Management of fever and neutropenia in children with cancer.

PURPOSE: Febrile neutropenia remains a common, life-threatening complication of chemotherapy in paediatric oncology. Delays in institution of empiric antibiotics have been identified at tertiary and regional centres caring for these patients and associated with decreased survival. Our objective was to reduce the time to administration of empiric antibiotics to less than 60 min from the time of presentation to hospital. METHODS: A retrospective study of the records of oncology patients presenting to the emergency department of a tertiary hospital over a 3-month period was performed and time to first antibiotic administration recorded. Potential causes of delay in commencement of antibiotics were identified and an algorithm-based approach to the management of fever in immunocompromised children developed and implemented. Follow-up evaluation data were collected at 12 and 60 months post-intervention. Causes of delay in commencement of antibiotics at regional hospitals that share care with the tertiary hospital were identified through questionnaires, interviews and focus groups, involving patients and medical and nursing staff. The impact of the introduction of the algorithm at one peripheral hospital was evaluated. RESULTS: The mean time to empiric antibiotics was reduced from 148 min (95% confidence interval (CI) 81-216) at baseline to 76 min (95% CI 50-101) at 12 months post-intervention and sustained at 65 min (95% CI 52-77) 5 years after the intervention. At the peripheral hospital, mean time to antibiotic delivery was reduced from 221 min (95% CI 114-328) to 65 min (95% CI 42-87) at 12 months after the intervention. CONCLUSION: The introduction of the guideline, with teaching and support for staff and parents, resulted in an improvement in practice, meeting international guidelines and achieving sustained results at 5 years after introduction at a tertiary hospital. The guideline has been shown to be feasible and effective at a regional hospital.

Pediatric bone marrow transplantation update.

PURPOSE/OBJECTIVES: To review the diseases of childhood for which bone marrow transplantation (BMT) is an accepted treatment modality. DATA SOURCES: Book chapters, journal articles. DATA SYNTHESIS: BMT is used to treat a wide variety of nonmalignant and malignant childhood conditions. Despite treatment successes, BMT and its complications present a serious threat to children and a challenge for care providers. Identification of suitable donors is an ongoing concern. CONCLUSIONS: Acute and chronic/long-term effects of BMT are many and varied. Care of children and their families is ongoing and critical to achieving quality of life following successful transplantation. IMPLICATIONS FOR NURSING PRACTICE: In addition to the intensive care required by BMT, nurses must be knowledgeable about normal growth and development and encourage each child to achieve his or her full potential.

Munchausen syndrome by proxy.

Munchausen Syndrome by proxy as a form of child abuse is appearing with greater frequency in the literature. It is essential for pediatric nurses to know this form of child abuse and to aid in early detection, diagnosis, and intervention. The purpose of this article is to present a model of care to assist nurses in detecting and managing affected children and their families.

Gene therapy techniques in the treatment of adenosine deaminase--deficiency severe combined immune deficiency syndrome.

Gene therapy is an innovative technique utilized in the treatment of a primary immunodeficiency known as severe combined immune deficiency syndrome (SCIDS). The first human trials of gene therapy for SCIDS were conducted in 1990, by attempting to insert the gene for adenosine deaminase into peripheral white blood cells to treat children with adenosine deaminase (ADA)-deficiency SCIDS. Recently, three infants with ADA-deficiency SCIDS received gene therapy with genetically manipulated hematopoietic stem cells. This clinical update reviews basic immunology function and malfunction, describes gene therapy, and specifically highlights hematopoietic stem cell gene therapy treatment for ADA-deficiency SCIDS.

Intravenous gamma-globulin: clinical applications in pediatric care.

Intravenous gamma-globulin is being used with increasing frequency in the care of children. This article reviews the physiology of the immune system, the pharmacology of intravenous gamma-globulin, and presents four case studies. Administration guidelines, adverse reactions, and appropriate interventions are discussed. A table comparing four commonly used products is presented.