Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children

Background Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion, however there is debate regarding the need for heparin and evidence to suggest 0.9% sodium chloride (normal saline) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. Objectives To assess the clinical effects (benefits and harms) of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children. Search Methods The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (Issue 3, 2015). We also searched the reference lists of retrieved trials. Selection criteria Randomised controlled trials that compared the efficacy of normal saline with heparin to prevent occlusion of long term CVCs in infants and children aged up to 18 years of age were included. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Data Collection and Analysis Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. Rate ratios were calculated for two outcome measures - occlusion of the CVC and central line-associated blood stream infection. Other outcome measures included duration of catheter placement, inability to withdraw blood from the catheter, use of urokinase or recombinant tissue plasminogen, incidence of removal or re-insertion of the catheter, or both, and other CVC-related complications such as dislocation of CVCs, other CVC site infections and thrombosis. Main Results Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin, however, between studies, all used different protocols for the standard and experimental arms with different concentrations of heparin and different frequency of flushes reported. In addition, not all studies reported on all outcomes. The quality of the evidence ranged from low to very low because there was no blinding, heterogeneity and inconsistency between studies was high and the confidence intervals were wide. CVC occlusion was assessed in all three trials (243 participants). We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence). The duration of catheter placement was reported to be similar between the two study arms, in one study (203 participants). Authors' Conclusions The review found that there was not enough evidence to determine the effects of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children: A systematic review

Background Around the world, guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) vary greatly. To prevent occlusion, most institutions recommend the use of heparin when the CVC is not in use. However, there is debate regarding the need for heparin and evidence to suggest normal saline may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased costs. Objectives To assess the clinical effects (benefits and harms) of heparin versus normal saline to prevent occlusion in long-term central venous catheters in infants, children and adolescents. Design A Cochrane systematic review of randomised controlled trials was undertaken. - Data sources: The Cochrane Vascular Group Specialised Register (including MEDLINE, CINAHL, EMBASE and AMED) and the Cochrane Register of Studies were searched. Hand searching of relevant journals and reference lists of retrieved articles was also undertaken. - Review Methods: Data were extracted and appraisal undertaken. We included studies that compared the efficacy of normal saline with heparin to prevent occlusion. We excluded temporary CVCs and peripherally inserted central catheters. Rate ratios per 1000 catheter days were calculated for two outcomes, occlusion of the CVC, and CVC-associated blood stream infection. Results Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin. However, between studies, all used different protocols with various concentrations of heparin and frequency of flushes. The quality of the evidence ranged from low to very low. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence). Conclusions It remains unclear whether heparin is necessary for CVC maintenance. More well-designed studies are required to understand this relatively simple, but clinically important question. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

Decision-making in a death investigation: Emotions, families and the coroner

The role of the coroner in common law countries such as Australia, England, Canada and New Zealand is to preside over death investigations where there is uncertainty as to the manner of death, a need to identify the deceased, a death of unknown cause, or a violent or unnatural death. The vast majority of these deaths are not suspicious and thus require coroners to engage with grieving families who have been thrust into a legal process through the misfortune of a loved one's sudden or unexpected death. In this research, 10 experienced coroners discussed how they negotiated the grief and trauma evident in a death investigation. In doing so, they articulated two distinct ways in which legal officers engaged with emotions, which are also evident in the literature. The first engages the script of judicial dispassion, articulating a hierarchical relationship between reason and emotion, while the second introduces an ethic of care via the principles of therapeutic jurisprudence, and thus offers a challenge to the role of emotion in the personae of the professional judicial officer. By using Hochschild's work on the sociology of emotions, this article discusses the various ways in which coroners manage the emotion of a death investigation through emotion work. While emotional distance may be an understandable response by coroners to the grief and trauma experienced by families and directed at cleaner coronial decision-making, the article concludes that coroners may be better served by offering emotions such as sympathy, consideration and compassion directly to the family in those situations where families are struggling to accept, or are resistant to, coroners' decisions.

Weaving the past into the present : Indigenous stories of education across generations

In Queensland, there is little research that speaks to the historical experiences of schooling. Aboriginal education remains a part of the silenced history of Aboriginal people. This thesis presents stories of schooling from Aboriginal people across three generations of adult storytellers. Elders, grandparents, and young parents involved in an early childhood urban playgroup were included. Stories from the children attending the playgroup were also welcomed. The research methodology involved narrative storywork. This is culturally appropriate because Aboriginal stories connect the past with the present. The conceptual framework for the research draws on decolonising theory. Typically, reports of Aboriginal schooling and outcomes position Aboriginal families and children within a deficit discourse. The issues and challenges faced by urban Murri families who have young children or children in school are largely unknown. This research allowed Aboriginal families to participate in an engaged dialogue about their childhood and offered opportunities to tell their stories of education. Key research questions were: What was the reality of school for different generations of Indigenous people? What beliefs and values are held about mainstream education for Indigenous children? What ideas are communicated about school across generations? Narratives from five elders, five grandparents, and five (urban) mothers of young Indigenous children are presented. The elders offer testimony on their recollected experiences of schooling in a mission, a Yumba school (fringe-dwellers’ camp), and country schools. Their stories also speak to the need to pass as non-indigenous and act as “white”. The next generation of storytellers are the grandparents and they speak to their lives as “stolen children”. The final story tellers are the Murri parents. They speak to the current and recent past of education, as well as their family experiences as they parent young children who are about to enter school or who are in the early years of school.

Mustering a wild bunch

A travel article about the South Dakota Governor's annual Buffalo Roundup Publication title: "Saddle up for South Dakota Governor Buffalo Roundup" “The crowd always cheers for the buffalo,” says Linda Daugaard, wife of the South Dakota governor. Up to now she and I have been talking about life in the state and her role, as its First Lady, in promoting youth literacy and other programs for families and children...

Social influences and the physical activity intentions of parents of young-children families: An extended Theory of Planned Behavior Approach

Evidence within Australia and internationally suggests parenthood as a risk factor for inactivity; however, research into understanding parental physical activity is scarce. Given that active parents can create active families and social factors are important for parents’ decision making, the authors investigated a range of social influences on parents’ intentions to be physically active. Parents (N = 580; 288 mothers and 292 fathers) of children younger than 5 years completed an extended Theory of Planned Behavior questionnaire either online or paper based. For both genders, attitude, control factors, group norms, friend general support, and an active parent identity predicted intentions, with social pressure and family support further predicting mothers’ intentions and active others further predicting fathers’ intentions. Attention to these factors and those specific to the genders may improve parents’ intentions to be physically active, thus maximizing the benefits to their own health and the healthy lifestyle practices for other family members.

Children with special health care needs : social and learning competence in the early years

The number of children with special health care needs surviving infancy and attending school has been increasing. Due to their health status, these children may be at risk of low social-emotional and learning competencies (e.g., Lightfoot, Mukherjee, & Sloper, 2000; Zehnder, Landolt, Prchal, & Vollrath, 2006). Early social problems have been linked to low levels of academic achievement (Ladd, 2005), inappropriate behaviours at school (Shiu, 2001) and strained teacher-child relationships (Blumberg, Carle, O‘Connor, Moore, & Lippmann, 2008). Early learning difficulties have been associated with mental health problems (Maughan, Rowe, Loeber, & Stouthamer-Loeber, 2003), increased behaviour issues (Arnold, 1997), delinquency (Loeber & Dishion, 1983) and later academic failure (Epstein, 2008). Considering the importance of these areas, the limited research on special health care needs in social-emotional and learning domains is a factor driving this research. The purpose of the current research is to investigate social-emotional and learning competence in the early years for Australian children who have special health care needs. The data which informed this thesis was from Growing up in Australia: The Longitudinal Study of Australian Children. This is a national, longitudinal study being conducted by the Commonwealth Department of Families, Housing, Community Services and Indigenous Affairs. The study has a national representative sample, with data collection occurring biennially, in 2004 (Wave 1), 2006 (Wave 2) and 2008 (Wave 3). Growing up in Australia uses a cross-sequential research design involving two cohorts, an Infant Cohort (0-1 at recruitment) and a Kindergarten Cohort (4-5 at recruitment). This study uses the Kindergarten Cohort, for which there were 4,983 children at recruitment. Three studies were conducted to address the objectives of this thesis. Study 1 used Wave 1 data to identify and describe Australian children with special health care needs. Children who identified as having special health care needs through the special health care needs screener were selected. From this, descriptive analyses were run. The results indicate that boys, children with low birth weight and children from families with low levels of maternal education are likely to be in the population of children with special health care needs. Further, these children are likely to be using prescription medications, have poor general health and are likely to have specific condition diagnoses. Study 2 used Wave 1 data to examine differences between children with special health care needs and their peers in social-emotional competence and learning competence prior to school. Children identified by the special health care needs screener were chosen for the case group (n = 650). A matched case control group of peers (n = 650), matched on sex, cultural and linguistic diversity, family socioeconomic position and age, were the comparison group. Social-emotional competence was measured through Social/Emotional Domain scores taken from the Growing up in Australia Outcome Index, with learning competence measured through Learning Domain scores. Results suggest statistically significant differences in scores between the two groups. Children with special health care needs have lower levels of social-emotional and learning competence prior to school compared to their peers. Study 3 used Wave 1 and Wave 2 data to examine the relationship between special health care needs at Wave 1 and social-emotional competence and learning competence at Wave 2, as children started school. The sample for this study consisted of children in the Kindergarten Cohort who had teacher data at Wave 2. Results from multiple regression models indicate that special health care needs prior to school (Wave 1) significantly predicts social-emotional competence and learning competence in the early years of school (Wave 2). These results indicate that having special health care needs prior to school is a risk factor for the social-emotional and learning domains in the early years of school. The results from these studies give valuable insight into Australian children with special health care needs and their social-emotional and learning competence in the early years. The Australia population of children with special health care needs were primarily male children, from families with low maternal education, were likely to be of poor health and taking prescription medications. It was found that children with special health care needs were likely to have lower social-emotional competence and learning competence prior to school compared to their peers. Results indicate that special health care needs prior to school were predictive of lower social-emotional and learning competencies in the early years of school. More research is required into this unique population and their competencies over time. However, the current research provides valuable insight into an under researched 'at risk' population.

Supporting children's language and literacy skills : the effectiveness of shared book reading intervention strategies with parents

Parents are encouraged to read with their children from an early age because shared book reading helps children to develop their language and early literacy skills. A pragmatic Randomised Controlled Trial (RCT) research design was adopted to investigate the influence of two forms of a shared reading intervention (Dialogic Reading and Dialogic Reading with the addition of Print Referencing) on children’s language and literacy skills. Dialogic reading is a validated shared reading intervention that has been shown to improve children’s oral language skills prior to formal schooling (Whitehurst & Lonigan, 1998). Print referencing is another form of shared reading intervention that has the potential to have effects on children’s print knowledge as they begin school (Justice & Ezell, 2002). However, training parents to use print referencing strategies at home has not been researched extensively although research findings indicate its effectiveness when used by teachers in the early years of school. Eighty parents of Preparatory year children from three Catholic schools in low income areas in the outer suburbs of a metropolitan city were trained to deliver specific shared reading strategies in an eight-week home intervention. Parents read eight books to their children across the period of the intervention. Each book was requested to be read at least three times a week. There were 42 boys and 38 girls ranging in age from 4.92 years to 6.25 years (M=5.53, SD=0.33) in the sample. The families were randomly assigned to three groups: Dialogic Reading (DR); Dialogic Reading with the addition of Print Referencing (DR + PR); and a Control group. Six measures were used to assess children’s language skills at pre and post, and follow-up (three months after the intervention). These measures assessed oral language (receptive and expressive vocabulary), phonological awareness skills (rhyme, word completion), alphabet knowledge, and concepts about print. Results of the intervention showed that there were significant differences from pre to post between the two intervention groups and the control group on three measures: expressive vocabulary, rhyme, and concepts about print. The shared reading strategies delivered by parents of the dialogic reading, and dialogic reading with the addition of print referencing, showed promising results to develop children’s oral language skills in terms of expressive vocabulary and rhyme, as well as understanding of the concepts about print. At follow-up, when the children entered Year 1, the two intervention groups (DR and DR + PR) group had significantly maintained their knowledge of concepts about prints when compared with the control group. Overall, the findings from this intervention study did not show that dialogic reading with the addition of print referencing had stronger effects on children’s early literacy skills than dialogic reading alone. The research also explored if pre-existing family factors impacted on the outcomes of the intervention from pre to post. The relationships between maternal education and home reading practices prior to intervention and child outcomes at post were considered. However, there were no significant effects of maternal education and home literacy activities on child outcomes at post. Additionally, there were no significant effects for the level of compliance of parents with the intervention program in terms of regular weekly reading to children during the intervention period on child outcomes at post. These non-significant findings are attributed to the lack of variability in the recruited sample. Parents participating in the intervention had high levels of education, although they were recruited from schools in low socio-economic areas; parents were already highly engaged in home literacy activities at recruitment; and the parents were highly compliant in reading regularly to their child during the intervention. Findings of the current study did show that training in shared reading strategies enhanced children’s early language and literacy skills. Both dialogic reading and dialogic reading with the addition of print referencing improved children’s expressive vocabulary, rhyme, and concepts about print at post intervention. Further research is needed to identify how, and if, print referencing strategies used by parents at home can be effective over and above the use of dialogic reading strategies. In this research, limitations of sample size and the nature of the intervention to use print referencing strategies at home may have restricted the opportunities for this research study to find more effects on children’s emergent literacy skills or for the effectiveness of combining dialogic reading with print referencing strategies. However, these results did indicate that there was value in teaching parents to implement shared reading strategies at home in order to improve early literacy skills as children begin formal schooling.

Raising Children in Single-Parent Families

Children from single-parent families fare more poorly on multiple outcomes than those in two-parent families. Most explanations for these differences assume that compromised parenting and parent mental health play a central role. This chapter explores the contribution of a range of factors to the parenting and mental health of single mothers using data from approximately 1000 Australian single mothers with a child aged 4–5 or 8–9 years. The findings show that single mothers are more likely than couple mothers to experience parenting and mental health difficulties; however, they also face heightened adversity in their home and extra-familial environments. Importantly, this comparison of single and couple mothers facing similar levels of adversity shows no difference in poor parenting practices, although single mothers remain more vulnerable to psychological distress. These findings have policy implications since they challenge the prevailing view that single-parent families inherently provide sub-optimal environments for raising children.

Young Children and the Environment : Early Education for Sustainability [2nd Edition]

This book is a practical resource that illustrates the difference that early childhood educators can make by working with children, their families and the wider community to tackle one of the most important contemporary issues facing the world today: sustainable living. This second edition has been substantially revised and updated, with a new section exploring sustainability education in a variety of global contexts. Researched and written by authors recognised as leaders in their own countries, the chapters in this new section provide readers with international resources and perspectives to further their teaching about early childhood education for sustainability.

Treatment for gender dysphoria in children : the new legal, ethical and clinical landscape

- Gender dysphoria is a condition in which a child's subjectively felt identity and gender are not congruent with her or his biological sex. Because of this, the child suffers clinically significant distress or impairment in social functioning. - The Family Court of Australia has recently received an increasing number of applications seeking authorisation for the provision of hormones to treat gender dysphoria in children. - Some medical procedures and interventions performed on children are of such a grave nature that court authorisation must be obtained to render them lawful. These procedures are referred to as special medical procedures. - Hormonal therapy for the treatment of gender dysphoria in children is provided in two stages occurring years apart. Until recently, both stages of treatment were regarded by courts as special medical treatments, meaning court authorisation had to be provided for both stages. - In a significant recent development, courts have drawn a distinction between the two stages of treatment, permitting parents to consent to the first stage. In addition, it has been held that a child who is determined by a court to be Gillick competent can consent to stage 2 treatment. - The new legal developments concerning treatment for gender dysphoria are of ethical, clinical and practical importance to children and their families, and to medical practitioners treating children with gender dysphoria. Medical practitioners should benefit from an understanding of the recent developments in legal principles. This will ensure that they have up-to-date information about the circumstances under which treatment may be conducted with parental consent, and those in which they must seek court authorisation.

Children living in HIV families : a review

This review article summarizes the current knowledge about children born or living in families affected by HIV, a topic of recent interest in the HIV field. It also presents a case study of a child's narrative about the implications of living with a HIV parent. The case study is part of a larger study involving both parents and children living with HIV in Bangladesh. The paper discusses the implications of HIV for children, their families, and social services to gain a better understanding of some of the social issues, such as stigma, associated with this illness. The paper recommends that the development of effective social and service interventions using appropriate language, information, and access to social support services are urgently needed to reduce the concerns and increases the life opportunities of children living in HIV families.

Family-based programmes for preventing smoking by children and adolescents (Review)

Background There is evidence that family and friends influence children's decisions to smoke. Objectives To assess the effectiveness of interventions to help families stop children starting smoking. Search methods We searched 14 electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO, CINAHL unpublished material, and key articles' reference lists. We performed free-text internet searches and targeted searches of appropriate websites, and hand-searched key journals not available electronically. We consulted authors and experts in the field. The most recent search was 3 April 2014. There were no date or language limitations. Selection criteria Randomised controlled trials (RCTs) of interventions with children (aged 5-12) or adolescents (aged 13-18) and families to deter tobacco use. The primary outcome was the effect of the intervention on the smoking status of children who reported no use of tobacco at baseline. Included trials had to report outcomes measured at least six months from the start of the intervention. Data collection and analysis We reviewed all potentially relevant citations and retrieved the full text to determine whether the study was an RCT and matched our inclusion criteria. Two authors independently extracted study data for each RCT and assessed them for risk of bias. We pooled risk ratios using a Mantel-Haenszel fixed effect model. Main results Twenty-seven RCTs were included. The interventions were very heterogeneous in the components of the family intervention, the other risk behaviours targeted alongside tobacco, the age of children at baseline and the length of follow-up. Two interventions were tested by two RCTs, one was tested by three RCTs and the remaining 20 distinct interventions were tested only by one RCT. Twenty-three interventions were tested in the USA, two in Europe, one in Australia and one in India. The control conditions fell into two main groups: no intervention or usual care; or school-based interventions provided to all participants. These two groups of studies were considered separately. Most studies had a judgement of 'unclear' for at least one risk of bias criteria, so the quality of evidence was downgraded to moderate. Although there was heterogeneity between studies there was little evidence of statistical heterogeneity in the results. We were unable to extract data from all studies in a format that allowed inclusion in a meta-analysis. There was moderate quality evidence family-based interventions had a positive impact on preventing smoking when compared to a no intervention control. Nine studies (4810 participants) reporting smoking uptake amongst baseline non-smokers could be pooled, but eight studies with about 5000 participants could not be pooled because of insufficient data. The pooled estimate detected a significant reduction in smoking behaviour in the intervention arms (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.68 to 0.84). Most of these studies used intensive interventions. Estimates for the medium and low intensity subgroups were similar but confidence intervals were wide. Two studies in which some of the 4487 participants already had smoking experience at baseline did not detect evidence of effect (RR 1.04, 95% CI 0.93 to 1.17). Eight RCTs compared a combined family plus school intervention to a school intervention only. Of the three studies with data, two RCTS with outcomes for 2301 baseline never smokers detected evidence of an effect (RR 0.85, 95% CI 0.75 to 0.96) and one study with data for 1096 participants not restricted to never users at baseline also detected a benefit (RR 0.60, 95% CI 0.38 to 0.94). The other five studies with about 18,500 participants did not report data in a format allowing meta-analysis. One RCT also compared a family intervention to a school 'good behaviour' intervention and did not detect a difference between the two types of programme (RR 1.05, 95% CI 0.80 to 1.38, n = 388). No studies identified any adverse effects of intervention. Authors' conclusions There is moderate quality evidence to suggest that family-based interventions can have a positive effect on preventing children and adolescents from starting to smoke. There were more studies of high intensity programmes compared to a control group receiving no intervention, than there were for other compairsons. The evidence is therefore strongest for high intensity programmes used independently of school interventions. Programmes typically addressed family functioning, and were introduced when children were between 11 and 14 years old. Based on this moderate quality evidence a family intervention might reduce uptake or experimentation with smoking by between 16 and 32%. However, these findings should be interpreted cautiously because effect estimates could not include data from all studies. Our interpretation is that the common feature of the effective high intensity interventions was encouraging authoritative parenting (which is usually defined as showing strong interest in and care for the adolescent, often with rule setting). This is different from authoritarian parenting (do as I say) or neglectful or unsupervised parenting.

Comparing family functionality perception between non-Aymara and indigenous Aymara families in northern Chile

We compared perception of family functioning in a sample (N = 1,496) of Aymara and non-Aymara parents and children living in Arica, Chile. The children were aged from 9 to 15 years and were recruited from the 5th to 8th grades of 9 elementary schools (4 public, 5 government-subsidized private schools) serving lower socioeconomic areas. Participants completed the Family Functioning Test (FF-SIL), which consists of 14 events or characteristics that may occur in a family. The results showed that parents and children from the Aymara group recorded lower scores for their perception of family functioning than did the non-Aymara group. Addressing this issue may be important in the prevention of psychological problems in these families.

Fathers as informants of children’s fears and worries

The recognition of excessive fears and worries in children is important for early intervention. Despite current knowledge about the important contribution fathers make to their children’s emotional, social and cognitive development, more emphasis is often given to the views of mothers in both research and practice. This paper reports on a community study of 220 families. Fathers, mothers and children reported on children’s fears and worries using three different methods. While father and mother ratings were moderately correlated on two of the measures, there was relatively poor parent-child agreement. Implications for the role of fathers in the assessment of childhood fears and worries are discussed.