Sound sleep in infants lessens likelihood of drug abuse in later years
October 29, 2007
A long-term study has found a significant connection between sleep problems in children’s toddler years and the chance that they’ll use alcohol, cigarettes, and drugs early in their teen years. Young teens whose preschool sleep habits were poor were more than twice as likely to use drugs, tobacco, or alcohol.
The surprising finding, made by a University of Michigan Health System team as part of a family health study that followed 257 boys and their parents for 10 years, held true even after other issues such as depression, aggression, attention problems, and parental alcoholism were taken into account. Long-term data on girls are not yet available.
Based on their result, the researchers suggest that early sleep problems may be useful as a “marker” for predicting later risk of early adolescent substance use - and that there may be a common biological factor underlying both traits. The relationship between sleep problems and the use and abuse of alcohol in adults is well known, but this is the first study to look at the issue in children.
They also emphasize that parents should take the finding only as one more reason to focus on healthy sleep habits for their children - not as a reason to worry.
The findings will be published in the April issue of Alcoholism: Clinical and Experimental Research by a team from the U-M Addiction Research Center (UMARC), in the Department of Psychiatry, and a colleague from Michigan State University.
The data come from an ongoing longitudinal project that uses interviews and standardized research questionnaires to look at mental and physical health issues in families over the long term. The study was recently extended for another 10 years, with further funding from the National Institutes of Health in the form of a MERIT Award.
“What’s so interesting about this finding is that the effect exists regardless of a number of other factors that previously had been identified as relating to risk for substance use and abuse,” says senior author and UMARC director Robert Zucker, Ph.D. “It appears to indicate some shared neurobiological dysfunction whose details we don’t yet know. Further studies will be crucial to our understanding.”
“Taken together with other studies in this area, our findings help make up a chain of evidence linking sleep disturbances to alcohol problems across a large segment of the life span,” says lead author and research assistant professor Maria Wong, Ph.D.
The finding does not mean there’s a cause-and-effect relationship, notes co-author and psychiatry professor Kirk Brower, M.D., who has studied the interplay of alcohol and sleep in adults, and is Executive Director of the Chelsea Arbor Treatment Center, which treats teen and adult substance abusers. (Chelsea Arbor is a joint program of U-M and Chelsea Community Hospital.)
“Our finding sees early childhood sleep disturbances as a marker, or predictor, for early use of drugs and alcohol in adolescence, not a predetermined trajectory,” he says. “But for parents, this is one more reason to take your child’s sleep problems seriously, not to dismiss them, and to talk with your child’s pediatrician or family doctor.”
The new study extends into early childhood the growing knowledge about how sleep and sleep disorders relate to alcohol use and alcoholism, drug use and abuse, and tobacco use. For instance, alcoholics and non-alcoholic adults often use alcohol to try to help them sleep - even though their slumber is often disrupted when the alcohol wears off, and the amount of alcohol needed to make them sleepy grows over time as they develop a tolerance. And people with insomnia are far more likely than others to abuse alcohol, smoke, and develop drug habits.
Also, several studies based on one-time interviews of teens have shown a high co-incidence of sleep problems and drug and alcohol use, although depression or aggression appeared to account for some of the effect. But the studies’ designs don’t allow study of causal relationships.
The new U-M study looked at data taken at three points in the boys’ lives:
In all, one-third of the children were reported to have had a sleep problem in early childhood, whether trouble sleeping, overtiredness, or both. Sixty percent of the children had one parent with an alcohol problem, reflecting the larger study’s weighted population. All of the children lived with both parents, and all were Caucasian. The children were from similar economic backgrounds.
By age 12 to 14, about 32 percent of the boys had started drinking alcohol, and 40 percent of that group had been drunk at least once. About one-tenth regularly smoked cigarettes, and 17 percent had used at least one kind of illicit drug.
There was no connection between parental alcoholism and children’s sleep problems or behavior issues. But children of alcoholics were, as expected, more likely to have started using alcohol and drugs early in adolescence. This kind of family-associated risk is well known to exist.
The link between sleep problems and substance use was clear, even after controlling for parental alcoholism. Boys with early-childhood sleep problems were 2.3 times more likely to have started using alcohol by age 14, and 2.3 times more likely to smoke cigarettes occasionally or regularly, than boys whose mothers hadn’t cited sleep problems.
They were also 2.6 times more likely to have used marijuana, and 2.2 times more likely to have used illicit drugs. The only issue to which sleep problems weren’t significantly linked was the first time the boys had gotten drunk.
The researchers re-analyzed the data to examine whether the relationship between sleep problems and the early onset of substance use was in part due to the presence of attention problems, aggression, and anxiety/depression. Although early childhood sleep problems predicted attention problems and anxiety/depression in late childhood, these problems did not predict the onset of substance abuse independent of sleep problems.
The researchers note that early onset of alcohol use is known to be linked to a higher risk of later alcohol abuse and dependence, as well as injuries, violence and drunk-driving. If sleep problems in early childhood might be a useful marker to signal an increased risk of early substance use, they note, sleep problem screenings could help identify children who could be at risk.
And, they say, the fact that children’s sleep habits can be improved by careful attention from parents and doctors means that there’s some chance the long-term risk could be addressed.
“Parents should pay attention to their children’s complaints about insomnia and overtiredness,” says Wong. “If necessary, they should discuss those problems with their child’s health care provider. They should also set a regular sleep schedule for their child, ensure they get adequate amounts of sleep, and encourage their children to engage in relaxing, not stimulating, activities before bed.”
Wong and her colleagues will continue analyzing data from the family study to look for further patterns in girls, and as the boys grow older. They also hope to use wrist-band movement monitors and brain-activity sleep tests called polysomnography to study the issue further.
Teens are obese due to lack of exercise
October 29, 2007
The American Council on Exercise (ACE), America’s nonprofit fitness advocate, today applauds the recent findings by University of California San Diego School of Medicine and San Diego State University researchers stating that the lack of physical activity was the most significant obesity risk factor contributing to obesity in 11- to 15-year-olds.
Published in this month’s “Archives of Pediatric and Adolescent Medicine,” http://archpedi.ama-assn.org/, the study looked at 878 adolescents from the practices of 45 primary care physicians in six San Diego County clinics.
According to the study, the proportion of overweight adolescents has increased dramatically in recent years, but the behavioral risk factors for overweight youth are not well understood. The objective of the study was to examine how diet, physical activity, and sedentary behaviors relate to overweight status in adolescents. “Daily activities such as walking to school, physical education classes, after-school activities, chores and general playing have been replaced with a sedentary lifestyle in front of the TV, computer, or video games,” said Ken Germano, president of the American Council on Exercise. “This study highlights the need for effective physical activity programs targeted at young people.
It is important for us to continually teach our kids to lead healthy and active lives now so they can avoid serious health problems in the future.” Established in 1990, Operation FitKids (OFK) is the youth outreach program for the American Council on Exercise. OFK is dedicated to improving the health and fitness of America’s youth. OFK provides high quality educational materials and top-notch professional training to educators, fitness professionals, health professionals and parents working in youth fitness. For more information on OFK log onto http://www.acefitness.org/ofk/.
Most common skin condition, Molluscum Contagiosum
October 29, 2007
From diaper rash to eczema to warts, your child’s skin can play host to a seemingly endless variety of lumps, bumps and rashes. Although often itchy and uncomfortable, most are benign conditions that can be easily treated or controlled with readily available treatment. Some are the result of allergies or skin irritants, while others are caused by viruses. One of the most common, although maybe not the one with the most recognizable name, is molluscum contagiosum.
Molluscum is a common skin growth caused by a viral infection in the top layers of the skin. It’s easily spread by skin contact, entering through small breaks in the skin or through hair follicles. The molluscum “bumps” are usually small, shiny, flesh-colored or pink dome-shaped growths, often with a small indentation in the center. They can appear in clusters on different areas of the body, such as the chest, abdomen, arms, groin or buttocks.
The virus that causes molluscum, which belongs to the family of viruses called poxviruses, can spread from child to child through skin-to-skin contact. The virus is easily shared with family members. Kids can also contract the virus by bathing or swimming in a pool with an infected child.
Although molluscum growths will eventually go away on their own without leaving a scar, because it could take from six months to five years for all of them to go away, and because they’re so easily spread to others, most physicians advise treatment. Your child’s doctor may remove the growths by:
- freezing them with liquid nitrogen.
- destroying them with various acids or blistering solutions.
- treating them with an electric needle.
- scraping them off with a sharp instrument.
- treating them daily with a topical retinoid cream or gel.
- eliminating them with the user of laser therapy.
While it’s best for your child to avoid contracting the virus at all, it may be difficult, especially for siblings who share such close contact at home. However, having them avoid bathing together or coming into contact with the actual lesions will reduce their risk of infection. But if your child does sprout these growths, not to worry. They are treatable and won’t leave any lasting scars.
For more health news from The Children’s Hospital of Philadelphia
Trials of antidepressants for children consistently exaggerated their benefits while playing down their possible harm
October 29, 2007
Antidepressants should not be used to treat children and teenagers, a controversial new Australian study has warned, saying clinical trials have exaggerated the benefits of the drugs and played down their side effects.
However, doctors are split over the findings, arguing that the drugs have a valid place in the treatment of young people.
The Australian study, published in the British Medical Journal, found trials of antidepressants such as Zoloft, Prozac, Arapax, Efexor and Cipramil for children consistently exaggerated their benefits while playing down their possible harm.
The study also found drug companies had either paid for the trials or remunerated the authors of at least three of four larger studies.
Jon Jureidini, the study’s lead author, said the findings showed antidepressants could not confidently be recommended as a treatment for children.
This follows international concern that the use of selective serotonin reuptake inhibitor antidepressants (SSRIs) to treat childhood and adolescent depression is linked to increased suicide risk and self-harm.
But other experts warned against an over-simplistic approach, arguing that the use of antidepressants depended on the treatment options available.
In younger children, the evidence on antidepressant use was not as clear and he believed the prescription of the drugs was best left to psychiatrists with experience in treating children.
Low carb diets should be avoided by growing children and adolescents
October 29, 2007
Even if you’re not eating “low-carb,” it’s a good bet you at least know several people who are. Many people have found this the way to lose and maintain weight, while others argue that although you may see results, it could ultimately cause health problems such as heart disease. Most pediatricians would agree that a low-carb diet is not one a growing child should embrace.
In fact, some experts believe these kind of diets are downright dangerous for kids. Since glucose, which comes from carbohydrates, is the brain’s preferred source of energy, a child who takes in very limited carbs may not grow or perform as well in school as he should.
In addition, many of the foods that are eliminated on most low-carb diets are ones that children need to grow healthy and strong bodies. A severe restriction of whole grains, fruits and many vegetables can do children a real health disservice. These foods, which are rich in vitamins, minerals, fiber and cancer-fighting phytochemicals, should be part of a well-balanced diet for kids. Not only that, low-fat milk — an important source of calcium — is often restricted, leaving children at higher risk for osteoporosis.
Most doctors and nutritionists agree that children need to learn healthy eating habits that they can stick with for life. So instead of restricting your kids’ carbohydrate intake, make sure they eat varied diet of low-fat meats, vegetables, dairy and whole grains — then make sure the whole family lives a healthy lifestyle:
- Limit your child’s sedentary activities (such as watching television and playing video games) to less than two hours a day.
- Encourage your child to drink water, instead of sugar-laden soda and fruit-flavored beverages.
- Give your child healthy snacks and meals at regular times, to discourage continuous “grazing” on high-fat, high-sugar junk food.
- Play with your child — dance, play catch, take a walk. Simple activities can have a great health effect and keep your family close.
- Set a good example by eating right and staying physically active.
Breast-feeding may protect against SIDS
October 29, 2007
Breast-fed babies arouse more readily from deep sleep, Monash researchers have found, in a discovery that could help reduce deaths due to Sudden Infant Death Syndrome (SIDS).
An ability to wake up from sleep is believed to be an important survival mechanism that may be impaired in victims of SIDS. Although education programs to encourage parents to put babies to sleep on their backs and protecting babies from exposure to passive smoke have been effective in reducing the number of SIDS cases worldwide, it remains the major cause of death in infants aged between one month and one year.
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| Supporting breast-feeding: Dr Rosemary Horne. |
Dr Rosemary Horne and colleagues from the Department of Paediatrics and the Ritchie Centre for Baby Health Research at the Monash Institute of Reproduction and Development have investigated whether breast-fed infants wake more readily from sleep than formula-fed infants.
Their research has been published in the Archives of Disease in Childhood.
Babies have two basic sleep states - quiet sleep and active sleep. Active sleep is equivalent to REM (rapid eye movement) sleep in adults, which is a deep sleep and when dreaming occurs. Quiet sleep is similar to non-REM sleep.
“People have queried which sleep state is the most dangerous for babies,” Dr Horne said. “In quiet sleep, babies have more control over their physiology - their breathing and heart rate are quite regular. But in active sleep their breathing and heart rate are irregular and often babies will stop breathing for short periods of time. It appears that SIDS babies may be unable to rouse themselves and start breathing again.
“We also believe that babies who die from SIDS die toward the morning, which is when they have more active sleep.”
Dr Horne and her colleagues - Dr Peter Parslow, Ms Dorita Ferens, Ms Anne-Maree Watts and Associate Professor Michael Adamson - studied 43 healthy full-term infants who had been breast-fed or formula-fed and looked at how readily these infants woke from active sleep and quiet sleep.
The researchers attempted to wake the infants with a ticklish sensation - a gentle puff of air up the nose - when the babies were aged two to four weeks, two to three months and five to six months.
“We found that breast-fed infants were more easily aroused from active sleep at two to three months of age than formula-fed infants,” Dr Horne said. “Two to four months is the age at which the risk of SIDS is greatest. Very few babies die under one month, and the number dramatically decreases after four to five months.”
The researchers found no difference in the arousal responses of formula- and breast-fed babies during quiet sleep at any of the three ages studied.
“These study results support breast-feeding of infants during the critical risk period for SIDS, as reduced arousal, particularly in active sleep, could impair the ability of an infant to respond appropriately to a life-threatening situation,” Dr Horne said.
Lack of vigorous physical activity is the main contributor to obesity in adolescents ages 11 to 15
October 29, 2007
Lack of vigorous physical activity is the main contributor to obesity in adolescents ages 11 to 15, according to a study of 878 adolescents by researchers at the University of California, San Diego (UCSD) School of Medicine, in collaboration with investigators at San Diego State University.
One of the largest studies ever to look at the multiple factors of diet, physical activity and sedentary behavior on obesity in adolescents, the report was published in the April 2004 issue of the American Medical Association’s Archives of Pediatric and Adolescent Medicine.
In analyzing dietary factors, the researchers found that fiber intake, and not fat calories, was most closely related to an individual’s weight. While the percentage of calories consumed from fat did not differ significantly between a group of normal-weight adolescents and those identified as being at-risk for obesity, or already overweight, the normal-weight adolescents consistently reported higher intake of fibrous foods such as whole grains, fruits and vegetables, as compared to the at-risk and overweight children.
“This is a potentially important finding from this study and emphasizes the need to improve diet quality for adolescents,” commented the study’s principal investigator, Kevin Patrick, M.D., a UCSD professor of family and preventive medicine.
The study was also one of the largest to examine differences related to gender and ethnic background. A significant finding was that more Hispanic girls (54.8 percent) than non-Hispanic white girls (42 percent) were either overweight or at risk for obesity. However, no difference was found for weight status between boys based on their ethnic heritage.
Consistent with past studies, the researchers also found that boys’ overweight status was related to time spent watching television. Boys in the at-risk and overweight group reported significantly more minutes of television watching per non-school day (141.5 minutes/day) than the normal weight boys (108.4 minutes/day), whereas no group difference was found for girls.
“There’s often too much emphasis on what people consume and not on how much energy they’re expending during a given day,” said Patrick. “Our study points to the importance of examining both sides of the energy balance equation when considering the population-wide increase we’ve seen in overweight in this age group in the past couple of decades. Insufficient physical activity and too much time spent on sedentary behaviors like computer games and watching TV may equal, and even exceed, diet quality as important contributors to overweight in adolescence.”
To assess physical activity, the researchers used an accelerometer, a small device worn on a belt that stores data on amount and level of physical activity every minute for a week. The investigators found that both girls and boys in the normal-weight group participated in two to four more minutes per day of vigorous physical activity than those in the at-risk and overweight group. However, only boys showed a statistical difference between groups for minutes per day of moderate physical activity.
“Although this is a seemingly small difference, these adolescents are getting four to 12 minutes of vigorous activity daily and this type of activity burns a lot of energy,” Patrick said.
He noted that the findings illustrate a particular need for increased exercise by all girls and improved interventions with Hispanic girls that takes into account social and cultural aspects that may impact weight.
Recruiting adolescents from the practices of 45 primary care physicians in six San Diego County clinics, the investigators found that 45.7 percent of the 878 children were either at risk for becoming overweight, or were already classified as overweight by the standard body mass index (BMI) for age. The sample was diverse with approximately 42 percent of participants from ethnic backgrounds, primarily Hispanic.
Using a combination of measurement tools and adolescent self-reports for dietary and sedentary behaviors, the researchers compiled data on minutes of physical activity per day, hours of television per day, percentage of calories from total fat, percentage of calories from saturated fat, and amount of fiber (grams per day).
The researchers noted that limitations of their study included its restriction to one geographic region, the use of self-report for dietary and sedentary behaviors, and a relatively narrow age range.
“Nonetheless, the findings from the study contribute to the body of evidence suggesting that adolescents continue to require interventions that target multiple aspects of physical activity and nutrition,” the authors said in their report.
Trauma Highly Prevalent Among Delinquents
October 29, 2007
Almost every boy and girl currently detained in a juvenile facility in the United States has experienced at least one major trauma, and a large proportion of these children have post-traumatic stress disorder, according to a study in the April issue of Archives of General Psychiatry. Karen M. Abram and colleagues at the Psycholegal Studies Program at the Feinberg School of Medicine at Northwestern University showed that over 90 percent of delinquent youth in a large, temporary detention center for juveniles had had one or more traumas, such as witnessing violence or being threatened with a weapon. Abram and co-researchers assessed psychiatric disorders in 900 African American, non-Hispanic white and Hispanic teens who were 10 to 18 years old and randomly selected at admission to the Cook County Juvenile Temporary Detention Center. About 8,500 juveniles enter the facility each year for pre-trial detention and brief sentences. The Cook County facility was selected because it is typical of other urban detention centers nationwide. Results of the study also showed that a significantly higher number of boys than girls — 93 percent versus 84 percent — reported at least one traumatic experience. More than 12 percent of the participants met the diagnostic criteria for post-traumatic stress disorder. “While it’s true that the study participants, like most juvenile detainees in the United States, live in urban areas that have high rates of violence, our findings also are consistent with research linking traumatic victimization in childhood and subsequent psychosocial problems, such as delinquency and drug use,” Abram said. Among their other recommendations, the researchers said that the mental health system must improve services for high-risk youth who are victims of trauma; improve the detection of post-traumatic stress disorder in juvenile detainees; and avoid re-traumatizing children during detention. Abram is assistant professor of psychiatry and behavioral sciences. Her co-authors on this study were Linda A. Teplin, Owen L. Coon Professor of Psychiatry and Behavioral Sciences and director of the Psycholegal Studies Program; Devon R. Charles; Sandra L. Longworth; Gary M. McClelland, research assistant professor of psychiatry and behavioral sciences, and Mina K. Dulcan, M.D., professor of psychiatry and behavioral sciences and head of child and adolescent psychiatry, Children’s Memorial Hospital. This study was supported by grants from the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, the Office of Juvenile Justice and Delinquency Prevention, the Robert Wood Johnson Foundation, the William T. Grant Foundation and a consortium of other agencies.
More evidence needed to link symptoms like tics or behavioral problems to a strep infection
October 29, 2007
Doctors should wait for more evidence before signing on to the notion that the sudden development of symptoms like tics or behavioral problems in a child is related to a strep infection, according to researchers writing in the April issue of the journal Pediatrics.
In the last few years, debate has heated up among both parents and doctors about a purported link between an infection caused by strep bacteria and the development of neuropsychiatric symptoms such as tics or obsessive-compulsive behavior. It’s known as the PANDAS hypothesis - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS). Some doctors suspect that a strep infection triggers the body to produce antibodies that then attack or damage the brain, triggering or worsening tics or obsessive-compulsive disorder (OCD) and similar conditions in children.
“Doctors and parents are confused - they’re not sure what to think. That’s understandable. At this point, there’s not enough data to resolve the issue,” says neurologist Roger Kurlan, M.D., chief of the Cognitive and Behavioral Neurology Unit at the University of Rochester’s Strong Memorial Hospital.
In the Pediatrics paper, Kurlan and Edward L. Kaplan, M.D., of the University of Minnesota assert that the criteria for establishing a connection between strep and behavioral disorders are too vague. For instance, one PANDAS hallmark is the abrupt onset of symptoms - but oftentimes once parents learn more about tics, they realize that their children have had them for quite awhile. The researchers say that while strep has been linked to other disorders such as rheumatic fever and Sydenham’s chorea, large and carefully controlled studies have demonstrated those connections. They say the same is not true of PANDAS.
“Tics are such that they wax and wane,” says Kurlan. “Oftentimes patients come in to the doctor’s office soon after their symptoms have peaked, so it proves nothing to show that a child’s symptoms subsided after they saw a doctor and were treated with antibiotics. It’s quite possible that doctors could give such children a green-bean diet, and the children would get better. That’s why we need a carefully done placebo-controlled study.”
Perhaps once a month Kurlan treats a child whose parents are concerned about a possible link between the child’s symptoms and strep, and he fields frequent phone calls from parents with similar concerns. And it’s true, he says, that nearly every child he sees has had a strep infection, and that many had a recent infection. That’s because it’s extremely rare to find a child who has never been infected by strep, and most have been infected several times, Kurlan says. That means that nearly every child who has behavioral problems, or for that matter any problems, has been infected by strep. It’s a little bit similar to arguing that drinking water causes broken bones, since nearly everyone who has broken a bone has drunk water or a water-based fluid the same day the fracture occurred.
“It’s human nature to try to ascribe the onset of symptoms to a specific preceding event,” he says. “There has to be a very carefully done clinical study to determine whether that preceding event is truly linked, or whether the two events occurred simultaneously just by chance. This is especially true when dealing with a very common event like strep infection.
“It’s human nature to want a explanation. For almost every parent who recognizes tics and obsessive-compulsive behavior in their children, almost immediately, as soon as they recognize it, their minds shift into high gear, questioning why the child has these symptoms.”
Kurlan says that about one in every five children has some tics at some point while growing up, and another one in five will show some obsessive-compulsive behavior. Most of these will outgrow the symptoms naturally within a few weeks or months, while generally children whose symptoms last more than a year may need treatment. He says that family history -genetics - appears to be the biggest cause of tics and OCD.
With funding from the National Institute of Neurological Disorders and Stroke, Kurlan is now studying 80 children who have physical or vocal tics or have been diagnosed with obsessive-compulsive disorder. A team from 11 medical centers around the country is tracking the youngsters for two years, logging both strep infections and behavioral difficulties in an attempt to uncover any link between the two. Every three months the children receive a physical exam, including a blood test, regardless of how they feel, since children with strep often feel fine. In addition, nurses obtain throat cultures from the children every month, and whenever children have a sore throat, or when their obsessive-compulsive symptoms or tics worsen, doctors examine them. The study will be completed next year.
Online, web-based system for ordering total parenteral nutrition (TPN)
October 29, 2007
Researchers at the Johns Hopkins Children’s Center have designed an online, Web-based system for ordering total parenteral nutrition (TPN) that identifies and pre-emptively eliminates potentially serious calculation errors.
The Children’s Center team describes its “TPN Calculator” in the April issue of Pediatrics.
“TPN Calculator” not only reduced TPN order errors in the Hopkins Neonatal Intensive Care Unit (NICU) by nearly 90 percent, but also proved to be faster and easier to use than the standard paper-based order system, the team reports.
“TPN calculations historically have required a lengthy process involving a series of mathematical calculations to determine the correct formulations for each patient,” says the study’s lead author, Christoph U. Lehmann, M.D., a neonatalogist at the Children’s Center. “With each step there was a potential for mistake. The calculator was developed to address the complexity and thereby reduce problems.”
“Caregivers using the system report they are saving up to eight minutes per order, meaning they have more time for patient care,” he adds. “This system has also had a huge impact on our pediatric pharmacists, who previously had to recalculate each individual TPN order that they received. Now, rather than recalculating everything by hand, they can simply review each online order.”
Lehmann, one of the developers of the TPN Calculator, says the system’s design was based on existing paper forms to provide users with a familiar format and maximum comfort level.
“We addressed only what was thought to be the ‘broken link’ in the TPN order process, namely calculation errors and knowledge problems, in order to preserve the majority of the existing ordering process. But at the same time, we were able to provide a system we knew our users would recognize and find easy to use,” he adds.
TPN provides patients with all required nutrients, including protein, fats, carbohydrates, fluid and vitamins, through a specially tailored solution given intravenously. Premature or ill infants who cannot breastfeed or take a bottle often receive TPN while in the NICU. However, because the TPN solution must be carefully formulated for each patient, hospitals nationwide have seen large numbers of medical errors associated with TPN orders.
For their study, the Children’s Center researchers first recorded a baseline total of 60 errors (10.8 per 100 TPN orders) from October through November 2000 that required the pharmacist to contact the provider to clarify or correct the order. After the paper-based TPN order system was replaced by the TPN Calculator, they saw just 20 errors from November to December 2000 (4.2 errors per 100 orders). Two years later, the error reduction rate soared to 89 percent, with just eight errors (1.2 errors per 100 orders) detected from August to October 2002.
The TPN Calculator computes all necessary fluid and component calculations, contains nutritional guidelines, and includes 62 rule-based alerts and reminders that prompt providers to review their information if any errors are detected. Lehmann says training takes an average of 10 minutes.
“This study demonstrates that it’s possible to identify a situation with a potential for errors and use existing infrastructure to develop a practical, technological solution, while leaving aspects of the remaining system intact,” Lehmann says.
The development of the TPN Calculator is one of many examples of the Johns Hopkins Children’s Center’s commitment to patient safety. In 2001, the Children’s Center initiated its own pediatric patient safety program, “Safe and Sound,” to proactively identify and remedy processes most vulnerable to human mistakes. The program is a collaboration of physicians, nurses, pharmacists, and allied health professionals and staff of the Children’s Center, united with families in safeguarding the well-being of children and adolescents.
Co-authors on the study were Kim Conner of the Divisions of Pediatric Pharmacy and Gastroenterology and Nutrition, and Jeanne Cox of the Division of Gastroenterology and Nutrition at the Johns Hopkins Children’s Center. Their work was supported by the Center for Innovation in Quality Patient Care at The Johns Hopkins Hospital.
