Use of sedation and local anesthesia to prepare children for procedures.

Analgesic and sedative needs depend on the type of procedure, the child's age and the degree of cooperation from the child and parents. Local anesthesia, which may be administered subcutaneously or in topical gel form, generally is sufficient for common procedures such as lumbar puncture and laceration repair. Frequently used local anesthetics in children include buffered lidocaine, the eutectic mixture of lidocaine and prilocaine and the combination of tetracaine, adrenaline and cocaine. To reduce the potential for systemic absorption and toxicity, anesthetics should not be applied on or near mucosal areas. To minimize drug interactions, only a single sedating drug should be used, with dosage limits defined and never exceeded. If sedation is necessary, continuous pulse oximetry, a resuscitation cart and personnel trained in sedative drug use and advanced airway management must be available. Because of its therapeutic index and low toxicity, chloral hydrate has long been a popular sedative-hypnotic drug. Midazolam may be considered when amnesia is desired.

Management of the febrile infant.

The management of the febrile infant is truly a complex and evolving topic in pediatrics. The clinical practice guideline provides a map for physician decision making in this important clinical issue. An individual physician may alter the course of action based on his or her treatment threshold but must recognize the limitations of that approach. Documentation of management decisions that deviate from published guidelines are important for patient care. The medical record must carefully represent the appearance of the patient, the actions taken, and the discussion with the family regarding management. Close follow-up includes phone contact with documentation and reexamination of the patient in a reasonable period of time. All who deal with the common problem of fever in infants should follow this subject closely and be ready to adopt new management strategies when evidence from outcomes-based research emerges. In the mean time, the current practice guideline offers an excellent starting point in the management of this common and vexing clinical problem.

Pediatric resident training in a school environment. A prescription for learning.

OBJECTIVE: To describe our experience with developing, implementing, and evaluating the educational effect of a school health experience for pediatric residents. DESIGN: Descriptive. SETTING: University-based pediatric residency program and five public elementary and middle schools in surrounding communities. PARTICIPANTS: Eleven pediatric residents. INTERVENTION: A school health experience for pediatric residents was developed in response to the report of the American Academy of Pediatrics Task Force on Pediatric Education and the new training recommendations of the Residency Review Committee of the American Council for Graduate Medical Education. Residents spent 3 weeks in the schools engaged in teaching and observational activities. MAIN OUTCOME MEASURES: Questionnaires of residents' attitudes and knowledge, structured resident interviews, and teacher questionnaires. RESULTS: Positive effect on resident's knowledge of school structure, child development, communication with children, school-related problems, and special education. Positive effects on resident's attitudes about teamwork between teachers and pediatricians and roles of pediatricians in schools. Teacher feedback showed acceptance by the school community. CONCLUSIONS: Pediatric residents benefit from exposure to children in school settings. Schools provide an opportunity to observe normal childhood development and behavior in a more natural setting than that provided in the hospital.