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Objective. Multiple cross-sectional physician surveys have documented poor cardiac auscultation skills. We evaluated the impact of 2 different educational interventions on pediatric resident auscultation skills. Methods. The auscultation skills of all first-year (PGY1; n = 20) and second-year pediatric residents (PGY2; n = 20) were evaluated at the beginning and end of the academic year. Five patient recordings were presented: atrial septal defect, ventricular septal defect, pulmonary valve stenosis, bicuspid aortic valve with insufficiency, and innocent murmur. Residents were asked to classify the second heart sound, identify a systolic ejection click, describe the murmur, and provide a diagnosis. All PGY1 and most PGY2 (14 of 20) participated on the inpatient cardiology service for 1 month. PGY2 on the cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/ week to use a self-directed cardiac auscultation computer teaching program. Results. Resident auscultation skills on initial evaluation were dependent on training level (PGYI: 42 [+ or -] 15% correct; PGY2:53 [+ or -] 13% correct), primarily as a result of better classification of second heart sound (PGYI: 45%; PGY2: 63%) and diagnosis of an innocent murmur (PGYI: 35%; PGY2: 65%). There was no difference in the ability to identify correctly a systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by 21%, primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). Combined, diagnostic accuracy was best for ventricular septal defect (55%) and innocent murmur (60%) and worst for atrial septal defect (18%) and pulmonary valve stenosis (15%). However, 40% identified the innocent murmur as pathologic and 21% of pathologic murmurs were diagnosed as innocent. Conclusions. Pediatric resident auscultation skills were poor and did not improve after an outpatient cardiology rotation. Auscultation skills did improve after the use of a self-directed cardiac auscultation teaching program. These data have relevance given the American College of Graduate Medical Education's emphasis on measuring educational outcomes and documenting clinical competencies during residency training. Pediatrics 2004;113:1331-1335; auscultation, murmurs, educational intervention, computer-based learning. ABBREVIATIONS. PGY1, first year pediatric residents; PGY2, second-year pediatric residents; ASD, atrial septal defect; VSD, ventricular septal defect; PVS, pulmonary valve stenosis; BAV/AI, bicuspid aortic valve with aortic regurgitation; S2, second heart sound., Cardiac murmurs are common in pediatric patients, with an incidence of up to 90%. (1-11) Because METHODS All first-year (PGY1) and second-year pediatric residents (PGY2) were asked to participate in [...]

Dexamethasone does not appear to be effective in preventing neurological complications or hearing impairment in children with bacterial meningitis. Dexamethasone is a corticosteroid that works as an anti-inflammatory. A total of 143 children between eight weeks and 12 years old with bacterial meningitis were treated and evaluated. All children received the antibiotic ceftriaxone. Sixty-nine of the children also received four days of treatment with 0.15 milligrams of dexamethasone per kilogram of weight every six hours. Neurological and hearing exams were performed within 24 hours of admission and again at six weeks and one year after discharge. Twenty-two children had moderate-to-severe hearing loss in both ears at the time of the first exam. There was no significant difference in the number of children with hearing impairment between the dexamethasone-treated and the antibiotic-only treated children. There was also no significant difference in neurologic complications between the two groups., Objective. To determine whether treatment with dexamethasone and ceftriaxone for children with bacterial meningitis reduces the frequency of either sensorineural hearing loss or other neurologic sequelae. Design. This was a prospective, multicentered, placebo-controlled clinical trial. Subjects were followed for 1 year. Setting. The study was conducted in six children's hospitals located in Pittsburgh, Houston, Los Angeles, Chicago, Washington, D.C., and Columbus, Ohio. Patients. Enrolled were 173 children, 8 weeks to 12 years of age, with suspected bacterial meningitis; 143 children were evaluable. Eighty-seven percent of patients were followed for at least 6 weeks to 3 months, and 67% were followed for 1 year. Interventions. Subjects were randomized to receive ceftriaxone with or without dexamethasone (0.15 mg/kg every 6 hours for 4 days). Auditory brainstem responses (ABR) were measured within 24 hours of admission. Main outcome measures. Hearing, development, and neurologic sequelae were assessed at the time of discharge and 6 weeks and 1 year later. Main results. One hundred forty-three patients (69 received dexamethasone and 74 received placebo) with bacterial meningitis were evaluable: Haemophilus influenzae type b (83), Streptococcus pneumoniae (33), Neisseria meningitidis (24), and three others. Overall, there was no significant difference in auditory outcome between dexamethasone and placebo recipients. Twenty-two children had bilateral moderate or more severe hearing loss at the time of the first ABR. At follow-up, the resolution of hearing impairment was nearly identical for each group. Nine of ten children who remained persistently deaf were deaf at the time of the first ABR. There were no differences in neurologic or developmental outcome between groups. Conclusion. All but one child with persistent bilateral moderate or more severe hearing loss had demonstrable deafness at the time of the first ABR. Dexamethasone did not significantly improve audiologic, neurologic, or developmental outcome in children with bacterial meningitis. Pediatrics 1995;95:21-28; bacterial meningitis, steroids, dexamethasone, Haemophilus influenzae.

* Objectives. - To describe demographic and medical characteristics of a sample of children younger than age 3 years who required lengthy hospitalization in a tertiary care hospital. To determine the proportion of children in the sample with biologic handicaps, developmental delays, or risk factors for developmental disorders who met eligibility criteria for early intervention services based on federal law PL 99-457 and state regulations. Design. - Survey of medical records. Setting. - Large, urban, tertiary care children's hospital. Patients. - All 135 children younger than age 3 years hospitalized for more than 30 days during 1990 and 1991. Interventions. - None. Main Results. - The most prevalent cause of lengthy hospitalization was congenital anomaly followed by chronic and perinatal conditions; 38 patients (28%) required technology assistance at the time of discharge. Seventy-three children (54%) were eligible for early intervention services based on the presence of a biologic handicap or developmental delay. An additional 48 patients (36%) were eligible for developmental screening and periodic developmental monitoring on the basis of medical and social risk factors. Conclusions. - Because of the high prevalence of developmental disorders and risk factors in infants and toddlers requiring lengthy hospitalizations, hospital-wide systems for identification, developmental assessment, and early intervention services should be designed and implemented. (AJDC 1993;147:211-215), Hospitals should implement programs to detect and address developmental disorders among infants and children hospitalized for long periods of time. While the risks of developmental disorders among premature infants are known and many programs have been installed to meet their needs, the developmental needs of hospitalized children outside of neonatal intensive care units (NICU) often go unrecognized. Of 135 children who were hospitalized for longer than 30 days in a Pennsylvania hospital, 85% had multisystem diseases, and 46% had birth defects. Fifty-four percent were eligible for early intervention services in Pennsylvania, and 36% were eligible for identification, screening and tracking due to medical or social risk factors. Overall, 90% were eligible for some developmental service. Identifying children outside of NICUs who need developmental services will require cooperation among pediatricians, nurses and administration but is critical given the high incidence of disorders among children with lengthy hospital stays.

Extracorporeal membrane oxygenation (ECMO) is a relatively new technique which oxygenates the blood outside the body. It is used to treat newborns who have cardiopulmonary (heart-lung) failure caused by any of a group of disorders. ECMO is used chiefly in large medical centers, and its use is controversial because the long-term effects of its use, especially on neurological development, are unknown. Physiological problems experienced by the infants may cause central nervous system (brain and spinal cord) damage, while ECMO may affect blood supply to the brain due to surgical procedures and anticlotting medication associated with its use. To better understand the long-term outcome of children treated with ECMO, the status of 67 out of 87 survivors of cardiopulmonary failure and ECMO therapy was assessed. Children unavailable for follow-up more often had lower birth weights, were black, or had low socioeconomic status. Children were aged six months to 10 years old. A normal outcome was found in 64 percent, while 25 percent were suspect and 11 percent were abnormal. Ninety percent of school children, 70 percent of preschoolers, and 57 percent of infants were normal, and this may reflect higher mortality when the ECMO program was started, improvement of status from infancy to school age, or limited predictive results from testing. Two of the nine school children tested as normal had problems in the school setting. Hearing loss occurred in 21 percent of children, a frequency similar to that in infants with similar cardiopulmonary problems given conventional treatment. Seventeen children had chronic lung disease in infancy, with older children tending to have improved conditions. Poor or suspect neurodevelopmental status was found in seven children with abnormal computed tomography scans or ultrasound images, while nine others with abnormal findings were normal during testing. The study suggests that newborns treated with ECMO have outcomes similar to those treated conventionally; thorough medical follow-up is important. (Consumer Summary produced by Reliance Medical Information, Inc.)