Because the commonly used drug propofol can cause low blood pressure, prolonged sleepiness and decreased breathing, this study’s results can help anesthesiologists safely treat a common type of surgical patient that is often misunderstood.

“Little information is available to assist anesthesiologists in determining the right dose of medication to give to an obese child,” said Dr. Olutoyin A. Olutoye, of Texas Children’s Hospital in Houston, and lead author of the study.

Companies that make these medications do not specifically study their effects in this group of children before the drug is released for general use,  researchers say.

Anesthesiologists now must decide whether anesthetic drug doses should be based on a child’s actual weight or lean body weight. In obese children, 75 percent of their excess body weight is comprised of fat tissue, which alters drug distribution.

“Obese adults often need a smaller dose of propofol than normal weight adults, but a correlation to children isn’t guaranteed since adults and kids handle medications differently,” said Dr. Olutoye in a news release.

For this study, 40 obese and 40 non-obese children were observed using a process called the biased coin design. This process requires fewer patients and provides greater accuracy in the calculation of dose requirements than other techniques.

After measuring each child’s response 20 seconds after the propofol was administered, researchers discovered obese children needed 2 mg/kg of propofol to bring about unconsciousness at the beginning of surgery, compared to the normal weight children who needed 50-60 percent more propofol (3.2mg/kg).

“When providing care for obese children with propofol, 95 percent of children will likely need only a smaller dose of propofol to initiate anesthesia for surgical procedures,” said Dr. Olutoye, commenting on the study‘s results.

This study is important, Dr. Olutove said,  because propofol can cause low blood pressure, which can be worsened if larger-than-needed amounts are given.

Researchers say more pediatric studies are needed to determine if there are other differences in medication responses for obese and non-obese children in clinical practice.

For more on child medical safety issues, see the library of articles by Daytona Beach child injury attorney.

Unfortunately for this young 24-year-old mother, lack of attention to complications and warning signs, and lack of communication between a nurse and doctor, resulted in the delayed birth and permanent brain damage to her baby.

When the young woman with full term pregnancy began to experience pain and leak fluid, she called her obstetrician to confirm if she was in labor. Her doctor advised her to use a peripad, rest, and call back if the symptoms increased.

About two hours later she went to the emergency room in severe pain. She was admitted at 8:15 p.m. with leaking green/brown fluid.
The nurse placed an electronic fetal monitor (EFM). The patient was 1-2cm dilated and 50 percent effaced. Per EFM, the fetus was showing heart rate decelerations to 90 and decreased beat-to-beat variability. Meconium, or the earliest stools from the baby, was present on the patient’s peri-pad.

The patient requested analgesics for pain, and the RN called the obstetrician. She advised him that the EFM strip looked good, and requested an order for Nubain IM for pain, which was administered shortly thereafter.

The obstetrician arrived at 9:20 p.m. Meconium was still present, and the EFM strip showed some decelerations and decreased variability. The obstetrician questioned if it might be due to either the Nubain or to the EFM picking up the maternal pulse. He decided to treat her conservatively with hydration and oxygen. The patient was 3cm dilated, and she received an epidural.

At 10:50 p.m., as the EFM showed late decelerations and decreased variability, the RN called the obstetrician to the patient’s room. The patient was now 5cm dilated. Fetal scalp PH tests were performed by the obstetrician, and results were abnormal at 7.15. The obstetrician determined the fetus was in distress, and ordered an emergency C-section.

An infant girl was born at 11:24 p.m., weighing 6.4 pounds, with Apgar scores of 1 at 1 minute, 5 at 5 minutes and 7 at 10 minutes. Her heart rate was less than 80, and she required vigorous resuscitation.
The infant ultimately developed seizures and was diagnosed with hypoxic ischemic encephalopathy or lack of blood flow to the brain. She suffers neurological defects from cerebral palsy, such as: right sided hemi paresis – injury to the left side of the brain, which controls language and speaking; cognitive difficulty and speech delays.

Important factors which led to the settlement of this medical malpractice case include:

The nurse did not accurately communicate the maternal-fetal status to the obstetrician. This negatively effected the physician’s decisions and caused a delay in diagnosis of fetal distress. Specific significant results, such as EFM tracings must be shared during the phone consult. An incomplete status report may lead the physician in charge to miss important clues necessary to understand what is needed next, as was the case here.

Early recognition of fetal distress signs require baseline measures to assess trends. New medications initiated at the hospital can complicate ongoing patient evaluation.

The obstetrician initially told her to stay home during her first call. Telephone assessments in a case that is perceived as “low-risk” present a risk of under-evaluation of what the patient is experiencing. Probing questions that a high-risk pregnancy requires may be important for any pregnancy. Good documentation of all phone conversations that have taken place will result in better flow of information and ultimately better care of the patient.

Lack of a process for relaying important details. Care teams need to develop an understanding of what needs to be communicated during patient status reports over the telephone. In order to consider more urgent possibilities in the differential diagnosis, all providers must understand the value of their observations. Physicians and nurses can use mental or written checklists to make sure everyone knows about the presence of significant symptoms.

Viruses, which do not respond to antibiotics, cause more than two-thirds of upper respiratory tract infections or URIs, but URIs account for approximately 75 percent of  children’s antibiotic prescriptions.

The researchers report that parents who hear positive comments during their child’s examination, such as “no problem,” in contrast to comments suggesting that there is a “problem” to be concerned about, are less likely to question the doctor’s plan not to use antibiotics to treat the URI.

The researchers analyzed videotapes of 261 patient encounters for viral childhood URI involving 38 California pediatricians in 27 community practices. They found that comments during the physical exam occurred in 71 percent of these visits (61 percent with only “no problem” comments, 10 percent with at least one “problem” comment).

For patient encounters for viral URI, “problem” comments were associated with a 13 percent increase in parents’ questioning of the subsequent no-antibiotic treatment plan compared with visits involving “no problem” comments or no comments during the examination.

Statements ruling out the need for antibiotics were independently associated with a 24 percent boost in parents’ questioning of the treatment plan. Patient visits in which the doctor made any “problem” comments resulted in 27 percent more inappropriate prescriptions of antibiotics than visits in which only “no problem” comments were made.

“Clinicians should consider the consequences of raising parental expectations for an antibiotic with an announcement of a ‘problem’ examination finding, or of being seen to commit themselves to a prescription by the same action,” researchers conclude in the study. In addition to influencing perceptions, ‘no problem’ commentary “may contribute to rapport building by giving insight into the physician’s reasoning about symptoms, and reassuring parents that symptoms are mild.”

The study was funded in part by the Agency for Healthcare Research and Quality and was published in the Patient Education and Counseling Journal.

For more on medical issues, see the library of articles by Daytona Beach medical malpractice and child injury attorney.

The guidance, titled “Dosage Delivery Devices for Orally Ingested OTC Liquid Drug Products,” describes how easy-to-use dosage delivery devices and devices that minimize the risk of unintentional overdose can be provided for OTC medicines such as liquid pain relievers, cold medicine, cough syrups, and digestion aids.

“Accidental medication overdose in young children is an increasingly common, but preventable public health problem,” said Dr. Karen Weiss, program director for the Center for Drug Evaluation and Research’s Safe Use Initiative, in a press release.

The FDA issued the guidance because of ongoing concerns about the potential accidental drug overdoses that can result from the use of dosage delivery devices with markings that are confusing, unclear or inconsistent with the labeled dosage directions.

Key recommendations in the guidance include:

• Dosage delivery devices should be included for all orally ingested OTC liquid drug products.
• Devices should be marked with calibrated units of liquid measurement (e.g., teaspoon, tablespoon, or milliliter) that are the same as the units of liquid measure specified in the directions for the product and there should not be any unnecessary markings.
• Manufacturers should ensure that dosage delivery devices are used only with the products they are packaged with.
• Liquid measure markings on dosage delivery devices should be clearly visible and not obscured when the liquid product is added to the device.

According to the FDA, parents and caregivers should follow 10 tips when giving medicine to an infant or child:

1. Always read and follow the Drug Facts label on your OTC medicine.
2. Know the ‘active ingredient’ in your child’s medicine.
3. Give the right medicine, in the right amount, to your child.
4. Talk to your doctor, pharmacist, or nurse to find out what mixes well and what doesn’t.
5. Use the dosing tool that comes with the medicine, such as a dropper or a dosing cup.
6. Know the difference between a tablespoon and a teaspoon.
7. Know your child’s weight.
8. Prevent a poison emergency by always using a child-resistant cap.
9. Store all medicines in a safe place.
10. Check the medicine three times.

The FDA recommends that anyone with questions about dosage delivery devices or how to measure liquid OTC medicines contact a physician, pharmacist, or other health care professional.

For more on child medical issues, see the library of articles by Daytona Beach child injury attorney.

While past studies in young animals have shown anesthetics cause potential developmental and behavioral changes, this particular study found no evidence of a similar detrimental effect in children.

“Fortunately, our study did not find a relation between neuro-degeneration and anesthesia in young children. The findings should help reassure parents that if their child needs to undergo surgery, a minimal amount of anesthesia does not appear to influence subsequent education achievements later in life,” said Dr. Tom G. Hansen, in a press release. “However, we cannot fully conclude that anesthetics are safe in all cases. More human data need to be collected to exclude effects in more particular domains of neurobehavioral outcome.”

Investigators compared the academic performance of all Danish children born between 1986-1990 who underwent inguinal hernia repair prior to one year of age (2,689 individuals) to a randomly selected sample of 5 percent of the remaining Danish children of the same age (14,575 individuals).

Primary analysis compared the average test scores of participants in adolescence during the ninth grade, adjusting for gender, birth weight, and parents’ age and education, as well as the presence of other congenital malformations.

The study found there was no statistically significant difference in academic performance between the hernia group and the general population sample. Results showed the majority of children who underwent hernia repair in infancy did not show any signs of neurological impairment in adolescence.

“Dr. Hansen’s study is very timely with the recent U.S. Food and Drug Administration’s Anesthetic and Life Support Drugs Advisory Committee meeting,” said Anesthesiology Editor-in-Chief Dr. James C. Eisenach.  “The meeting determined that anesthesiologists must continue to actively pursue investigation in this area of research to fully evaluate potential developmental and behavioral changes in children exposed to anesthesia.”

The results of the study are published in the May issue of Anesthesiology.

For more on child medical issues, see the library of articles by Daytona Beach child injury attorney.

The Leapfrog Group, a hospital quality watchdog, recently released study findings that show wide disparities among hospitals in the number of elective early deliveries. Some hospitals deliver more than 40 percent of newborns early for no medical reason. Some deliver less than 5 percent unnecessarily early.

Early deliveries are associated with higher infant mortality and birth injury rates and are medically recommended only when vaginal delivery may pose a risk to the mother or baby. However, C-sections are becoming more common for non-medical reasons such as convenience.

Medical experts have long stressed that babies should not be born before 39 weeks unless medically necessary because their brains, lungs and other organs are not fully developed until the last few weeks in the womb.

If your baby has suffered brain damage a the hands of a negligent doctor, you have just been thrust into a war zone. So called litigation literature is just one of the many weapons doctors wield to protect themselves when they make mistakes and to torpedo your child’s chances of ever achieving some semblance of justice.

Litigation literature describes any study masquerading as an honest, scientific study but was written to refute plaintiffs’ claims in court. One such example is the requirement that brain damaged babies must prove that something the doctor did actually caused the brain damage – lawyers call this causation. The American College of Obstetrics and Gynecology (ACOG) wrote a paper purporting to be an honest scientific study that claimed that 90 percent of brain damaged babies received those injuries before birth.

A common claim in court is that brain damage is caused by a baby’s inability to get oxygen to its brain during birth. In 1992 however, doctors got tired of losing trials after negligently delivering a baby so they decided to promote some arguments that would protect them.

This particular study manipulated the existing medical literature to create a false sense of four essential criteria without which lack of oxygen during birth could not cause brain damage. The study claimed that birth injury to the brain could not be caused by lack of oxygen unless all four of these criteria were present:

1. Ph of less than 7.0;
2. Apgar scores of 0-3 for five or more minutes;
3. Symptoms like seizures and coma; and,
4. Multi-organ dysfunction following birth.

Of great interest is that neither number two nor four are considered valid today. Criteria number two is Apgar score, a numerical indicator given by nurses of how well the baby is breathing and moving after birth. However, in response to this article, hospitals had nurses assign Apgar scores of four or more. Thus, by artificially inflating the score, doctors and hospitals could avoid liability if a jury bought into the junk science they were propounding.

The truth is that a real scientific study based on hard evidence show the ACOG theory to be absolutely false. In fact at least 80 percent of brain damaged babies studied suffered injury due to lack of oxygen during birth. This evidence was gathered from autopsies and MRI scans which can reliably indicate the degree and timing of brain damage due to hypoxia (lack of oxygen).

We as plaintiffs’ lawyers work hard to overcome litigation literature and discredit the so called experts who propound these junk science theories, but the fight goes on and newly misleading articles continue to be published. A tragic side effect is that these junk science studies are entering the medical literature and are misleading well meaning health care providers.

There’s a new movement gaining momentum that casts doubts on the scientific evidence behind “shaken baby syndrome.” Medical and legal practitioners are begining to ask whether it is actually possible to shake a baby to death.

Shaken baby syndrome is usually diagnosed in the absence of physical signs of child abuse like bruises, cuts and broken bones. However, even without those symptoms, babies arrive at the emergency room with bleeding at the back of the eye, brain swelling and bleeding. This set of symptoms is often diagnosed as shaken baby syndrome and attributed to an adult vigorously shaking the baby.

Experts said that those three symptoms could only occur as the result of a shaking that produced forces equal to those of a car crash at speeds of 25-40 mph or a fall from a three story building. Some recent research using devices similar to crash test dummies suggests that aggressive shaking only produces injuries equal to those suffered in a 2-to 3-foot fall.

Reason and Discover magazine have published interesting articles about this growing group who are suspicious of shaken baby syndrome.