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Pediatric Airway ManagementPediatric Airway Management
Dave French, MD, NREMT-PDave French, MD, NREMT-P
Attending ED Physician,Attending ED Physician,
Albany Medical CenterAlbany Medical Center
Medical Director,Medical Director,
Albany & Schenectady Fire DepartmentsAlbany & Schenectady Fire Departments
GoalsGoals
Decision-makingDecision-makingBasicsBasics IntubationIntubationRescue devicesRescue devicesMedicationsMedicationsVentilatorsVentilatorsBroselowBroselow
Decision-makingDecision-making
What do I need to accomplish (why ETT)?What do I need to accomplish (why ETT)?How aggressive should I be (BLS vs. ALS)?How aggressive should I be (BLS vs. ALS)?What is my back-up plan?What is my back-up plan?What is the long-term picture?What is the long-term picture?
Reasons to Manage AirwayReasons to Manage Airway
Inadequate oxygenationInadequate oxygenation Low OLow O22
PneumoniaPneumonia CHFCHF
Inadequate ventilationInadequate ventilation High COHigh CO22
Asthma/COPDAsthma/COPD
Inadequate protectionInadequate protection AMSAMS Airway traumaAirway trauma
Anticipated courseAnticipated course HematomasHematomas Long transportsLong transports
BLS vs. ALSBLS vs. ALS
We think intubation is easyWe think intubation is easyWe are not good at itWe are not good at it
Prehospital success rate as low as 70%Prehospital success rate as low as 70%We can manage many patients with BLSWe can manage many patients with BLSRSI can kill peopleRSI can kill people
Who Should Be Intubated?Who Should Be Intubated?
AHA recommends prehospital intubationAHA recommends prehospital intubation De-emphasized under new ACLS/PALS guidelinesDe-emphasized under new ACLS/PALS guidelines
AAP developed PEPP courseAAP developed PEPP course Teaches intubation but not the focusTeaches intubation but not the focus
What does the literature say?What does the literature say?
Who Should Be Intubated?Who Should Be Intubated?
Gausche, et al in Los Angeles, 2000Gausche, et al in Los Angeles, 2000 Randomized trial comparing BVM, intubationRandomized trial comparing BVM, intubation 830 patients under 12 years830 patients under 12 years
No difference in survival or neurologic outcomeNo difference in survival or neurologic outcome No difference in complication rateNo difference in complication rate
2% esophageal intubation all died2% esophageal intubation all died 14% tube dislodged (6% unrecognized)14% tube dislodged (6% unrecognized) 24% wrong sized tube24% wrong sized tube
Should we be intubating Should we be intubating ANY pediatric patients?!?!ANY pediatric patients?!?!
Jury is still out, but some states Jury is still out, but some states already forbid it.already forbid it.
Predicting the Difficult AirwayPredicting the Difficult Airway
Difficulty ventilatingDifficulty ventilating Facial traumaFacial trauma ObesityObesity ObstructionsObstructions Stiff lungs (asthma)Stiff lungs (asthma)
Difficulty intubatingDifficulty intubating External factors (obesity)External factors (obesity) Evaluate mouth openingEvaluate mouth opening ObstructionObstruction
Smaller airwaysSmaller airways
Neck mobility (trauma)Neck mobility (trauma)
Easy or Hard?Easy or Hard?
Easy or Hard?Easy or Hard?
Easy or Hard?Easy or Hard?
The Debate on Prehospital The Debate on Prehospital Pediatric Intubation Continues…Pediatric Intubation Continues…
Back-up PlanBack-up Plan
Can’t ventilate or basics not workingCan’t ventilate or basics not workingConsider adjuncts (OPA/NPA/positioning)Consider adjuncts (OPA/NPA/positioning) Intubation?Intubation?
Can’t intubateCan’t intubateRescue devicesRescue devices
Can’t rescueCan’t rescueSurgical procedureSurgical procedure
Okay to stick with basics if workingOkay to stick with basics if working
It’s Not Okay to Continue It’s Not Okay to Continue with Failed Techniqueswith Failed Techniques
Long-Term IssuesLong-Term Issues
Securing the tubeSecuring the tubeTape vs. tiesTape vs. tiesCommercial devicesCommercial devicesRestraintsRestraints
Long-Term IssuesLong-Term Issues
SedationSedationAgent and administration (drip vs. bolus)Agent and administration (drip vs. bolus)Paralytics?Paralytics?
Ventilator managementVentilator managementWhat if the tube comes out?What if the tube comes out?
BasicsBasics
PositioningPositioningAdjunctsAdjuncts
OPA - good choice if toleratedOPA - good choice if toleratedNPA - easy to tear mucosaNPA - easy to tear mucosa
Effective BVM use is most important skillEffective BVM use is most important skillGet a good seal (two person better)Get a good seal (two person better)Don’t over ventilateDon’t over ventilate
Don’t forget the suctionDon’t forget the suction
Intubation -Intubation -PreparationPreparation
PreoxygenatePreoxygenateMonitors - ECG, pulse oxMonitors - ECG, pulse oxSellick’sSellick’sGood basicsGood basics
Equipment selectionEquipment selectionMiller vs. MacMiller vs. MacCuffed vs. uncuffedCuffed vs. uncuffedETT sizeETT size
PositioningPositioning
Airway EquipmentAirway Equipment
Straight blade to age 4?Straight blade to age 4?Better able to control epiglottis?Better able to control epiglottis?Choose for comfortChoose for comfort
Smaller tubesSmaller tubesLess stabilityLess stabilityMore resistanceMore resistance
Uncuffed tubes < 8 years of ageUncuffed tubes < 8 years of age
Airway EquipmentAirway Equipment
SuctionSuctionMagill forcepsMagill forcepsStyletStyletTube check and securing devicesTube check and securing devices
Tube SizeTube Size
ETT sizeETT size (Age in years/4) + 4(Age in years/4) + 4Diameter of nareDiameter of nareDiameter of pinkyDiameter of pinkyBroselow tapeBroselow tapeHave one size smaller and largerHave one size smaller and larger
Tube PlacementTube Placement
ETT depth – use the black lineETT depth – use the black line (Age in years/2) + 12(Age in years/2) + 12ETT internal diameter x 3ETT internal diameter x 3
Intubation -Intubation -PositioningPositioning
Goal is to align three axesGoal is to align three axesOA/PA/LAOA/PA/LA
Medical positioningMedical positioningHead tilt chin liftHead tilt chin liftTowels (older = head, younger = shoulders)Towels (older = head, younger = shoulders)
Trauma positioningTrauma positioningManual in-line stabilizationManual in-line stabilization
Positioning-Positioning-MedicalMedical
vs.vs.TraumaTrauma
Adapted from Walls et al. Manual of
Emergency Airway Management.
2nd Ed. 2004.
PositioningPositioning
Adapted from Walls et al. Manual of
Emergency Airway Management.
2nd Ed. 2004.
Intubation -Intubation -ApproachApproach
Remember, much different than adultsRemember, much different than adultsExternallyExternally
Larger head/occiputLarger head/occiputHead flexes forward and can obstructHead flexes forward and can obstruct
InternallyInternallyLarger tongueLarger tongueFriable tissuesFriable tissuesDifferent angles and shapesDifferent angles and shapes
Airway DifferencesAirway Differences
Nose
Tongue
TracheaCricoidAirway
Adapted from Walls et al. Manual of
Emergency Airway Management.
2nd Ed. 2004.
Airway ShapeAirway Shape
Adapted from Walls et al. Manual of
Emergency Airway Management.
2nd Ed. 2004.
Intubation -Intubation -ApproachApproach
Further differencesFurther differences ““Pinker” vocal cords worsen visualizationPinker” vocal cords worsen visualizationDifferent location of narrowest pointDifferent location of narrowest point
More precise ETT choiceMore precise ETT choiceAir leak vs. trauma/stenosisAir leak vs. trauma/stenosisPeds cuffed tubes?Peds cuffed tubes?
Smaller cricothyroid membraneSmaller cricothyroid membraneNo surgical crics in childrenNo surgical crics in childrenNeedle crics difficultNeedle crics difficult
Other ConsiderationsOther Considerations
More gastric insufflation with BVMMore gastric insufflation with BVMDifferent oxygenation abilitiesDifferent oxygenation abilities
Higher basal usageHigher basal usageLess residual lung capacityLess residual lung capacityQuicker desats during intubationQuicker desats during intubation
10 kg to 90% in <4 minutes (vs. 8 for adult)10 kg to 90% in <4 minutes (vs. 8 for adult)
More likely to have vagal responseMore likely to have vagal response
Intubation -Intubation -TechniquesTechniques
Always enter from the right cornerAlways enter from the right cornerTongue control is criticalTongue control is criticalLift the epiglottis with the MillerLift the epiglottis with the MillerSlide the Mac into the valleculaSlide the Mac into the vallecula
Can lift the epiglottis if neededCan lift the epiglottis if needed
Adapted from Walls et al. Manual of
Emergency Airway Management.
2nd Ed. 2004.
Intubation -Intubation -Trouble-shootingTrouble-shooting
Can’t see the cordsCan’t see the cordsLook for landmarksLook for landmarksControl the tongueControl the tongueBURP maneuver if epiglottis seenBURP maneuver if epiglottis seen
Another attempt needed (limit number)Another attempt needed (limit number)RepositionRepositionChange something (blade, tube)Change something (blade, tube)
Avoid hypoxia Avoid hypoxia
Blind TechniquesBlind Techniques
Exist but need practice for proficiencyExist but need practice for proficiencyDigital intubationDigital intubation
Small work areaSmall work areaBlind nasotracheal intubationBlind nasotracheal intubation
Tough angles for tube placementTough angles for tube placementRemember anatomic differencesRemember anatomic differencesContraindicated until >10 years oldContraindicated until >10 years old
In general, blind techniques In general, blind techniques not useful in childrennot useful in children
Intubation -Intubation -ConfirmationConfirmation
Visualize tube passing through cordsVisualize tube passing through cordsBreath sounds and epigastric soundsBreath sounds and epigastric soundsEnd Tidal COEnd Tidal CO22 (ETCO (ETCO22))Commercial devicesCommercial devices
Not effective on uncuffed tubesNot effective on uncuffed tubesBe careful if used in childrenBe careful if used in children
REMINDER: REMINDER: It’s Not Okay to Continue It’s Not Okay to Continue with Failed Techniqueswith Failed Techniques
Rescue DevicesRescue Devices
LMAs (laryngeal mask airway)LMAs (laryngeal mask airway) I-LMAs (intubating LMA)I-LMAs (intubating LMA)CombitubeCombitubeBougieBougiePick one or two and practicePick one or two and practice
Need to be comfortable before crisisNeed to be comfortable before crisis
LMALMA
Used in any ageUsed in any age Easy to place Easy to place Few complicationsFew complications Contraindications: Contraindications:
Gag reflexGag reflex FBsFBs Airway obstructionAirway obstruction High ventilation pressureHigh ventilation pressure
Does not secure airwayDoes not secure airway
LMA SizingLMA Sizing
LMA SizeLMA Size Patient SizePatient Size
11 Neonate / Infants < 5 kgNeonate / Infants < 5 kg
1 ½ 1 ½ Infants 5-10 kgInfants 5-10 kg
22 Infants / Children 10-20 kgInfants / Children 10-20 kg
2 ½ 2 ½ Children 20-30 kgChildren 20-30 kg
33 Children/Small adults 30-50 kgChildren/Small adults 30-50 kg
44 Adults 50-70 kgAdults 50-70 kg
55 Large adult >70 kgLarge adult >70 kg
I-LMAI-LMA
Only sizes 3, 4, 5Only sizes 3, 4, 5 Same rules and sizing Same rules and sizing
as LMAas LMA Need special armored Need special armored
tube for intubationtube for intubation New similar devices New similar devices
existexist Leave LMA portion in Leave LMA portion in
place in fieldplace in field
CombitubeCombitube
Two sizesTwo sizes Small (4 to 5.5 feet tall)Small (4 to 5.5 feet tall) Regular (over 5.5 feet tall)Regular (over 5.5 feet tall) Not useful in most kidsNot useful in most kids
Easy to placeEasy to place ContraindicationsContraindications
Gag reflexGag reflex Esophageal diseaseEsophageal disease Caustic ingestionsCaustic ingestions FBs/Airway obstructionFBs/Airway obstruction
BougieBougie
Replaces styletReplaces stylet Able to use with poor Able to use with poor
viewview Feel tracheal ringsFeel tracheal rings Feel carinaFeel carina
Intubate over itIntubate over it Keep blade in placeKeep blade in place Two person techniqueTwo person technique
Need to practiceNeed to practice
Other ToysOther Toys
Lighted styletLighted stylet Flexible fiberoptic Flexible fiberoptic
scopesscopes Rigid fiberoptic Rigid fiberoptic
scopesscopes BullardBullard ShikaniShikani
Video laryngoscopyVideo laryngoscopy
Surgical Airways -Surgical Airways -CricothyrotomyCricothyrotomy
Indications (only if >10 years old)Indications (only if >10 years old)Failed airwayFailed airwayFailed ventilationFailed ventilation
Predictors of difficultyPredictors of difficultyPrevious neck surgeryPrevious neck surgeryObesityObesityHematoma or infectionHematoma or infection
Cricothyrotomy -Cricothyrotomy -TechniquesTechniques
OpenOpen Locate CTMLocate CTM Stabilize larynx/prepStabilize larynx/prep Incise skinIncise skin
VerticalVertical Horizontal through CTMHorizontal through CTM
Insert spacer/dilatorInsert spacer/dilator Insert cuffed tubeInsert cuffed tube Check breath soundsCheck breath sounds
ClosedClosed Locate CTMLocate CTM Stabilize larynx/prepStabilize larynx/prep Insert needleInsert needle
Direct inferiorlyDirect inferiorly Insert guidewireInsert guidewire Remove needleRemove needle
Small skin incisionSmall skin incision Insert dilators/UC tubeInsert dilators/UC tube Check breath soundsCheck breath sounds
Cricothyrotomy -Cricothyrotomy -ComplicationsComplications
BleedingBleedingLaryngeal or tracheal injuryLaryngeal or tracheal injury InfectionInfectionPneumomediastinumPneumomediastinumSubglottic stenosisSubglottic stenosis
Surgical Airways -Surgical Airways -Needle CricNeedle Cric
Same indications (all ages, tougher if young)Same indications (all ages, tougher if young)Must use with TTJV (jet ventilator)Must use with TTJV (jet ventilator)
Cannot use with superior airway obstructionCannot use with superior airway obstructionSimilarly difficult patientsSimilarly difficult patients
Needle Cricothyrotomy -Needle Cricothyrotomy -ProcedureProcedure
Identify CTM and stabilize/prep larynxIdentify CTM and stabilize/prep larynx Insert needle on syringe, direct inferiorlyInsert needle on syringe, direct inferiorly
Large bore needle (12-16 gauge)Large bore needle (12-16 gauge)Catheter over needleCatheter over needle
Advance catheterAdvance catheter Connect to TTJV (BVM for infants - 3.0 ETT)Connect to TTJV (BVM for infants - 3.0 ETT)
Oxygen pressure (20-30 psi)Oxygen pressure (20-30 psi)1 second on/2-3 seconds off1 second on/2-3 seconds off
Needle Cricothyrotomy -Needle Cricothyrotomy -ComplicationsComplications
Similar complications to other cricsSimilar complications to other cricsPneumothorax/subcutaneous emphysemaPneumothorax/subcutaneous emphysemaBarotraumaBarotraumaEsophageal injuryEsophageal injuryObstructionObstruction
TTJVTTJV
What About RSI?What About RSI?
Rapid Sequence IntubationRapid Sequence Intubation
Does increase intubation successDoes increase intubation successYou stop intrinsic breathingYou stop intrinsic breathing
You can kill themYou can kill themLittle place for peds in prehospital settingLittle place for peds in prehospital setting
RSI MedicationsRSI Medications
Same as adultsSame as adultsLidocaine Lidocaine EtomidateEtomidateSuccinylcholineSuccinylcholineVecuroniumVecuronium
Remember atropineRemember atropineConsider ketamineConsider ketamine
Pretreatment - Pretreatment - LidocaineLidocaine
Mechanism: Decrease ICP, bronchospasmMechanism: Decrease ICP, bronchospasm Indications: Asthma, head injuryIndications: Asthma, head injuryContraindications: AllergyContraindications: AllergyDosage: 1.5 mg/kg 3 minutes before ETTDosage: 1.5 mg/kg 3 minutes before ETT
Pretreatment -Pretreatment -AtropineAtropine
Mechanism: Blunt vagal responseMechanism: Blunt vagal responsePrevent bradycardia from intubationPrevent bradycardia from intubationMore prevalent in childrenMore prevalent in children
Indications: All children <10 years oldIndications: All children <10 years oldContraindications: AllergyContraindications: AllergyDosage: 0.02 mg/kg 3 minutes before ETTDosage: 0.02 mg/kg 3 minutes before ETT
Induction -Induction -EtomidateEtomidate
Mechanism: Hypnotic, not analgesicMechanism: Hypnotic, not analgesicMost hemodynamically stableMost hemodynamically stable Inhibits excitationInhibits excitation
Indications: All inductionsIndications: All inductionsLess protection from bronchospasmLess protection from bronchospasmNo ICP issuesNo ICP issues
Contraindications: None (careful in shock)Contraindications: None (careful in shock)Dosage: 0.3 mg/kg for induction (15-45 sec)Dosage: 0.3 mg/kg for induction (15-45 sec)
Induction -Induction -KetamineKetamine
Mechanism: PCP derivativeMechanism: PCP derivativeAnalgesia, anesthesia, amnesiaAnalgesia, anesthesia, amnesiaLittle respiratory or hemodynamic effectLittle respiratory or hemodynamic effect Increases cerebral oxygen demandIncreases cerebral oxygen demand
Indications: RAD, children?, hemodynamicsIndications: RAD, children?, hemodynamicsContraindications: Contraindications:
Elevated ICP (worsens)Elevated ICP (worsens)Re-emergence in adults (hallucinations)Re-emergence in adults (hallucinations)
Dosage: 1-2 mg/kg for induction (45-60 sec)Dosage: 1-2 mg/kg for induction (45-60 sec)
Paralysis -Paralysis -SuccinylcholineSuccinylcholine
Mechanism: Depolarizing agentMechanism: Depolarizing agentBinds to NMJ and firesBinds to NMJ and fires
Indications: Paralysis w/ fasciculationIndications: Paralysis w/ fasciculationContraindications/Complications: Contraindications/Complications:
Hyperkalemia (Burns, crush, renal failure)Hyperkalemia (Burns, crush, renal failure) Increased ICP, globe injuryIncreased ICP, globe injuryProlonged blockade, MHProlonged blockade, MH
Dosage: 1.5-2 mg/kg (2 for younger)Dosage: 1.5-2 mg/kg (2 for younger)Rapid onset, brief duration (30 secs – 4 min)Rapid onset, brief duration (30 secs – 4 min)
Paralysis -Paralysis -VecuroniumVecuronium
Mechanism: Nondepolarizing agentMechanism: Nondepolarizing agentCompetitive blockade at NMJCompetitive blockade at NMJ
Indications: Indications: Pretreatment before SCh (no fasciculations)Pretreatment before SCh (no fasciculations)ParalysisParalysis
Contraindications: None (difficult airway)Contraindications: None (difficult airway)Dosage: 0.1-0.15 mg/kg in 90-120 secsDosage: 0.1-0.15 mg/kg in 90-120 secs
Lasts 60 minutesLasts 60 minutes1/101/10thth dose for pretreatment dose for pretreatment
Ventilator ManagementVentilator Management
Pressure vs. volume controlPressure vs. volume controlDepends on patientDepends on patientNeed to reassessNeed to reassess
Tidal volumes 8-10 mL/kgTidal volumes 8-10 mL/kgSimilar to adultSimilar to adultAgain, adjust according to patientAgain, adjust according to patient
Titrate other settingsTitrate other settingsLast resorts: HFOV, ECMOLast resorts: HFOV, ECMO
Ventilator ManagementVentilator Management
Volume control (constant volume)Volume control (constant volume)Set Rate and Tidal VolumeSet Rate and Tidal VolumeSet PEEP (Set PEEP (~~5) & Pressure Support5) & Pressure Support
Pressure control (constant pressure)Pressure control (constant pressure)Set Rate and PIP (20-25)Set Rate and PIP (20-25)Set PEEPSet PEEP
All settings require FIOAll settings require FIO22
Ventilator ManagementVentilator Management
To alter OTo alter O22
Change FIOChange FIO22
Change PEEPChange PEEPChange I:E ratioChange I:E ratio
To alter COTo alter CO22
Change rateChange rateChange tidal volume (or PIP)Change tidal volume (or PIP)
Ventilator ManagementVentilator Management
CPAP and BiPAPCPAP and BiPAPNot much use in younger childrenNot much use in younger childrenNeed to be able to comply with treatmentNeed to be able to comply with treatmentGood modalities in some settingsGood modalities in some settingsRarely (if ever) useful in prehospital settingRarely (if ever) useful in prehospital setting
Last but not least…Last but not least…
Broselow TapeBroselow Tape
Lubitz, et al. (1998)Lubitz, et al. (1998) Most accurate 3.5 - 25 kgMost accurate 3.5 - 25 kg More accurate than RN or MDMore accurate than RN or MD 94% vs 63%94% vs 63%
Broselow TapeBroselow Tape
Rowe, et al. (1998)Rowe, et al. (1998) Calculation error rate 3%Calculation error rate 3% Recheck increases to 10%Recheck increases to 10% Under stress, up to 25%Under stress, up to 25%
Broselow TapeBroselow Tape
Equipment sizesEquipment sizes Airway adjunctsAirway adjuncts Intubation equipIntubation equip Oxygen deliveryOxygen delivery Vascular accessVascular access DefibrillationDefibrillation NGT, suction cathsNGT, suction caths BP cuffBP cuff Chest tubesChest tubes FoleyFoley
MedicationsMedications AntiarrhythmicsAntiarrhythmics Arrest medicationsArrest medications AnticonvulsantsAnticonvulsants Overdose medsOverdose meds Increased ICP medsIncreased ICP meds Induction agentsInduction agents ParalyticsParalytics VasopressorsVasopressors IV dripsIV drips
Broselow TapeBroselow Tape
Broselow TapeBroselow Tape
8 color codes (6-36 kg)8 color codes (6-36 kg) Broselow-Luten Emergency Broselow-Luten Emergency
SystemSystem Color-coded bags with equipColor-coded bags with equip Quicker, more efficientQuicker, more efficient
SummarySummary
Think carefully about your goalsThink carefully about your goalsAssess your optionsAssess your optionsGood BLS is the most important skillGood BLS is the most important skill Intubate or not?Intubate or not?Have a back-up planHave a back-up planUse your BroselowUse your Broselow
Questions?Questions?
ReferencesReferences Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation Gausche M, et al. Effect of out-of-hospital pediatric endotracheal intubation
on survival and neurologic outcome. on survival and neurologic outcome. JAMAJAMA. 2000. 283(6): 783-790.. 2000. 283(6): 783-790. Gilligan BP, et al. Pediatric Resuscitation. In Gilligan BP, et al. Pediatric Resuscitation. In Rosen’s Emergency Medicine: Rosen’s Emergency Medicine:
Concepts and Clinical PracticeConcepts and Clinical Practice, 6, 6thth Ed Ed. Mosby, 2006.. Mosby, 2006. Hazinski MF, et al (Ed). Hazinski MF, et al (Ed). PALS provider manualPALS provider manual. AHA, 2005. . AHA, 2005. Lee BS, et al. Pediatric airway management. Lee BS, et al. Pediatric airway management. Clin Ped Emerg MedClin Ped Emerg Med. 2001. . 2001.
2(2): 91-106.2(2): 91-106. Lubitz DS. A rapid method of estimating weight and resuscitation drug Lubitz DS. A rapid method of estimating weight and resuscitation drug
doses from length in the pediatric age group. doses from length in the pediatric age group. Ann Emerg MedAnn Emerg Med.. 1998. 1998. 17(6):576-581.17(6):576-581.
Luten R. Error and time delay in pediatric trauma resuscitation: Addressing Luten R. Error and time delay in pediatric trauma resuscitation: Addressing the problem with color-coded resuscitation aids. the problem with color-coded resuscitation aids. Surg Clin of N AmerSurg Clin of N Amer. 2002. . 2002. 82(2).82(2).
Luten RC. The pediatric patient. In Luten RC. The pediatric patient. In Manual of Emergency Airway Manual of Emergency Airway Management, 2Management, 2ndnd Ed Ed. Lippincott, 2004.. Lippincott, 2004.
Tobias JD. Airway management for pediatric emergencies. Tobias JD. Airway management for pediatric emergencies. Pediatric AnnalsPediatric Annals. . 1996; 25:317-281996; 25:317-28