventricular tachycardia. However, sinus arrhythmia resulting from changes in vagal tone from inspiration and expiration is benign. Children with congenital heart defects or other chronic illnesses or children taking certain medications may present with various forms of arrhythmia, Ms Lisanti noted. A handout of Ms Lisanti’s presentation is available at www.pediatricnursing.net/conf/ handouts/2010/Session_114_Lisanti.pdf.

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Flap Moves

The Flow-Vu

Inspiratory Flow Indicator • Visual indicator moves when patient inhales, so caregiver can help monitor if the patient is inhaling correctly

Anti-Static Technology

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MEDIUM MASK CHAMBER

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SMALL MASK CHAMBER

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This product is intended to be used by patients who are under the care or treatment of a physician or licensed healthcare professional. The device is intended to be used by these patients to administer aerosolized medication from most pressurized Metered Dose Inhalers. The intended environments for use include the home, hospitals and clinics.

INDICATIONS FOR USE

Shake the MDI immediately before each use as per the instructions supplied with the MDI.

Remove cap from the MDI.

Carefully examine the product for damage, missing parts or foreign objects. Remove any foreign objects prior to use. The product should be replaced IMMEDIATELY if there are any damaged or missing parts. If necessary, use the Metered Dose Inhaler (MDI) alone until a replacement is obtained. If the patient's symptoms worsen, please seek immediate medical attention.

Breathe out gently and depress the MDI at the beginning of a slow inhalation. Use the Flow-Vu® Indicator to assist in the coordination of this maneuver. Maintain seal for 5 – 6 breaths after the MDI is depressed. Administer one (1) puff at a time.

Apply mask to face and ensure an effective seal. The Flow-Vu® Inspiratory Flow Indicator only moves if the patient has a good seal.

Insert the MDI into the backpiece of the chamber.

Cautions: • To ensure proper performance this product should only be cleaned according to these instructions. • Do not leave the chamber unattended with children. • Federal (USA) law restricts the sale of this device on or by the order of a physician.

Medium Mask

Mouthpiece

Large Mask

Shake out excess water from the parts and allow to air dry in a vertical position. Ensure parts are dry before reassembly.

Follow instructions supplied with the MDI on how long to wait before repeating steps 3 – 6 as prescribed.

TIPS

If possible, give treatments when the child is happy and not crying.

Subsidiary of Forest Laboratories, Inc. St. Louis, MO 63045 Monaghan Medical Corporation, 5 Latour Ave., Suite 1600, Plattsburgh, NY 12901

Distributed by:

To reassemble, center the Alignment Feature on the Backpiece with the Flow-Vu® Indicator, as shown. Press firmly to attach the Backpiece.

Use teddy bears or dolls to ‘pretend’ to use the chamber to make it look like a game.

Give praise and rewards.

© 2009 Monaghan Medical Corporation. ™ and ® are trademarks and registered trademarks used under license by Forest Pharmaceuticals, Inc. Printed in USA. Covered by one or more of the following patents # 5,645,049; 5,848,588; 5,988,160; 6,293, 279; 6,345,617; 6;435,177; 6,904,908 and patents pending. RMC 16417 Revision: 01/10

Small Mask

Rinse parts in clean water.

Soak the parts for 15 minutes in a mild solution of liquid dish detergent and lukewarm clean water. Agitate gently.

• Storage and operating range 5° C - 40° C (41° F - 104° F) at 15 to 95% relative humidity. • Product may need to be replaced after 12 months of use. Environmental conditions, storage and proper cleaning can affect product life span. • THIS PRODUCT CONTAINS NO LATEX. • Do not share this medical device. • Clarity of the chamber is a result of the properties of the StatBan ® anti-static material. • If you notice medication build-up in your chamber, wash the inside of the chamber gently with a soft cloth.

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Remove the Backpiece only. Do not tamper with valve during cleaning or disassemble the product beyond what is recommended or damage may result.

THIS PRODUCT CAN BE USED RIGHT OUT OF THE PACKAGE AND THEN CLEANED WEEKLY.

CLEANING INSTRUCTIONS

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78384_L1_107548_r1:Layout 1 7/20/10 12:39 AM Page 2

Primary Care

The Pediatric Medical Home: Pediatric Nurse Practitioner and Physician Assistant Responsibilities and Opportunities Barbara J. Deloian, PhD, RN, CPNP Special Kids, Special Care, LLC

he concepts of the “medical home” and the “patient-centered medical home” will increasingly impact our clinical practice, not only regarding the quality of care we provide but also because of the controversial legislative issues that may impact our scope of practice. As the healthcare practitioners who work with the nation’s most vulnerable population and coordinate continuity between primary and specialty care, nurse practitioners (NPs) and physician assistants

ed the need for training to include interdisciplinary teamwork and family engagement. As a result of these recommendations, 2 early medical home implementation projects – in North Carolina and Hawaii – were initiated between 1978 and 1979.2,3 First, North Carolina introduced the concept of a “health care home” that included individualized primary care services, which were believed to be more cost-effective. This model emphasized health prevention and promotion

The AAP defines the medical home approach as being accessible, continuous, comprehensive, family centered, coordinated, and compassionate, and developed under the direction of a physician well trained in pediatrics.

(PAs) have been instrumental in providing access to high-quality and coordinated pediatric primary healthcare for years. The medical home concept has evolved as a strategy to improve this access through an ongoing providerpatient relationship and a “whole person” approach that is appropriately reimbursed.1 This article will provide background information on the medical home concept, from its inception to current issues, and will discuss opportunities for NPs and PAs to act as leaders, both in their current practices as well as in innovations to improve the quality of pediatric primary and specialty care. Initial Health/Medical Home Projects The medical home concept has had a long history. In 1967, the American Academy of Pediatrics (AAP) Council on Pediatric Practice (COPP) published its Standards of Child Health Care, which recommended that a child's medical records be centralized for children with special health care needs (CSHCN). The AAP COPP felt that this would enhance the quality of care for CSHCN, since they frequently have numerous providers who work independent of each other, resulting in gaps and duplication of services. In addition, because there is often a lack of coordinated communication among CSHCN providers, the AAP COPP recommend-

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as well as the need for collaboration between both public and private partners. Although the model was never implemented because it did not receive legislative approval, the concept of a medical home became more than a repository for a child’s medical records; instead, it became associated with quality pediatric care addressing the “total child and family relationship in health, education, family support, and social environment.”4 At the same time, Hawaii developed an approach to pediatric care proposing that “every child deserves a medical home,” not just those with special needs. The medical home model was defined as being family centered; community based (financially accessible and available); continuous, comprehensive, and coordinated; and integrated with related community services. Coordinated efforts involved home-visiting programs, early intervention services, child abuse programs, and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) under Medicaid. Public health nursing played a significant role in this system of care.4 The success of this model led to the evolution of the medical home concept known today. National Center for Medical Home Implementation In 1992, the AAP published the first policy statement to define (in terms sim-

ilar to those used in the Hawaii model) the medical home approach as being accessible, continuous, comprehensive, family centered, coordinated, and compassionate, and delivered under the direction of a physician well trained in pediatrics.2,5,6 Also at this time, the Maternal and Child Health Bureau (MCHB) Title V adopted the medical home concept for CSHCN and in 1999 provided the AAP with a 5-year cooperative agreement to develop the National Center of Medical Home Initiatives for

Children With Special Needs (“National Center”), whose purpose was to support pediatricians, family members, and other medical and nonmedical providers who care for CSHCN.6 In 2002, the AAP published the Medical Home Policy Statement and defined the original 6 medical home components, with the addition of cultural effectiveness; 37 operational activities were also described as needed within a medical home.6 The National Center partnered Continued on page 10

Table 1. Medical Home Index Domains for CSHCN and Their Families Domains

Indicator Themes

1. Organizational capacity

• Mission of the practice • Communication/access • Access to medical records • Office environment • Family feedback • Cultural competence • Staff education

2. Chronic condition management

• Identification of CSHCN in the practice • Care continuity • Continuity across settings • Cooperative management between primary care provider (PCP) and specialist • Supporting the transition to adulthood (revised August 2006) • Family support

3. Care coordination

• Care coordination/role definition • Family involvement • Child and family education • Assessment of needs/plans for care • Resource information and referrals • Advocacy

4. Community outreach

• Assessment of needs for CSHCN • Outreach to agencies and schools

5. Data management

• Electronic data support • Data retrieval capacity

6. Quality improvement/change

• Quality standards (structures) • Quality activities (process)

Adapted from CMHI: Center for Medical Home Improvement. The medical home index: pediatric. http://www.medicalhomeimprovement.org/pdf/CMHI-MHI-Pediatric_FullVersion.pdf. Revised 2006. Accessed August 24, 2010.9

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Primary Care The Pediatric Medical Home...continued from page 9 Table 2. Measurement Tools for Evaluating the Medical Home • Consumer Assessment of Healthcare Providers and Systems (CAHPS) Child Primary Care Questionnaire 2.0 (beta) • Components of Primary Care Instrument (CPCI) • Family-Centered Care Self-Assessment Tool • Medical Home Index (MHI) and Medical Home Family Index (MHFI) • Medical Home Implementation Quotient (MHIQ) • Measure of Processes of Care (MPOC) • Primary Care Assessment Survey (PCAS) • Primary Care Assessment Tools (PCAT) • Promoting Healthy Development Survey (PHDS) • Physician Practice Connections® – Patient-Centered Medical Home™ (PPC®-PCMH™) • Parent’s Perceptions of Primary Care (P3C) • Young Adult Health Care Survey (YAHCS) Adapted from Malouin RA, Merten SL. Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and Family-Centered Medical Home. Elk Grove Village, IL: AAP/NCMHI; 2010. http://www.medicalhomeinfo.org. Accessed August 24, 2010.10

with numerous organizations, including Family Voices, MCHB, children’s hospitals, national and local public health organizations, and the AAP, to develop the first CSHCN national survey database on medical home components. Early survey data demonstrated that CSHCN without a medical home were more likely to have delayed healthcare and unmet health needs compared with those with access to medical home components.7,8 Thus, it was neither the person who provided care nor the place of care, but rather the medical home approach to care itself, that mattered most. The National Center also introduced the Medical Home Index (MHI), which encouraged pediatric providers to evaluate practice changes that would achieve a medical home approach for the care of CSHCN.9 The MHI included 6 domains for potential practice changes (Table 1),9 and since then, numerous other medical home measurement tools have been developed (Table 2).10 Evolution of the Patient-Centered Primary Care Collaborative Between 1990 and 2001, the Institute

Table 3. PPC®-PCMH™ Standards and Practice Expectations Standards

Practice Expectations

1. Access and communication

Addresses patient access and communication and uses data to show that standard has been met

2. Patient tracking and registry functions

Includes a patient information data system (both clinical and nonclinical), as well as paper or electronic charting to identify diagnoses and types of conditions within the practice in order to track patient follow-up reminders and needed services

3. Care management

Utilizes evidence-based guidelines for a minimum of conditions and uses reminders to follow up with preventive services through nonphysician staff, care conferences, and care plans for both inpatient and outpatient facilities

4. Patient self-management support

Addresses barriers to communication (including language barriers) and actively supports patient self-management

5. Electronic prescribing

Utilizes electronic systems for prescriptions, including safety and cost checks

6. Test tracking

Uses system to track tests and abnormal results, order and retrieve tests, and flag duplicate tests

7. Referral tracking

Uses paper or electronic referral-tracking system

8. Performance reporting and improvement

Utilizes system to measure clinical performance across the practice or by provider and set goals for improvement

9. Advanced electronic communications

Provides access to interactive Web site for patient identification and care management support

Abbreviation: PPC®-PCMH™ indicates Physician Practice Connections® – Patient-Centered Medical Home™. Adapted from National Committee for Quality Assurance. PPC-PCMH content and scoring. NCQA Web site. http://www.idph.state.ia.us/hcr_committees/common/pdf/medical_home/090209_scoring_sheet.pdf. Accessed August 10, 2010.13

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of Medicine placed an increased emphasis on primary care and the concept of the medical home. Thus, although the medical home concept began with an emphasis on children, especially CSHCN, family medicine began to use the term medical home as a model for primary care. This model furthered their efforts to renew the practice of family medicine through “The Future of Family Medicine: A Collaborative Project of the Family Medicine Community,” which stressed that all individuals, regardless of age, race, sex, or socioeconomic status, should receive acute, chronic, and preventive medical services through a personal medical home.11 In addition, the American Academy of Family Physicians (AAFP) described how the Wagner Chronic Care Model, which was used to improve the quality and cost-effectiveness of care of patients with chronic illnesses, might also apply to models of primary care. By 2007, multiple physician groups had endorsed the Joint Principles of the PatientCentered Medical Home (PCMH), which included a personal physician, physician-directed medical care, whole person orientation, coordination of care, quality and safety of care, access, and appropriate payment, to document the value of primary care.11,12 In 2006, the Patient-Centered Primary Care Collaborative (PC-PCC) was formed, representing not only physician groups but also many insurance providers. In collaboration with the National Committee for Quality Assurance (NCQA), 9 standards were adopted to evaluate and certify practices as medical homes (Table 3).13 Scope of Practice Partnership and Coalition for Patient Rights As the value of primary care and the medical home has been accepted and integrated into legislation, 2 different coalitions have formed. In 2005 the American Medical Association (AMA) convened the Scope of Practice Partnership (SOPP) coalition with various physician organizations to track through a geomapping project the scope of state practice legislation and regulations as well as education for nonphysician healthcare providers.14,15 This project focused on select healthcare providers using information from the state licensing boards, but it was undertaken without collaboration from the respective health disciplines. As a result, the Coalition for Patients’ Rights (CPR) was formed to address concerns about the potential efforts to limit the legal authority of qualified healthcare providers, other than physicians, under the guise of healthcare quality and safety.

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Primary Care

The CPR – comprised of a diverse group of healthcare professionals, including registered nurses, naturopathic doctors, psychologists, audiologists, physical and occupational therapists, advanced practice registered nurses (certified registered nurse anesthetists,

cate for their patients and promote their roles in the implementation of medical home initiatives. Some examples of how to creatively work together to implement the medical home concepts might include: • Finding ways to bring the medical

In order to determine their own future, NPs and PAs must reestablish their roles in primary care and articulate what their individual primary care responsibilities include and how they can improve them. nurse practitioners, certified nurse-midwives, and clinical nurse specialists), optometrists, and chiropractors – has also encouraged provider-inclusive language in legislation related to medical home demonstration projects.15 Unfortunately, the medical home concept – initially developed with the promise of enhancing primary care services, improving coordination and continuity of care, promoting public and private partnerships, enabling interdisciplinary team collaboration, and initiating cross-disciplinary training – has begun to show the strains of interdisciplinary conflict and competition for control by individual discipline providers under the name of quality and patient safety. Nurse Practitioner and Physician Assistant Responsibilities and Opportunities NP and PA practice was founded on primary care principles and values, especially for children. To date, providing health and developmental screening, anticipatory guidance, and coordination of care across disciplines has been fundamental to our practice because of the cost-effectiveness of NPs and PAs. Today, both the trend toward shorter primary care visits due to low reimbursement, as well as the recognition that primary care has value in health promotion and disease prevention for adults as well as children, have changed the implementation of primary care. Because of this, the practice of NPs and PAs has instead shifted to acute care and care of minor acute illnesses rather than primary care. In order to determine their own future, NPs and PAs must reestablish their roles in primary care and articulate what their individual primary care responsibilities include and how they can improve them. They must also become knowledgeable and proactive partners in medical home implementation strategies and the legislative process. Table 4 lists the many different ways NPs and PAs can advo-

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home model to child care centers, homeless shelters, and foster care programs • Involving and educating families and supporting their roles and responsibilities in the medical home model • Working to bring the medical home model to rural sites and federally qualified health centers, even when there is no physician on site In conclusion, NPs are nurses first, and we should maintain our collaborative relationships with school nurses, nurses in early intervention, and nurses working with the foster care system. Ultimately, NPs and PAs have the knowledge, the skills, and the foresight to implement the concepts of a medical home, not only in the private office setting, but also in the multitude of nontraditional practice sites that we encounter daily in our profession. References 1. Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home. PCPCC Web site. http://www.pcpcc. net/content/jointprinciples-patient-centered-medical-home. February 2007. Accessed August 3, 2010. 2. American Academy of Pediatrics. Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110(1 pt 1):184-186. 3. American Academy of Pediatrics, Council on Pediatric Practice. Pediatric records and a “medical home.” In: Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967:77-79. 4. Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics. 2004;113(5 suppl):1473-1478. 5. American Academy of Pediatrics, Ad Hoc Task Force on the Definition of the Medical Home. The medical home. Pediatrics. 1992;90(5):774. 6. National Center for Medical Home Implementation. Overview: goals. NCMHI Web site. http://www.medicalhomeinfo.org/about/. Accessed August 15, 2010. 7. US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children With Special Health Care Needs: Chartbook 2005-2006. Rockville, MD: USHHS; 2008. http://mchb. hrsa.gov/cshcn05/. Accessed August 15, 2010. 8. American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Policy statement: organizational principles to guide and define the child health care system and/or improve the health of all children—the medical home. Pediatrics. 2004;113(5):1545-1548. 9. Center for Medical Home Improvement (CMHI). The medical home index: pediatric—measuring the organization and delivery of pediatric primary care for all children, youth and families. http://www.medicalhome

Table 4. NP/PA Responsibilities and Opportunities Within Medical Home Implementation Advocacy • Support your local as well as professional organizations • Become informed about the medical home and patient-centered medical home activities at both the state and national level • Educate your state and national legislators regarding medical home issues and how your role addresses the issues around access to care, especially for vulnerable and at-risk populations, through quality primary as well as specialty care based on the components of a medical home • Become familiar with the health disparities in your own state and what is being done to address barriers to care and gaps in services Quality Improvement • Explore the medical home measurement tools and identify a quality improvement project for your practice • Survey the families utilizing your practice to learn what they appreciate in the practice and what they might like to see changed • Engage in new strategies to promote positive behavior changes, such as motivational interviewing, coaching, or SAM (Stop, Assess, and Motivate) • Implement standardized developmental screening tools if not already in use • Review the Bright Futures Guidelines and identify a new one to implement (see http://www.brightfutures.org/) Family Engagement • Encourage interested parents to pursue family leadership opportunities so that they can advocate for children in the community. For example, the Colorado Family Leadership Institute (http://cokidswithbrainin jury.com/blog/wp-content/uploads/2009/11/FLTI-Brochure_2010Sites.pdf) and the Connecticut Parent Leadership Institute (http://www.cga.ct.gov/coc/plti_about.htm) Coordination of Care • Connect with Part C early intervention, public health nursing, and your Title V program, EPSDT outreach, school nurses, and other community resources to keep informed about their services and provide the resources needed by the families in your practice • Communicate with specialty providers to learn what information they need prior to referrals and the most efficient way for them to communicate back to you (fax, phone, e-mail) regarding the results of the referral improvement.org/pdf/CMHI-MHI-Pediatric_FullVersion.pdf. Accessed August 24, 2010. 10. Malouin RA, Merten SL. Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and FamilyCentered Medical Home. Elk Grove Village, IL: AAP/NCMHI; 2010. 11. Robert Graham Center. The Patient Centered Medical Home: History, Seven Core Features, Evidence, and Transformational Change. Washington, DC: Robert Graham Center; 2007. http://www.graham-center.org. Accessed May 23, 2010. 12. Patient-Centered Primary Care Collaborative. Patient-Centered Medical Home: Building Evidence and Momentum—a compilation of PCMH pilot and demonstration projects. Washington, DC: PC-PCC; 2008. http://www.pcpcc.net. Accessed May 23, 2010.

13. National Committee for Quality Assurance. PPCPCMH content and scoring. NCQA Web site. http://www.idph.state.ia.us/hcr_committees/common/ pdf/medical_home/090209_scoring_sheet.pdf. Accessed August 10, 2010. 14. American Medical Association House of Delegates. Resolution 814: Limited Licensure Health Care Provider Training and Certification Standards. September 2005. http://www.aaom.info/ama814.pdf. Accessed August 26, 2010. 15. Lindeke LL, KellyThomas K. The SOPP and the Coalition for Patients’ Rights: implications of continuing interprofessional tension for PNPs. J Pediatr Health Care. 2010;24(1):62-65.

october 2010 I VoL 1, No 1

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CONTINUING EDUCATION RELEASE DATE: OCTOBER 1, 2010. EXPIRATION DATE: OCTOBER 1, 2011. ESTIMATED TIME TO COMPLETE: 1.0 HOUR

Pulmonary Hypertension in Infants and Children: Pathophysiology and Diagnostic Workup Deborah Walter, BSN, MSN, ACNP, Cardiology/Cardiac Surgery Nurse Practitioner Heart Institute, Rady Children’s Hospital, San Diego, California

ulmonary arterial hypertension (PAH) in infants and children can be a significant contributor to mortality and morbidity in many different pediatric cardiac, pulmonary, hematologic, rheumatologic, and other diseases. This is the first of a 2-part article discussing pulmonary hypertension (PH) in infants and children. In this first Deborah Walter, BSN, part, we will MSN, ACNP focus on the definition, pathophysiology, incidence, and diagnostic workup of PH. PAH is defined1,2 by a mean pulmonary artery pressure >25 mm Hg at rest, a pulmonary arterial wedge pressure ≤15 mm Hg, and an increased pulmonary vascular resistance (PVR) of

>3 Woods units m2. Long-term survival of children diagnosed with idiopathic pulmonary arterial hypertension (IPAH) has been dismal, with an estimated median survival of 10 months.3,4 In a 1965 series of 35 patients with IPAH, 22 died within 1 year of symptom onset

vascular narrowing caused by increased tone, structural remodeling of the vessel wall, obstruction of the vessel lumen, and decreased vascular growth and surface area.6 Reactivity of the pulmonary vascular bed is maintained by a complex interaction of synthesis and/or

Pulmonary arterial hypertension in infants and children can be a significant contributor to mortality and morbidity in many pediatric diseases.

and the remaining within 7 years. In 1995 the prognosis still remained poor, with a median survival of 4.12 years in a series of 18 patients with IPAH.5 Pathophysiology PAH is a disease of the small pulmonary arteries. It is characterized by

CONTINUING MEDICAL EDUCATION ACCREDITATION AND DESIGNATION OF CREDIT STATEMENT LEARNING OBJECTIVES

Upon completion of this activity, participants should be able to: • Define the pathophysiology of pulmonary arterial hypertension • Describe the clinical classification model for pulmonary hypertension • Summarize the recommended diagnostic workup for patients the pulmonary hypertension TARGET AUDIENCE

Advanced practice nurses, registered nurses, and other interested healthcare professionals, especially those caring for pediatric cardiac patients. FACULTY

Deborah Walter, MSN, BSN, ACNP Cardiology/Cardiac Surgery Nurse Practitioner Heart Institute Rady Children’s Hospital San Diego, CA

activation of some vasoactive hormones and inactivation of others. In the normal and pathologic state, the balance among these substances influences the vascular tone and reactivity. The balance between nitric oxide (NO, a vasodilator), prostacyclin (a vasodilator), and endothelin (a vasoconstrictor)

is an important factor in this regulation. If the production of these vasoactive mediators is impaired, over time this can adversely affect vascular tone and cause vascular remodeling. The primary vascular changes seen are vasoconstriction, smooth muscle and endothelial cell proliferation, and thrombosis. Development of medial hypertrophy of the arterioles can lead to pulmonary arterial muscularization resulting in decreased vessel size, eventually leading to loss of small pulmonary arterioles. Studies of the histopathology of the pulmonary vessels have revealed medial hypertrophy, intimal proliferation and fibrosis, and thrombosis, which can be unevenly distributed throughout the lung.7 Alveolar oxygen tension is reduced with vasoconstriction, resulting in alveolar hypoxia. Hypoxia and acidosis work together synergistically. PVR is significantly increased when acidosis is present. An increase in pulmonary blood flow and/or PVR can

to disclose to the audience any relevant financial relationships with any commercial interest. Science Care must determine if the faculty’s relationships may influence the educational content with regard to exposition or conclusion and resolve any conflicts of interest prior to the commencement of the educational activity. Disclosures are as follows: • Deborah Walter, MSN, BSN, ACNP, has nothing to disclose PLANNER DISCLOSURES

No other planners or staff in the position to influence the content of this activity has any relationships with relevant commercial interests to disclose. CONTINUING NURSE EDUCATION ACCREDITATION AND CONTACT HOURS STATEMENT

Science Care is approved by the California Board of Registered Nursing as a provider of continuing nursing education, Provider number 15559. This program is acceptable for 1.0 contact hour. COMMERCIAL SUPPORT

This CE activity is not funded by any commercial supporters. PROGRAM FORMAT

Learners will participate in this educational activity by reading through article, answering multiple choice questions on the posttest, and completing the evaluation. There is no fee to participate in this CE activity. After reading the article, please log on to www.pediatricNPPA.com/pulmonary-hyperten sion-infants-children and click on “Click here to complete the posttest and obtain a CE certificate online.”

UNLABELED OR UNAPPROVED USE OF DRUGS OR DEVICES

SCIENCE CARE DISCLOSURE POLICY

DISCLAIMER

As a provider accredited by the California Board of Registered Nursing, Science Care must ensure balance, independence, objectivity, and scientific rigor in all its activities. All course directors, faculty, planners, and any other individual in a position to control the content of this educational activity are required

The opinions and recommendations expressed by faculty, authors and other experts whose input is included in this program are their own and do not necessarily represent the viewpoint of Science Care or Novellus Healthcare Communications, LLC. Copyright © 2010 by Science Care.

october 2010 I VoL 1, No 1

It is the policy of Science Care to require the disclosure of all references to unlabeled or unapproved uses of drugs or devices prior to the presentation of educational content. The audience is advised that this CE activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. Please consult the prescribing information for full disclosure of approved uses.

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CONTINUING EDUCATION cause pulmonary hypertension (PH). The right ventricle (RV) is normally a thin-walled structure. It is not capable of sustaining good function in the face of a rapid increase in PA pressures of greater that 40 to 50 mm Hg. This can result in sudden right heart failure. However, when PA pressures rise gradually, the RV will hypertrophy, and it can tolerate higher pressures, sometime systemic to suprasystemic levels for a longer period of time.8 Classification and Etiology A system of classifying PH was initially proposed at an international conference on primary pulmonary hypertension (now referred to as IPAH). It was endorsed by the World Health Organization (WHO) in 1973. Subsequent meetings in France in 1998 (Evian Classification), Venice in 2003, and Dana Point, California, in 2008 (see Table) have served to modify the classification to reflect current research and knowledge regarding etiology of PH.9 Incidence The incidence of PH in adults and children is not well known. It is estimated that the incidence of IPAH ranges from 1 to 2 new cases per million people in the general population.10

thrive, irritability, and syncope. Signs and symptoms seen in older children include dyspnea, chest pain, shortness of breath, decreased exercise tolerance, and syncope. While a complete physical examination of all systems should be done, there are key areas that should be focused on. Assessment of the heart should include palpation and auscultation. Palpation would demonstrate the presence of a right ventricular heave. Auscultation of the heart will demonstrate a loud second heart sound, murmur of tricuspid regurgitation, and pulmonary insufficiency. The presence of jugular vein distention should be assessed. Signs of right heart failure would include hepatosplenomegaly, a gallop rhythm, and peripheral edema. Vital signs including oxygen saturations should be assessed. Diagnostic Workup The diagnostic workup for PH is extensive and includes both imaging studies and blood work.11 A chest radiograph would demonstrate the presence of cardiomegaly and enlarged pulmonary arteries (Figure 1). A 12-lead EKG would demonstrate RV hypertrophy and/or ST-T wave changes (Figure 2). An echocardiogram would show the presence of RV hypertrophy, exclude

Quality of life, exercise capacity, hemodynamics, and survival have improved due to technological advances that allow for earlier diagnosis, a more definitive determination of severity, and more therapeutic options. Children with PH usually present with very nonspecific symptoms and subtle physical examination findings. In many instances, this allows the disease to go undetected or misdiagnosed. Quality of life, exercise capacity, hemodynamics, and survival have improved due to technological advances that allow for earlier diagnosis, a more definitive determination of severity, and more therapeutic options. Treating the underlying cause of PH is the most successful strategy. Performing a thorough history looking for any of the known causes of PH and a complete physical examination is very important to the diagnostic workup.11 A thorough history should include the following: a family history of PH, drug use (diet pills, contraceptives, and methamphetamines), prior cardiac or other surgeries, complete review of systems, noisy breathing or snoring at night, and residence at high altitude. Signs and symptoms exhibited by infants are poor feeding, tachypnea, cyanotic (â&#x20AC;&#x153;blueâ&#x20AC;?) spells, failure to

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congenital heart disease, and could quantify RV systolic pressure. The presence of pulmonary disease should be evaluated. This would include tests of the diffusing capacity of the lungs for carbon monoxide (DLCO) and/or bronchodilators to exclude obstructive/restrictive disease (if child is old enough); sleep study and pulse oximetry to evaluate the degree of hypoxemia or diminished ventilatory drive; CT or MRI scan of the chest to evaluate for thromboembolic or interstitial lung disease; ventilation-perfusion scan to look for evidence of thromboembolic disease and the presence of ventilation-perfusion defects; and a lung biopsy to define the histopathology of the lung tissue. The hypercoagulable evaluation includes the following blood work: disseminated intravascular coagulation (DIC) screen, factor V Leiden, antithrombin III, prothrombin mutation 22010, protein C and protein S, anticardiolipin IgG/IgM, and Russell's viper venom test.

An evaluation of the liver would include liver function tests, abdominal ultrasound (portopulmonary hypertension), and hepatitis panel. Testing for collagen vascular disease (for autoimmune disease) would include antinuclear antibody profile (DNA, Smith,

RNP, SSA, SSB, centromere, SCL-70), rheumatoid factor, erythrocyte sedimentation rate, and complement. Additional miscellaneous tests include HIV, thyroid function, and toxicology screen for cocaine and methamphetamines. Continued on page 16

Table. Updated Clinical Classification of Pulmonary Hypertension (Dana Point, 2008) 1. Pulmonary arterial hypertension (PAH) 1. Idiopathic PAH 2. Heritable 1.2.1 BMPR2 1.2.2 ALK1, endoglin (with or without hereditary hemorrhagic hemangiomatosis) 1.2.3 Unknown 3. Drug and toxin induced 4. Associated with 1.4.1 Connective tissue disease 1.4.2 HIV (human immunodeficiency virus) infection 1.4.3 Portal hypertension 1.4.4 Congenital heart disease 1.4.5 Schistosomiasis 1.4.6 Chronic hemolytic anemia 5. Persistent pulmonary hypertension of the newborn 6. Pulmonary veno-occlusive disease (PVOD) and/or pulmonary capillary hemangiomatosis (PCH) 2. Pulmonary hypertension due to left heart disease 1. Systolic dysfunction 2. Diastolic dysfunction 3. Valvular disease 3. Pulmonary hypertension due to lung disease and/or hypoxia 1. Chronic obstructive pulmonary disease 2. Interstitial lung disease 3. Other pulmonary diseases w/mixed restrictive and obstructive pattern 4. Sleep-disordered breathing 5. Alveolar hypoventilation disorders 6. Chronic exposure to high altitude 7. Developmental abnormalities 4. Chronic thromboembolic pulmonary hypertension (CTEPH) 5. Pulmonary hypertension with unclear multifactorial mechanisms 1. Hematologic disorders: myeloproliferative disorders, splenectomy 2. Systemic disorders: sarcoidosis, pulmonary Langerhans cell histiocytosis, lymphangioleiomyomatosis, neurofibromatosis, vasculitis 3. Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid disorders 4. Others: tumoral obstruction, fibrosing mediastinitis, chronic renal failure on dialysis Reprinted from Journal of the American College of Cardiology, vol. 54/Supplement. Simonneau G, Robbins IM, Beghetti M, et al. Updated clinical classification of pulmonary hypertension. S43-S54. Copyright 2009, with permission from Elsevier.9

october 2010 I VoL 1, No 1

CONTINUING EDUCATION Continued from page 15

Figure 1. Chest x-ray of patient with PH. Typical findings of cardiomegaly, prominent right heart, and pulmonary artery.

Figure 3. Cardiac angiography of PH patient with distal pulmonary artery pruning from loss of small arterioles.

Figure 2. EKG showing right ventricular hypertrophy (RVH) demonstrated by right axis deviation (predominant negative QRS in leads I and aVL) of QRS complex and qR pattern in V1. Sharp P waves in inferior leads and V1 indicate right atrial overload. T wave inversion in the inferior and anterior leads are secondary to RVH.

The gold standard for diagnosing PH is cardiac catheterization.12,13 A complete study would include defining the anatomy; measuring pressures and oxygen saturation throughout the heart, pulmonary arteries, and pulmonary veins; calculating shunts and PVR; and performing angiography to look for loss of (pruning) small pulmonary blood vessels (Figure 3). It is important to determine vasoreactivity of the pulmonary vascular bed for making decisions regarding therapeutic management. The consensus definition of a favorable response is a fall in pulmonary arterial mean pressure

(PAPm) of â&#x2030;Ľ10 mm Hg to reach a PAPm of <40 mm Hg.13 Pulmonary hypertension in children is a complex disease that can be secondary to pathologic conditions related to the cardiac, pulmonary, hepatic, hematologic, and rheumatologic organ systems. It can also be the primary disease, referred to as idiopathic. Idiopathic PH is a disease of exclusion: a complete workup has eliminated any other cause. A thorough history and physical are imperative in determining the path for the diagnostic workup. A complete diagnostic workup will pro-

vide important information for making decisions regarding the therapeutic management of these patients. These patients can be quite complex, and if pulmonary hypertension is suspected, they should be referred to a pulmonary hypertension center. In part 2 of this article, we will discuss the current treatment options available and options still in the research phase. References 1. Badesch D, Champion HC, Gomez Sanchez MA, et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54(1 suppl):S55-S66. 2. Ivy DD, Feinstein JA, Humpl T, et al. Non-congenital heart disease associated pediatric pulmonary hypertension. Prog Pediatr Cardiol. 2009;27:13-23. 3. Dâ&#x20AC;&#x2122;Alonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary hypertension: results from a national prospective registry. Ann Intern Med. 1991;115:343-349. 4. McLaughlin VV, Shillington A, Rich S. Survival in primary pulmonary hypertension: the impact of epoprostenol therapy. Circulation. 2002;106:1477-1482. 5. Rashid A, Ivy D. Severe paediatric pulmonary hypertension: new management strategies. Arch Dis Child. 2005;90:92-9098.

6. Abman SH. Pulmonary hypertension in children: a historical overview. Pediatr Crit Care Med. 2010;11(2 suppl):S4-S9. 7. Pietra GG, Edwards WD, Kay JM, et al. Histopathology of primary pulmonary hypertension: a qualitative and quantitative study of pulmonary blood vessels from 58 patients in the National Heart, Lung, and Blood Institute, Primary Pulmonary Hypertension Registry. Circulation. 1989;80:1198-1206. 8. Bronicki RA, Baden HP. Pathophysiology of right ventricular failure in pulmonary hypertension. Pediatr Crit Care Med. 2010;11(2 suppl):S15-S22. 9. Simonneau G, Robbins IM, Beghetti M, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2009;54(1 suppl):S43-S54. 10. Rosenzweig EB, Widlitz AC, Barst RJ. Pulmonary arterial hypertension in children. Pediatr Pulmonol. 2004;38:2-22. 11. Rosenzweig EB, Feinstein JA, Humpl T, et al. Pulmonary arterial hypertension in children: diagnostic workup and challenges. Prog Pediatr Cardiol. 2009;27:711. 12. Giglia TM, Humpl T. Preoperative pulmonary hemodynamics and assessment of operability: is there a pulmonary vascular resistance that precludes cardiac operation? Pediatr Crit Care Med. 2010;11(2 suppl): S57-S69. 13. Mullen MP. Diagnostic strategies for acute presentation of pulmonary hypertension in children: particular focus on use of echocardiography, cardiac catheterization, magnetic resonance imaging, chest computed tomography, and lung biopsy. Pediatr Crit Care Med. 2010;11(2 suppl):S23-S26.

Pediatric NP/PA will present part 2 of this CE activity in the December issue.

october 2010 I VoL 1, No 1

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Dermatology

Childhood Eczema: The Most Common Chronic Skin Disorder Rosemary Hansen

czema is a skin disorder that includes several types of inflammatory conditions, including atopic dermatitis, the most common form of eczema seen in children. Among infants and children, the growing prevalence of atopic dermatitis has reached 15% to 20%.1 Although the cause of the disorder remains unknown, genetic predisposition plays a significant role, and children of parents who have had eczema, asthma, or other allergies are more likely to develop atopic dermatitis. It is known that environmental factors and emotional stress can often trigger a flare-up of symptoms, and research is being done into the autoimmune aspects of the disease.2 As explained by Noreen Nicol, NP, chief clinical officer and chief nursing officer at National Jewish Medical and Research Center in Denver, Colorado, “Atopic dermatitis is associated with a

is multifaceted and requires a team approach that includes healthcare professionals, the family, and in the case of older children, the patient. Although the condition cannot be cured, it can be treated and usually controlled when parents understand the chronic nature of atopic dermatitis, its frequent relapses, and the need for individualized skincare plans. Moisturizers are generally the basis of all treatment regimens, and cream or ointment formulations are recommended rather than lotions.4 The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) provides a list of tips for parents that includes giving lukewarm baths followed immediately by application of a moisturizer, use of clothing made of soft cotton fabric, and the removal of known allergens and environmental factors that trigger flares.2 Avoiding woolen fabrics, harsh soaps,

Treating atopic dermatitis in children is multifaceted and requires a team approach that includes healthcare professionals, the family, and in the case of older children, the patient.

marked decrease in skin barrier function due to the downregulation of cornified envelope genes (filaggrin and loricrin), reduced ceramide levels, increased levels of endogenous proteolytic enzymes, and enhanced transepidermal water loss.”3 Appearing between 2 and 3 months of age, the first symptom of atopic dermatitis is usually a rash on the cheeks and scalp that later develops around the ears and on the wrists, arms, and legs. This rash presents with itchy, scaly, red patches, and in severe cases, with weeping and crusting as the itch-scratch-itch cycle develops. Pruritus may cause infants as young as 3 months to rub against surfaces such as bed clothes as a substitute for scratching.1 After age 2 years, the creases of the elbows and knees are the primary sites of the rash, which is also commonly seen on the neck, wrists, and ankles, and in the creases between the thighs and buttocks. Additionally, thickening of the skin may become evident, and perifollicular accentuation may result in skin that appears to have goose bumps, especially in children with darker skin.1 Treating atopic dermatitis in children

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rapid temperature changes, sweating, and stress is also recommended.5 Medical treatment may include topical corticosteroids, oral cyclosporine, or topical calcineurin inhibitors. A relatively newer treatment for atopic dermatitis, the calcineurin inhibitors tacrolimus and pimecrolimus act as immunomodulators and inhibit the skin’s inflammatory response.6 These agents had been approved by the FDA, but in 2006 they were required to include black box warnings regarding rare cases of skin and lymphoma malignancies. They are indicated as secondline therapy and are not indicated for treatment in children younger than 2 years or for long-term treatment in any age group. It should be noted that some studies of calcineurin inhibitors that included children as young as 3 months showed clinical benefit with excellent tolerance.1 Other medications may include antibiotics to treat infections that occur as a result of scratching and an oral antihistamine to be taken at bedtime to lessen nighttime itching, induce drowsiness, and promote more restful sleep.5 Parents of a child with atopic der-

Using moisturizer after a lukewarm bath can help to soothe a child with eczema.

matitis need to be diligent in identifying and avoiding as much as possible the triggers known to cause flares in their child. Treatment plans should be a joint effort, and parents and the healthcare team should be aware of the impact this condition can have on the quality of life of the patient and the family. Although it can be a warning sign for other allergic conditions and asthma, most children do outgrow atopic dermatitis. Excellent sources of information and treatment regarding atopic dermatitis are provided by the National Jewish Medical and Research Center in Denver, Colorado, and the Rady Eczema Center, Rady Children’s Hospital, San Diego, California, and Tips to Share With Parents of a Child With Eczema

Follow a lukewarm bath with moisturizer Dress child in soft cotton clothing (avoid woolen fabrics)

numerous Web sites, including those of NIAMS, www.niams.nih.gov; the National Eczema Organization, www.nationaleczema.org; and the American Academy of Dermatology, http://www.aad.org. References 1. Rady Children’s Hospital: The Eczema Center. http: //www.eczemacenter.org/eczema_center/index.htm. Accessed September 13, 2010. 2. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Atopic dermatitis. NIAMS Web site. http://www.niams.nih.gov/Health _Info/Atopic_Dermatitis/default.asp#d. Published May 2009. Accessed September 13, 2010. 3. Lebo S. Atopic dermatitis often precedes asthma. ADVANCE for NPs & PAs Web site. http://nurse-practitioners-and-physician-assistants.advanceweb.com/ Editorial/Content/Editorial.aspx?CC=89102. Updated May 16, 2007. Accessed September 13, 2010. 4. Sorhaindo L, Rossi A, Alexis A, et al. Atopic dermatitis: what’s new, what’s not. Expert Rev Dermatol. 2010;5(3):259-267. http://www.medscape.com/view article/723232_7. Accessed September 13, 2010. 5. Atopic dermatitis (eczema): lifestyle and home remedies. Mayo Clinic Web site. http://www.mayoclinic .com/health/eczema/DS00986/DSECTION=lifestyleand-home-remedies. Published August 22, 2009. Accessed September 13, 2010. 6. Atopic dermatitis in children. National Eczema Association Web site. http://www.nationaleczema.org /living/atopic_dermatitis_in_children.htm. Updated April 3, 2009. Accessed September 13, 2010.

Remove known allergens from home Do not use harsh soaps or detergents Avoid rapid temperature changes If possible, avoid perspiration Promote a stress-free environment for your child

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Vaccines H1N1 in Children...continued from cover were children younger than with H1N1 who required 18 years.4 admission to intensive care Unlike the seasonal flu units in the United that often turns well kids Kingdom revealed that 8 into very sick kids, H1N1 children presented in shock. seems to target chronically Four of these 8 children ill children and turns them suffered a type of cateinto much, much sicker cholamine-resistant and ones. In 2009, about twosteroid-resistant shock that thirds of the children who was felt to be unique to were hospitalized with H1N1 infection and not Scott Turner, NP H1N1 had an underlying typically seen with the seamedical condition vs one-third of the sonal flu.5 Since April 2009, there have been children hospitalized during a typical flu season.4 Asthma was the most common 341 laboratory-confirmed pediatric comorbidity seen in about 30% of both deaths; all but 3 were either confirmed children and adults. Chronic neurologi- or suspected to be due to 2009 H1N1 vs cal disease such as cognitive disability, seasonal flu.8 A study describing 36 of neuromuscular disease, or seizures was these H1N1-related deaths found that also a significant risk factor, accounting two-thirds had one or more high-risk for 20% of the children and 9% of the medical conditions, with 92% of these adults hospitalized with H1N1-related children having a chronic neurological complications. Disturbingly, up to 92% condition. The median age at death was of the children who died of H1N1 last 9 years (range, 2 months-17 years), and year had a chronic neurological dis- the duration of illness before death ranged from 1 to 28 days (median 6 ease.5 days). Among those with bacterial culWhat Are the Complications of tures reported, laboratory-confirmed H1N1? coinfections were seen in 43% of those While most of the children who con- who died.5 tracted H1N1 in 2009 had an uneventful course, many children had to be hospitalized with flu-related complications. What Are the Clinical Implications? • Be on the lookout for flu during the An Italian study confirmed that the off-season most common reason for hospitalization o While the typical flu season runs was respiratory complications, with from fall to spring each year, more than half of the children admitted

Unlike the seasonal flu that often turns well kids into very sick kids, H1N1 seems to target chronically ill children and turns them into much, much sicker ones.

with bronchitis and pneumonia.6 A syndrome of rapidly progressive hemorrhagic pneumonitis has also been described as being unique to H1N1.7 Case reports from children’s hospitals in Pittsburgh, Dallas, and Denver, as well as Turin, Italy, have identified a variety of neurological complications from the H1N1 strain. About 5% of children with a complicated course of H1N1 suffered neurological sequelae, most commonly acute encephalitis or acute demyelinating encephalomyelopathy (ADEM).6 This pattern was similar to that of the seasonal flu, which has been known to cause seizures, Reye’s syndrome, encephalopathy, acute necrotizing encephalitis, acute hemorrhagic encephalopathy, and transverse myelitis.7 An analysis of 13 children diagnosed

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H1N1 presented in April 2009, peaked between May and June 2009, and was declared over in August 20109 • Be willing to test for the flu when you wouldn’t normally suspect it o While a majority of those contracting H1N1 presented with cough, coryza, high fever, and muscle aches, nearly 40% of adults and children presented with vomiting and diarrhea. Studies are under way to determine if the H1N1 virus can be spread via an oral-fecal route4 o Unexplained seizures or mental status changes can be presenting signs of either seasonal flu or H1N17 • Treat suspected H1N1 illness aggressively in high-risk populations

o The CDC has recommended antiviral treatment for all patients with confirmed or suspected influenza virus infection who are hospitalized or who are at higher risk for influenza complications, including those with lung disease such as asthma or chronic obstructive pulmonary disease (COPD), diabetes, heart or neurologic disease, and pregnant women (see Table)10 o The neuraminidase inhibitors oseltamivir and zanamivir were more effective in treating H1N1 than the adamantanes (amantadine and rimantadine) and most effective when given within 48 hours of symptom onset.4 This is because H1N1 is almost entirely resistant to adamantanes but shows good susceptibility to the neuraminidase inhibitors11 o While both oseltamivir and zanamivir have been reported to cause neurological side effects (most commonly headache, dizzi-

ness, or vertigo), these are seen in less than 5% of patients. Rarely, delirium or self-injury has occurred following oseltamivir use, and the FDA recommends that people be monitored closely for abnormal behaviors12 • Monitor for significant respiratory, neurologic, and secondary infection complications o The most common complications of H1N1 were bronchitis and pneumonia. Less commonly, encephalitis, ADEM, catecholamine-resistant shock, and even death have occurred • Vaccinate all young people, not just the chronically ill (we did not see any of the feared complications from the vaccine) o According to the CDC, the 2009 H1N1 vaccines have shown safety profiles similar to those of the seasonal flu vaccines, which have very good safety records. The most common side effects followContinued on page 20

CASE STUDY

he patient was a normally developing 20-month-old boy from Colorado who was visiting his father in Mexico in November 2009 when he developed an acute febrile illness. He awoke at about 6 AM appearing pale and lethargic. While being cooled with a tepid rag, he developed generalized tonic-clonic movements that lasted for more than 10 minutes. He was rushed to a local hospital where he continued to seize intermittently for several hours despite receiving multiple doses of benzodiazepines. He was transferred to a larger facility some 3 hours away to access pediatric neurology and intensive care services. Upon arriving at the tertiary facility, he was given additional doses of anticonvulsants, intubated, and admitted to the intensive care unit in critical condition. Neuroimaging revealed encephalitis. Lumbar puncture showed a pattern consistent with viral meningitis, with polymerase chain reaction (PCR) confirming the presence of the H1N1 influenza virus. He remained in a coma for nearly 3 weeks. He had a complicated course of hemorrhagic pneumonitis and experienced cardiac arrest requiring CPR and defibrillation. A G-tube was placed. Seizures were controlled with phenytoin. Repeat neuroimag-

ing showed progressive loss of white matter volume, third and fourth ventricular enlargement, and cystic encephalomalacia adjacent to the left lateral ventricle in a pattern consistent with necrotizing encephalitis. He was discharged in early January with a G-tube and multiple home medications including phenytoin. He developed respiratory distress on the ride home to Colorado and was hospitalized with pneumonia for 9 days at a children’s hospital in El Paso, TX. He continued to have complications after discharge and was admitted to The Children’s Hospital in Aurora, CO, with pneumonia, stridor due to prolonged intubation, vocal fold edema, GERD, and spastic quadriparesis. Phenytoin was discontinued at discharge after repeat EEG was clear of epiletiform discharges. He has not had further seizures. His tone has been managed by Rehabilitation Medicine using a combination of baclofen and diazepam. He receives intensive physical, occupational, and speech therapy. He was slowly regaining the ability to reach for objects with the right hand, was not yet bearing weight to stand independently, and had no vocalizations during his neurology visit 9 months after contracting the illness.

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Vaccines H1N1 in Children...continued from page 19 Table. People at High Risk for Developing Flu-Related Complications10 • Children younger than 5 years, but especially younger than 2 years • Adults 65 years and older

monitored closely when sick to prevent serious complications. Rapid identification and treatment with the antiviral medications oseltamivir and zanamivir might prove life-saving to this most vulnerable population.

• Pregnant women References

People who have certain medical conditions: • Asthma • Neurological and neurodevelopmental conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury) • Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis) • Heart disease (such as congenital heart disease, congestive heart failure, and coronary artery disease) • Blood disorders (such as sickle cell disease) • Endocrine disorders (such as diabetes mellitus) • Kidney disorders • Liver disorders • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders) • Weakened immune system due to disease or medication (such as people with HIV or AIDS, cancer, or those on chronic steroids) • People younger than 19 years who are receiving long-term aspirin therapy ing flu vaccinations include soreness, redness, tenderness, or swelling at the injection site11 o A June 2010 article in the journal Vaccine discussed the safety of H1N1 vaccines in children. It found that while 48.3% of the subjects had made unsolicited reports of adverse events within 6 weeks after the first vaccination, minor illnesses such as upper respiratory infection (about 20%) and nasopharyngitis (about 6%) were the most common complaints. No deaths, vaccine-related serious ad-

verse events, or adverse events of special interest (such as optic neuritis, cranial neuropathy, brachial neuropathy, and Guillain-Barré syndrome) had been seen, but adverse event monitoring was to continue for 6 months after the second vaccination13 o While participating in the CDC’s vaccine surveillance program, our group at the University of Colorado did not observe any vaccine-related neurological sequelae (Amy Brooks-Kayal, personal communication, August 30, 2010)

Conclusion Though the 2009 flu pandemic might have failed to live up to the doomsday scenario predicted in the media, H1N1 remains a threat to global health, particularly for children and young adults. Primary care providers and specialists should be aware that H1N1 targets a younger population, presents with symptoms atypical of the seasonal flu, and can create considerable morbidity and mortality in kids with chronic illness and neurodevelopmental conditions. Certainly this group of children should be vaccinated against H1N1 and

1. Girard MP, Tam JS, Assossou OM, et al. The 2009 A (H1N1) influenza virus pandemic: a review. Vaccine. 2010;28:4895-4902. 2. Centers for Disease Control and Prevention. About 2009 H1N1 flu. http://www.cdc.gov/h1n1flu/abouth 1n1.htm. December 5, 2009. Accessed August 15, 2010. 3. Centers for Disease Control and Prevention. What you should know and do this flu season if you are 65 years and older. http://www.cdc.gov/h1n1flu/65andolder.htm. January 19, 2010. Accessed August 15, 2010. 4. Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 H1N1: influenza in the United States, April-June 2009. N Engl J Med. 2009;361:19351944. 5. Halasa NB. Update on the 2009 pandemic influenza A H1N1 in children. Curr Opin Pediatr. 2010;22:83-87. 6. Calitri C, Gabiano C, Garazzino S, et al. Clinical features of hospitalised children with 2009 H1N1 influenza virus infection [published online ahead of print July 22, 2010]. Eur J Pediatr. 7. Baltagi S, Shoykhet M, Felmet K, et al. Neurological sequelae of 2009 influenza A (H1N1) in children: a case series observed during a pandemic. Pediatr Crit Care Med. 2010;11:179-184. 8. Centers for Disease Control and Prevention. Flu View Weekly: 2009-2010 influenza season week 20 ending May 22, 2010. http://www.cdc.gov/flu/weekly/. Accessed August 18, 2010. 9. Centers for Disease Control and Prevention. 2009 H1N1 flu. http://www.cdc.gov/h1n1flu.htm. Accessed August 15, 2010. 10. Centers for Disease Control and Prevention. People at high risk of developing flu-related complications. http://www.cdc.gov/h1n1flu/highrisk.htm. November 10, 2009. Accessed August 15, 2010. 11. Centers for Disease Control and Prevention. Questions and answers: antiviral drugs, 2009-2010 flu season. http://www.cdc.gov/h1n1flu/antiviral.htm. November 17, 2009. Accessed August 15, 2010. 12. American Academy of Neurology. H1N1 influenza: Q&A with CDC neuroepidemiologist James J. Sejvar, MD. http://www.aan.com/news/?event=read&article _id=7686. May 4, 2009. Accessed August 15, 2010. 13. Lu CY, Shao PL, Chang LY, et al. Immunogenicity and safety of a monovalent vaccine for the 2009 pandemic influenza virus A (H1N1) in children and adolescents. Vaccine. 2010;28:5864-5870.

Out Mouths of Babes of the

As a tribute to your relationship with your patients, we will feature the special moments and comical quotes you share with us. Enjoy this month’s gems!

After giving a four-year-old patient two vaccines shots, I said, “ Wow, you’re so brave and you didn’t even cry.” My patient said, “I’m one tough chick!” -Alison Smith, San Diego Submit your patients’ quotes by visiting us at www.pediatricnppa.com or e-mailing kristin@novellushc.com.

october 2010 I VoL 1, No 1

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“WHEN I HAVE AN ASTHMA ATTACK I FEEL LIKE A FISH WITH NO WATER.” –JESSE, AGE 5

ATTACK ASTHMA. ACT NOW.

1- 866 - NO -ATTACKS W W W. N O AT TA C K S . O R G CDDIS 10/01

Profile Rady Children’s Hospital...continued from cover ous improvement of cliniPNPPA: Sue, Rady cal quality through a pracChildren’s Heart Institute is tice we call “Standardize to touted as an “institute withExcellence.” This is our out walls.” Can you describe approach to evidence-based what that means? practice, and it is impleMs Shepard: Many Rady mented through rigorously Children’s Hospital cardiac developed clinical pathnurses and NPs have spent ways, standardized order their vacation time traveling sets, and decision algorithms, to other countries on medwith medical and nursing ical missions. During these Sue Shepard, RN, BSN staff compliance rates of missions heart surgery has more than 90%. Based on this effort, we been performed on children with conwere the first children’s hospital in the genital heart disease. Many of these country to win the Codman Award from children would have died an early death the Joint Commission in 2002. without the surgery. Our nurses have provided hope where medical care is in PNPPA: How does that translate to short supply in such places as Belarus, better outcomes for your patients? Latvia, Cambodia, China, Dominican Republic, Ecuador, Honduras, India, Malawi, Nicaragua, Peru, Sudan, South Africa, Swaziland, and the Ukraine.

The Inspiration Fountain at Rady Children's Hospital.

Ms Fagan: We have 15 years of data that demonstrate improved clinical outcomes in multiple conditions and reduced costs as a direct result of our pathway program.

PNPPA: How has the pediatric cardiology nurse’s role changed in the last 5 years? Ms Shepard: The cardiac nurses are increasingly more involved in the care of children with cardiac disease. The nurses undergo an extensive cardiac training program that includes didactic learning and hands-on experience. Nurses attend regional surgery conferences prior to the patients’ surgery and also observe the patients in the OR during the operation. Currently our cardiac nurses present the patients to the cardiology/cardiac surgery teams during morning rounds in order to contribute to the comprehensive approach to patient care. PNPPA: Do you have any advice for younger nurses in the field? Ms Shepard: Learn, learn, learn!

The new 279,000-square-foot Acute Care Pavilion at Rady Children’s Hospital is scheduled to open on October 10, 2010.

Nursing school provides a great foundation, but there is so much more to learn! Find an area that piques your interest

PNPPA: Mary, what is in the future for Rady Children’s Hospital? Ms Fagan: The challenge for Rady

The cardiac nurses are increasingly more involved in the care of children with cardiac disease. The nurses undergo an extensive cardiac training program that includes didactic learning and hands-on experience.

and study all you can about it. Ask questions, know your expert resources, and step out of your comfort zone. Many nurses work part-time while raising their families. These nurses should not feel their contribution to the nursing profession is any less than that of their full-time colleagues. I believe there is always something to learn and offer!

Children’s Hospital, and for all healthcare providers, is to reliably deliver high-quality, safe, and efficient care.

Would you like to see your institution featured in a Profile article? Please send your nomination to us at profilenominations @novellushc.com.

Artwork Month of the

Violet, age 6

olivia, age 8

Submit your patients’ artwork by visiting us at www.pediatricnppa.com or e-mailing kristin@novellushc.com.

october 2010 I VoL 1, No 1

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Pulmonology

Update: Cystic Fibrosis Ruth S. DeVoogd, MSN, RN, PNP-AC/PC Advanced Practice Nurse, Pulmonary Department The Children’s Hospital, Aurora, Colorado

ith the advent of nationwide newborn screening for cystic fibrosis (CF), the number of children with CF is expected to increase. Although CF is not a common condition (there are only about 30,000 adults and children with CF in the United States),1 the care of children with CF by primary care providers (PCPs) is challenging. Understanding the newborn screening process, having an awareness of potential complications that occur in CF, and knowing that new treatments are on the horizon will assist providers in caring for the child who is living with CF. Briefly, CF is an autosomal recessive genetic condition. The child with CF has inherited 1 abnormal gene from each parent; the affected child must carry 2 genes to develop CF. If a child inherits only 1 gene, he or she will be a carrier but will not have CF. The abnormal gene in CF causes a problem with a protein that is responsible for transporting salt and water across the cell membranes of certain organs. In CF, the protein is abnormal, and salt and water ineffectively cross the cell membrane. This leads to thick, sticky secretions in certain organs, such as the pancreas and airways, leading to damage of these organs. The sticky secretions in the pancreas do not allow the enzymes to get into the intestine, resulting in malnutrition; in the airways they lead to infection and inflammation, and eventually to irreversible lung damage and death. Other body systems that can be affected by the abnormal salt and water transport include sweat glands, sinuses, liver, intestines, and reproductive organs. Newborn Screening for CF Many states have already been screening for CF for a number of years, but in December 2009, Texas became the final state to endorse newborn screening for CF. Now, no matter where a child is born in the US, the diagnosis of CF can be made in early infancy. Studies have shown that infants with CF who are identified early have better growth patterns, improved cognition, and decreased morbidity when compared with children diagnosed through traditional means (identified through a course of failure to thrive and frequent respiratory infections).2,3 The newborn screening process can be confusing and create a great deal of anxiety for families while they wait to find out if their baby truly has CF. PCPs are key to helping parents understand

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the screening process, which takes several weeks. Therefore, it is essential to understand how newborn screening is done in a particular state, as there is variation from state to state. Most states screen for a chemical called immunoreactive trypsinogen (IRT) that is made by the pancreas; IRT levels increase when the pancreas is injured, as it is in CF. When babies have elevations in the IRT, they are said to have an abnormal or positive newborn screen. As part of the newborn screening process, many states also look at the DNA for certain common gene mutations. This method is sometimes sufficient to make the diagnosis of CF, if 2 genes are identified on the screen.This DNA method can also identify babies who are carriers of CF, which has

CF Complications: a Different Kind of Diabetes Although healthcare providers tend to categorize CF as a condition that causes only lung infections and failure to thrive, other complications can occur. Sinus disease is extremely common. Liver disease is much less common. One complication that occurs with increasing frequency is CF-related diabetes (CFRD). CFRD is neither type 1 nor type 2 diabetes, but it shares features of both. It occurs due to scarring in the pancreas, which affects insulin production; there is also some insulin resistance. Children with CFRD usually do not present with the typical diabetes signs of polydipsia and polyuria. They may have difficulty gaining weight and an increased number of respiratory infec-

Understanding the newborn screening process, having an awareness of potential complications that occur in CF, and knowing that new treatments are on the horizon will assist providers in caring for the child who is living with CF. implications not only for these children later in life, particularly when they are considering having children of their own, but also for the parents, who now know that at least 1 parent is a carrier, and thus there is a chance that future children could be born with CF. These parents need careful genetic counseling. If the newborn screening test is positive, the child must have a sweat test done, which helps confirm or rule out the diagnosis of CF. However, the majority (over 90%) of babies who have positive newborn screens will actually end up not having CF by sweat test. This is, of course, good news, but the high false-positive rate means that parents have to live with the possibility that their newborn has CF while they wait for final results. Since newborn screening for CF may be confusing to the PCP, it is helpful to contact the nearest CF care center, which can be found through the Cystic Fibrosis Foundation Web site at www.cff.org. A knowledgeable person at the CF center can help both the PCP and the parents as they anxiously await the results. Sometimes it isn’t clear if a baby does have CF, even after newborn screening, genetic testing, and sweat testing, so it is essential that these babies be evaluated in a CF care center.

tions. The treatment for CFRD is individualized and may include insulin. For example, children may do fine until they get sick and develop problems with glucose control, particularly if they are taking steroids. They may need insulin at that time, but not any other time. What makes CFRD even more difficult to manage is that people with CF need a high-calorie diet because they also suffer from malabsorption, even when they take pancreatic enzymes. If they drink high-calorie oral supplements during the day, they may require insulin at that time to cover the glucose load. Similarly, their glucose control may be normal during the day, but if they have gastrostomy feedings overnight, they may become hyperglycemic and need insulin only at bedtime. Oral hypoglycemic agents are generally not used, however, because they have not been shown to be effective in CF.4 As individuals with CF age, they have an increased chance of developing CFRD. Approximately 30% of adults aged ≥35 years have CFRD.5 To monitor for this, the CF Foundation care guidelines recommend an annual oral glucose tolerance test (OGTT), starting as early as age 10 years. If a child in your practice is losing weight, it is a good idea to consider CFRD and refer him or her to a CF care center.

Palivizumab and RSV At this time, there is no consensus on the use of palivizumab for respiratory syncytial virus (RSV) prophylaxis for the healthy infant with CF. More studies are needed to determine its benefit in CF. If children meet the criteria based on other high-risk conditions, they should receive palivizumab as recommended.6,7 The Future When the CF gene was identified in 1989, doctors and scientists were sure that a cure was close at hand. As we know, that has not occurred. As a result of intensive research, however, new medications and treatment modalities are extending the life of people with CF. The median survival age of people with CF was 37.4 years in 2008. In fact, 46% of people with CF in the US are now adults (≥18 years).5 Children born today with CF live much healthier lives. Early identification through newborn screening improves outcomes. Regular follow-up with the PCP is essential for routine well-child care, childhood immunizations, and anticipatory guidance. These children also need to be followed regularly in a CF care center, where they can continue to learn more about CF and receive the latest treatments. When children develop CF complications, such as CFRD, they need consultation with CF specialists. CF is a complex chronic condition with many potential challenges. Parents need in-depth education and support to navigate through the healthcare system and provide the best care for their children with CF. Parents and healthcare providers want their children with CF to grow up believing that they aren’t going to die of CF; rather, they will live with CF. References 1. Cystic Fibrosis Foundation (CFF). Frequently asked questions. CFF Web site. http://www.cff.org/AboutCF/ Faqs/. Accessed September 12, 2010. 2.Wagener JS, Sontag MK, Sagel SD, et al. Update on newborn screening for cystic fibrosis. Curr Opinion Pulm Med. 2004;10:500-504. 3. Farrell PM, Kosorok MR, Rock MJ, et al. Early diagnosis of cystic fibrosis through neonatal screening prevents severe malnutrition and improves long-term growth. Pediatrics. 2001;107:1-13. 4. O’Riordan SM, Robinson PD, Donaghue KC, et al. Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes. 2009;10(suppl): 43-50. 5. Cystic Fibrosis Foundation. Cystic Fibrosis Foundation Patient Registry: Annual Data Report 2008. Bethesda, MD: Cystic Fibrosis Foundation; 2008 6. Robinson KA, Odelola OA, Saldanha I, et al. Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database Syst Rev. 2010;2:CD007743. 7. Giebels K, Marcotte JE, Podoba J, et al. Prophylaxis against respiratory syncytial virus in young children with cystic fibrosis. Pediatr Pulmonol. 2008:43;169-174.

october 2010 I VoL 1, No 1

A Day in the Life

Nursing in the Pediatric Cardiac Catheterization Laboratory Cyndi Murphy, RN, BSN Pediatric Cardiology Nurse, Cardiac Catheterization Laboratory, Rady Children’s Hospital, San Diego, California

s nurses, we wear many different hats. In every nursing specialty, we are expected to perform many different duties and assume many different roles. As we become increasingly specialized, the number of hats we wear increases. I chose to specialize in pediatrics, and then to further subspecialize in the care of patients in the cardiac catheterization laboratory (CCL). Of course, I did not initially anticipate the impact this choice would have on my life, but over time, working in the pediatric CCL has become very satisfying and rewarding. Every day there are new challenges driven by the constant advances and developments in the field of pediatric catheterization. As new procedures develop, I must acquire new knowledge and skills to meet the demands of this constantly changing field. Here, I would like to provide a glimpse into the world of nursing in the pediatric CCL at Rady Children’s Hospital in San Diego.

A Glimpse Into the Catheterization Lab Infants and children can’t have coronary artery disease – or can they? Yes, they can. However, most have abnormalities of heart structure and/or heart function. When I started working in the CCL 12 years ago, the primary purpose of the majority of our procedures was diagnostic. Our job was to determine and define the abnormal anatomy of a child’s congenital heart disease, enabling the surgeons to correct the abnormality. There are still patients in whom we continue to perform diagnostic catheterizations; however, many cardiologists at Rady Children’s Hospital are now performing the diagnostic catheterizations themselves. We cannot begin to discuss the nurse’s role in the pediatric CCL without first understanding the types of procedures performed there. Infants and children who are born with severe stenosis of their aortic or pulmonary valves, a patent ductus that does not close normally, or a hole between either the upper or lower chambers of the heart are often treated in the catheterization laboratory. In all these cases, surgery is not required. There are also patients who have undergone surgery for these conditions who may have residual problems needing diagnosis or intervention. In many cases, these patients come to the catheterization laboratory to benefit from a procedure

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Wall murals serve to distract and ease our patients.

performed through a vein in the leg, as opposed to undergoing a major operation. We have the ability to open stenotic valves or blood vessels with balloon catheters and/or stents and to close abnormal openings in the heart using devices or coils, and the newest

Most patients at Rady Children’s Hospital undergo their procedure under general anesthesia. It is the nurse’s role to assist both the cardiologist and the anesthesiologist. During induction, the anesthesiologists rely on my skills to assist them with starting IVs, drawing and

It is our professionalism, confidence, and compassion that make it possible for parents to trust us with their precious children.

technology enables us to replace certain heart valves in older children using stent-mounted heart valves. My Role in the Lab Working in the pediatric CCL is definitely challenging. I must be able to adapt quickly from caring for a 2-kilogram “preemie” to a 100-kilogram teenager, often multiple times within the same day. It is imperative that I understand not only the congenital heart defects of the patient, but also the abnormal cardiovascular physiology behind the defect. The physicians I work with rely on my knowledge and expertise to assist them in caring for the patient, as well as to understand the multiple catheters, wires, balloons, and devices that we have available in our inventory. In addition, it is my responsibility to keep a watchful eye on the patient’s hemodynamics as well as to inform the treating physician of any abnormal patient parameter and assist him or her in performing the required procedures and interventions.

sending the appropriate labs, and intubation. Unlike adults, our little patients often cannot effectively communicate with us, and they depend on me to position them, properly restrain them if necessary, and perform range-of-motion exercises to prevent injury as needed. In the catheterization laboratory, the nurse has multiple roles. I may be assigned as the “scrub nurse” to assist the doctor at the table for one procedure, the “circulating nurse” to obtain supplies needed to perform another procedure, or the “cardiovascular technologist” to obtain and record hemodynamic and procedural data. Further, during electrophysiology procedures required for patients with abnormal heart rhythms, I perform the pacing protocols and monitor the patient for induction and termination of their arrhythmia. In summary, I perform all the duties that are within the scope of practice in the catheterization laboratory, including those often performed by radiological and cardiovascular technologists.

My Role in Research I also have a major role as a catheterization research nurse. I am responsible for making sure that patients are properly screened for participation in research studies. If the patient is eligible, I ensure that all consents are signed, that all policies and protocols pertaining to the study are followed, and that all pertinent data are collected. After the procedure, I make sure that all the proper follow-up testing is done and that follow-up appointments are made. I perform data entry not only for the research, but also for the catheterization laboratory databases. This includes working with quality management to ensure proper tracking and reporting of adverse events. My Role as Patient Advocate Finally, one of my most important roles is the role of patient advocate. I am the eyes, ears, and voice of little patients who cannot speak for themselves. Some of these patients undergo multiple procedures. I do everything possible to make them more comfortable and less afraid prior to “going to sleep.” I make a point of distracting and playing with children as they are entering the laboratory. Our catheterization laboratory has wall murals of clouds with shapes of friendly animals and pleasant objects. I ask the patients to look around and tell me what they see. Before long, the parents are also involved in identifying animals and objects and everyone is smiling and talking. Parents entrust their children to us, praying that we will keep them safe. This is a huge responsibility, but one I and the other members of our team understand and accept. It is our professionalism, confidence, and compassion that make it possible for parents to trust us with their precious children. The Future of Nurses in the Catheterization Lab As for future roles, I believe there is room for an advanced practice nurse in the pediatric CCL. It would also be valuable to have a nurse practitioner to assist with obtaining vascular access for the procedures or performing the diagnostic portions of the cardiac catheterizations. In my view, the possibilities are endless for nurses who want to take on the challenge of being a pediatric cardiac catheterization laboratory nurse.

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The Gr wth Chart NeWS for the AgeS

Babies

Mother’s Weight Gain During Pregnancy Creates Risks for Children Women who gain excess weight during pregnancy tend to have babies with a high birth weight, a known risk factor for obesity and other health problems. A recent study published in The Lancet indicates for the first time that maternal weight gain during pregnancy increases birth weight independently of genetic factors. David Ludwig, MD, PhD, Harvard Medical School, and Janet Currie, PhD, Columbia University, reported on the correlations between maternal weight gain, high birth weight, and subsequent health risks. The study used birth records from Michigan and New Jersey to examine all known single births from 1989 through 2003. To control for the influence of genetics, mothers with 2 or more live births were identified. After excluding mothers with diabetes, infants born before 37 weeks or after 41 weeks of gestation, and infants having extremely low or high birth weight, data from 513,501 women and 1,164,750 infants were eligible for analysis. Compared with women who gained 18-22 pounds, those who gained 44-49 pounds and those who gained more than 53 pounds were 1.7 and 2.3 times, respectively, more likely to have a baby with a high birth weight, which was defined as 8 pounds, 13 ounces. “Since high birth weight, in turn, increases risk for obesity and diseases such as cancer and asthma later in life, these findings have important implications to general public health,” said Dr Ludwig. He also explained, “It’s appropriate for a baby to be born with some fat, but a baby born too fat indicates that the fetus developed in an abnormal environment during the most critical 9 months of life.” Updated guidelines from the Institute of Medicine suggest that women gain 28-40 pounds if they are underweight at the start of pregnancy, 25-35 pounds if normal weight, 15-25 pounds if overweight, and 11-20 pounds if obese.

Toddlers

Toddlers Still Watch Too Much TV

Toddlers in Oregon are still allowed to watch too much television, in spite of recurring reports and warnings about potential negative effects of excessive TV viewing. The Centers for Disease Control and Prevention (CDC) and researchers at the Oregon Public Health Division analyzed data obtained between 2006 and 2007 from 1868 respondents to a survey and found that 19.6% of 2-year-olds watched TV or videos for ≥2 hours daily. In guidelines published in 2001, the American Academy of Pediatrics recommended that children watch no more than 1 to 2 hours of “quality programming” per day. Children more likely to watch TV for ≥2 hours included those who had a TV in their bedroom, those who had been on fewer than 4 outings in the week prior to the survey, and those who did not spend any time in day care. In addition, 35.9% of non-Hispanic black mothers compared with 18.6% of nonHispanic white mothers allowed their toddlers to view TV or videos for ≥2 hours. According to Morbidity and Mortality Weekly Report (MMWR), the Oregon findings are comparable to data from Minnesota and Washington, which revealed that by 2 years of age, 90% of children regularly watched television or videos an average of more than 1.5 hours per day. The CDC recommends that healthcare professionals, parents, and caregivers be aware of the amount of time children spend viewing TV and videos, that other states conduct surveys on this issue, and that parents remove TVs from children’s bedrooms. Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5927a1.htm.

Sources: http://www.harvardscience.harvard.edu/medicine-health/articles/excess-maternal-weight-gain-increases-birthweight-study-finds. http://www.thelancet.com/journals/lancet/onlinefirst.

School-Age Kids

Teens

Treatment-Resistant Ringworm Is Prevalent Among Children in Urban Elementary Schools

Teens and the Transition Away From Pediatrics

Researchers who studied children in urban elementary schools found that 6.6% were infected with the scalp fungus Trichophyton tonsurans (T tonsurans), the leading cause of ringworm in the United States. Susan Abdel-Rahman, PharmD, Children’s Mercy Hospitals and Clinics in Kansas City, MO, was lead author of a study of 10,514 children in kindergarten through 5th grade in 44 schools in the Kansas City area. The study is the largest so far to examine the prevalence of this scalp fungus in children in a metropolitan area and is believed to have nationwide implications. The study results support what Dr Abdel-Rahman has seen regarding the prevalence of ringworm in children in metropolitan areas. If left untreated, ringworm can lead to permanent hair loss and damage to a child’s self-image. It may also worsen unrelated problems such as asthma and allergic rhinitis. Current treatment includes a 6- to 8-week course of oral antifungal medication until symptoms resolve. Often, however, the fungus is not completely eradicated, and children can continue to spread the infection to others. If a child has come in contact with another known to be infected, parents should watch for white patchy scaling, flakes that look like dandruff, itching, thinning or loss of hair, and small pus-filled bumps, all signs of infection. Also, children should not be allowed to share hats, combs, brushes, or pillows. Dr Abdel-Rahman explained, “T tonsurans has learned how to stay on the host and avoid eradication. This can be very frustrating for children who keep getting reinfected and for their parents who are doing everything they can to prevent this.”

Determining the age at which a teenager outgrows pediatric care can be complicated – for the patient and the physician. Although some teens are eager to move on, others find security in staying with their pediatrician, especially if they have had the same doctor throughout most of their childhood. Most pediatricians see patients until they are 18 to 21 years old, although many continue seeing patients who are older. According to Dr David Tayloe, a North Carolina pediatrician who is also a past president of the American Academy of Pediatrics, the number of young people staying with their pediatrician until they complete college is increasing. Often, pediatric offices create special waiting areas for teens and young adults, complete with age-appropriate furniture and magazines. However, if the pediatric practice sees a limited number of adolescents, teens may choose to transition to an internist, family practitioner, or gynecologist. The preference becomes strong among some teens for a doctor of the same sex. For teenagers with complex health problems or special needs, transitioning presents additional challenges. Teens and their parents may be reluctant to leave the doctor, nurses, and staff members they know and trust. Parents and healthcare professionals should be aware of the child’s preferences and feelings. The time may have come for a teen to stop being seen in the pediatrician’s office if there are indications that he or she feels awkward in the waiting room or during physical exams; avoids discussing important issues such as sexuality, drug abuse, or mental health concerns; or if the pediatrician sees only a few other teenage patients Source: http://online.wsj.com/article/NA_WSJ_PUB:health_journal.html.

Sources: http://www.virtualpressoffice.com/publicsiteContentFileAccess?fileContentId=284186&fromOtherPage ToDisableHistory=Y&menuName=News&sId=&sInfo=. http://pediatrics.aappublications.org/cgi/content/abstract/ 125/5/966.

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october 2010 I VoL 1, No 1

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