AAP Statement on Pediatric Palliative Care

The Committee on Bioethics and the Committee on Hospital Care of the American Academy of Pediatrics (AAP) have issued a statement on palliative care for children. The statement offers an integrated model for providing palliative care for children living with a life-threatening or terminal condition. The statement appears in the August 2000 issue of Pediatrics.

The AAP statement discusses principles for palliative care, including respect for the dignity of patients and their families, access to competent and compassionate palliative care, support for the caregivers, improved professional and social support for pediatric palliative care and continued improvement of pediatric palliative care through research and education. The statement also provides information on working with dying children and their parents, hastening death, barriers to the provision of pediatric palliative care and minimal standards for pediatric palliative care.

The AAP committees make the following recommendations:

• Palliative care and respite programs should be developed and widely available to provide intensive symptom management and promote the welfare of children living with life-threatening or terminal conditions.

• When a life-threatening or terminal condition is diagnosed, it is important to offer an integrated model of palliative care that continues throughout the course of illness, regardless of the outcome.

• Changes in the regulation and reimbursement of palliative care and hospice services are needed to improve access for children and families. Modifications in current regulations should include: (1) broader eligibility criteria concerning the length of expected survival, (2) the allowance of concurrent life-prolonging and palliative care, and (3) the provision of respite care and other therapies beyond those that are allowed by a narrow definition of “medically indicated.”

• Physicians who work with children need to become familiar and comfortable with the provision of palliative care to children.

• The practice of physician-assisted suicide or euthanasia for children should not be supported.

Weaning Patients from Mechanical Ventilation

Because of the costs associated with the use of life support technology and the related morbidity and mortality, the Agency for Healthcare Research and Quality (AHRQ) has released an evidence-based report on the criteria for weaning patients from mechanical ventilation.

The following questions defined the parameters of the report: (1) When should weaning be initiated? (2) What criteria should be used to initiate the weaning process? (3) What are the most effective methods of weaning from mechanical ventilation? (4) What are the optimal roles of non-physician health care professionals in facilitating safe and expeditious weaning? (5) What is the value of clinical practice algorithms and computers in expediting weaning?

Investigators reviewed the medical literature and retrieved reports on all relevant randomized controlled trials and clinical observational studies on weaning from mechanical ventilation. The following is a summary of their findings:

• According to current research, medical staff should begin testing for the opportunity to reduce life support soon after intubation and further reduce support at every opportunity.

• Differences in physicians' intuitive threshold for reduction or discontinuation of ventilatory support have a greater impact on the failure of spontaneous breathing trials or on reintubation than do modes of weaning.

• For step-wise reductions in mechanical support, pressure support mode or multiple daily T-piece trials may be superior to intermittent mandatory ventilation.

• For trials of unassisted breathing, low levels of pressure support may be beneficial.

• There may be substantial benefits to early extubation and institution of noninvasive positive pressure ventilation for patients who are alert, cooperative and ready to breathe without an artificial airway.

• While steroids can reduce post-extubation stridor in children, their impact on reintubation in children and adults is uncertain.

• The role of computerized weaning protocols has not been established.

A guideline based on this report is expected to be released this year by the American College of Chest Physicians, American Association for Respiratory Care and the Society for Critical Care Medicine.

Copies of “Criteria for Weaning from Mechanical Ventilation” (Evidence Report No. 23) are available from the AHRQ Publications Clearinghouse by writing to P.O. Box 8547, Silver Spring, MD 20907, or by calling 800-358-9295. The summary is also available on the AHRQ Web site athttp://www.ahrq.gov/clinic/mechsumm.htm.

Use of EEG to Evaluate First Seizure in Children

Each year, about 25,000 to 40,000 children in the United States have a first nonfebrile seizure. Nonfebrile seizures are unexpected and cannot be explained by an obvious cause such as head trauma. The American Academy of Neurology (AAN) has published guidelines on the use of electroencephalography (EEG) to evaluate the occurrence of a first seizure in children. The guidelines appear in the September 12, 2000 issue of Neurology.

According to the AAN guidelines, children who experience a first seizure without a fever should receive an EEG evaluation to predict future risk of seizures. The AAN reports that an examination with EEG after a non-febrile seizure is not often a routine procedure because of limited access to the equipment in emergency facilities. EEG can be used to predict additional seizures and identify the type of seizure and the possibility of epilepsy.

In addition, the guidelines discuss the need for more research on seizures in children. Areas for new research include the use of lumbar puncture, laboratory testing and neuroimaging to determine the cause of the seizure and potentially treatable abnormalities. The AAN also recommends evaluation of the timing of testing.

ACSM Statement on Exercise During Pregnancy

The American College of Sports Medicine (ACSM) has issued an official statement on exercise during pregnancy. The statement appears in the August 2000 Current Comment from the ACSM.

According to the ACSM, physical activity and reproduction are normal parts of life, so for normal healthy women, combining regular exercise and pregnancy appears to benefit mother and infant.

For pregnant women who want to exercise during pregnancy, the ACSM offers the following recommendations:

• Safety. Balance and coordination may be affected by changes in weight distribution. Exercise programs should be modified if they carry a risk of abdominal injury or fatigue instead of relaxation and a sense of well-being.

• Environment. Regulation of body temperature depends on hydration and environment. Exercising pregnant women should drink water before, during and after exercise; wear loose-fitting clothing; and avoid high heat and humidity, especially during the first trimester.

• Growth and Development. Exercise and diet should be monitored to ensure proper weight gain. If bleeding, pain or chronic fatigue occurs, exercise should be discontinued until a medical evaluation has been completed.

• Mode. Weight-bearing and non–weight-bearing exercise is thought to be safe during pregnancy. Walking, jogging and low-impact aerobics are good options for weight-bearing exercise. Heavy weightlifting, bicycle riding and scuba diving should be discouraged.

• Intensity. Exercise intensity should not exceed pre-pregnancy levels. Moderate to hard intensity is safe in women who are used to this level of exercise.

• Exercise. A healthy woman with a normal pregnancy may continue her regular exercise regimen or begin a new program during pregnancy.

Current Comments are official statements by the American College of Sports Medicine concerning topics of interest to the public at large. For more information, write to the ACSM, P.O. Box 1440, Indianapolis, IN 46206-1440 or call 317-637-9200.