Poke Plan: An Initiative to Improve Distraction and Pain Mitigation With Venous Access in Hospitalized Children.

BACKGROUND: Adequate pain control and anxiety relief during peripheral intravenous cannula (PIV) placement improves patient, parental, and staff satisfaction and reduces health care-induced stress in children. We noted a low rate of analgesic/anxiolysis use (<20%) and child life utilization (3%) in our institution. This quality improvement project was initiated to increase pain mitigation strategies in hospitalized children requiring PIV access. METHODS: From November 2020 to March 2021, we created a key driver diagram and summarized possible interventions with the aim to increase our use of pain control strategies to >40% and child life utilization to 25%. For 12 months, 8 Plan-Do-Study-Act cycles were conducted focusing on nursing education and training, improved documentation, electronic medical record optimization, easy access to analgesics and anxiolytics, family involvement, and weekly huddles. Our primary measure was the percentage use of pain medications for PIV access. The utilization of PIV experts from the ICU (advanced practice registered nurses and physicians) served as the balancing measure. RESULTS: A total of 883 patient charts were reviewed. The use of topical anesthetics and anxiolytics increased from 16.2% at baseline to 78.9% after the implementation of the quality improvement project. Eighty percent of parents reported their child was kept comfortable during the procedure using pain mitigation and comfort measures. A slight increase from 2% to 5.8% was noted in the utilization of advanced practice registered nurses and intensivists. CONCLUSIONS: Implementation of a standardized approach for PIV placement improved team communication and provided better preparation for pain control before needle insertions in hospitalized children.

Sex differences in the behavior of children with the 22q11 deletion syndrome.

High rates of psychiatric impairment in adults with 22q11 deletion syndrome (22q11DS, also referred to as DiGeorge or velocardiofacial syndrome) suggest that behavioral trajectories of children with 22q11DS may provide critical etiologic insights. Past findings that report Diagnostic and Statistical Manual (DSM) diagnoses are extremely variable; moreover, sex differences in behavior have not yet been examined. Child Behavior Checklist (CBCL) ratings from 82 children, including 51 with the 22q11DS and 31 control siblings, were analyzed. Strikingly consistent with rates of psychiatric impairment among affected adults, 25% of children with 22q11DS had high CBCL scores for Total Impairment, and 20% had high CBCL Internalizing Scale scores. Males accounted for 90% of high Internalizing scores and 67% of high Total Impairment scores. Attention and Social Problems were ubiquitous; more affected males than females (23% vs. 4%) scored high on Thought Problems. With regard to CBCL/DSM overlap, 20% of affected males as compared with 0 affected females had one or more high CBCL ratings in the absence of a DSM diagnosis. Behaviors of children with 22q11DS are characterized by marked sex differences when rated dimensionally, with significantly more males experiencing Internalizing and Thought Problems. Categorical diagnoses do not reflect behavioral differences between male and female children with 22q11DS, and may miss significant behavior problems in 20% of affected males.

Neuromotor deficits in children with the 22q11 deletion syndrome.

The 22q11 chromosomal deletion syndrome (22q11DS) is associated with a heterogeneous physical phenotype, neurocognitive deficits, and increased risk of later psychiatric illness. Sporadic clinical reports suggested motor differences, but quantitative studies of movement in children with 22q11DS are rare. If present in a majority of affected school-age children, characterization of neuromotor deficits may prove to be critical for intervention, neurocognitive test interpretation, and understanding etiology. We administered the Movement Assessment Battery for Children to 72 children ages 4.3 to 16.1, including 49 children confirmed positive for the 22q11 deletion and 23 control siblings. We predicted a higher frequency of global and domain impairment in manual dexterity, eye-hand coordination, and balance among affected children. Ninety-four percent of affected children had marked neuromotor deficits, and group scores differed broadly for both global and subarea measures. Secondary analyses showed no impairment differences between younger and older children with 22q11DS, and longitudinal trajectories for 12 affected children suggested stability of deficits over 3-year intervals. Neuromotor deficits in children with 22q11DS occur early in development, continue throughout the school-age years, should be considered in the interpretation of motor-based achievement and IQ tests, and require targeted and ongoing remediation throughout childhood and adolescence. Further studies examining the specificity of motor impairment to 22q11DS are needed.

Olfactory disorder in children with 22q11 deletion syndrome.

OBJECTIVE: 22q11 deletion syndrome, a common human interstitial deletion syndrome (1:5000), is associated with a heterogeneous physical phenotype, including several factors that markedly increase the risk for olfactory disorder. Despite its potential consequences, pediatric studies of impaired olfaction are rare, and odor detection in children with 22q11 deletion syndrome has not yet been examined. METHODS: The University of Pennsylvania Smell Identification Test was administered to 62 children, including 39 with 22q11 deletion syndrome and 23 neurotypical control siblings who ranged in age from 5.3 to 14.8 years. Lowered smell detection accuracy among affected children was predicted. RESULTS: Substantially more children with 22q11 deletion syndrome (68%) as compared with neurotypical control subjects (13%) had University of Pennsylvania Smell Identification Test scores > or = 2 SDs below the standardization sample mean. Frequency of impairment in younger versus older children did not differ. The score distributions of children with and without velopharyngeal insufficiency did not differ; however, markedly lower score variance among children with velopharyngeal insufficiency suggested its negative impact on olfaction. Posthoc error analyses revealed that affected children had special difficulty detecting smells that are associated with fumes and smoke. CONCLUSIONS: Odor detection failures are ubiquitous among children with 22q11 deletion syndrome and are not associated with developmental delay or performance characteristics of younger affected children. Additional studies are needed to examine further the impact on olfaction of velopharyngeal insufficiency and compromised nasal airway patency. Children with 22q11 deletion syndrome should be evaluated routinely for olfactory disorder. When deficits are identified, caregivers should be warned of potential dangers that are associated with this type of sensory impairment.