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Pain is an inherently subjective experience and should be assessed and treated as such; however, it is well documented that pediatric pain remains under assessed and under treated by nurses and healthcare professionals. To treat pain adequately, ongoing assessment of its presence and severity is critical to improving outcomes for pediatric patients. Although reliable, valid, and clinically sensitive assessment tools are available to healthcare providers, self-report is considered the "gold standard" to assess pain given its subjective nature. Children, particularly those between 1 and 7 years of age, are one of the most vulnerable populations with respect to poor pain management. Due to progression of cognitive development, they often lack the verbal fluency or vocabulary needed to describe the location, radiation, quality, and intensity of the pain they experience. As a result, pain often goes under treated; and, studies reveal that inadequately treated pain can have a detrimental impact on the course of childhood development. In order to prevent mismanagement of pain, parental pain reports are often used when self-report is inadequate or unable to be provided. This thesis provides a comprehensive review of research literature regarding the role of the parent in pediatric pain assessment and the ability of parents to serve as a proxy in reporting pain for their child. Studies included methods and behaviors parents use to assess their children's pain; parental assessment with use of clinically reliable pain measurement tools; and, comparisons of parental pain assessments to those made by nurses and healthcare professionals. The findings of the review of literature were used to make recommendations for nursing research, education and clinical practice.

Purpose: The purpose of this study is to determine the impact that the introduction of articaine has had on local anesthetic selection by general and pediatric dentists for use in three different age groups of children.Methods: Using a cross sectional survey design, a questionnaire regarding the use of local anesthetics in children was mailed to a random sample of 500 general dentists from North Carolina, 500 general dentists from Virginia, and all 230 pediatric dentists from North Carolina and Virginia. The 16-item questionnaire included questions regarding the preferred local anesthetic to use in three different age groups, 2-3 years of age, 4-6 years of age, and 7-10 years of age. Furthermore, the questionnaire also included questions specifically on articaine use in the three different age groups and any related side effects. The association between dental practitioner type and anesthetic use was tested using chi-square or Fisher's exact test.Results: A sample of 337 dentists completed the questionnaire. There was no significant difference in preference of articaine except in older patients aged 7-10 years old where general dentists prefer articaine significantly more than do pediatric dentists (28.1% versus 15.9%). Lidocaine with epinephrine was the local anesthetic that was most preferred in all age groups by all practitioners. Pediatric dentists preferred lidocaine more often than general dentists and general dentists preferred lidocaine without epinephrine more often than pediatric dentists. Twenty-one percent of all dentists surveyed have used articaine in children under 4 years of age and 13% list articaine as the preferred local anesthetic for children under 4 years of age.Conclusion: While lidocaine with epinephrine is still the preferred local anesthetic for use in children, the use of articaine in children is very prevalent among general and pediatric dentists. Articaine use becomes more prevalent as the age of the patient increases and many pediatric and general dentists are using articaine in children under four years of age.

Purpose: To assess dental students and pediatric dental residents’ knowledge and attitudes towards motivational interviewing and evaluate the efficacy of a pediatric-focused brief motivational interviewing training program. Methods: A total of 66 participants were enrolled; 35% were third year dental students, 46% were fourth year dental students and 18% were pediatric dental residents. Participants completed three questionnaires: the first before the training, the second immediately after the training and the third approximately 3.5 months after the training. Results: A significant increase in correct responses was found for 4 of the 5 questions assessing participants’ knowledge. Participants were satisfied with the training (94%) and were interested in further training (89%). Participants believed patients and their parents would benefit from the intervention (97%). Conclusions: The pediatric-focused BMI training program is a valuable addition to pre-doctoral and residency curricula by preparing students and residents to employ this beneficial technique.

Missed nursing care, according to Kalisch and Williams, is nursing care that is not completed to the highest quality of care, leading to an increase in hospital costs and poor patient outcomes. Missed nursing care can occur with any patient population; however, a survey by Kasich called the MISSCARE Survey has only been used in the adult and neonatal populations. Pediatric patients are a diverse and complex subset of the population, differing greatly from the adult and neonatal populations, thus identifying a need for a focused pediatric survey to effectively study missed nursing care in the pediatric setting. The purpose of this research, therefore, was to create and validate a pediatric nursing care survey A convenience sample of 10 pediatric experts completed the Expert Panel Survey to determine a content validity ratio (CVR) and content validity index (CVI) of a modified, MISSCARE Survey (Kalisch & Williams, 2009). Items determined to be essential by ninety percent or more of the participants (CVR> 0.78), were included in the MISSCARE-Pediatric Survey. Results showed that the CVI of the MISSCARE-Pediatric Survey determined by the Expert Panel was 0.9, meaning the items are essential to the pediatric population (Gilbert & Prion, 2016a). The created MISSCARE-Pediatric Survey includes 18 questions in section A (Types of Missed Nursing Care), 28 questions in section B (Reasons for Missed Nursing Care), and 9 questions in Demographics. Future research will determine content reliability of the MISSCARE-Pediatric Survey.

Pediatric obesity has become a major health care concern over the last several decades. This condition can lead to detrimental life-long physical and mental comorbidities. Pediatric primary care providers have a unique opportunity to both prevent and treat pediatric obesity in their clinics. However, discussing this topic with families can be uncomfortable and time consuming. Time efficient resources to educate and increase confidence are needed to improve the management of pediatric obesity. This quality improvement project integrated the Healthy Care for Healthy Kids by the National Institute for Children's Healthcare Quality (2014) into the electronic medical record at a pediatric primary care office in rural East Tennessee. This toolkit included handouts, management algorithms, and provider education for pediatric obesity. After an 8-week implementation period, improvements in lab draws and evaluation of a family's readiness to change were noted. Overall, providers reported the toolkit was helpful and improved patient interaction. Currently, the clinic is still utilizing the integrated resources and handouts.

The nursing culture of an inpatient pediatric unit was resistant to activating pediatric rapid response team (PRRT) alerts despite guidelines for activation. Nurses routinely assessed patients and assigned a pediatric early warning score (PEWS); however, the level of illness severity was not interpreted consistently among nurses and a PEWS action algorithm did not exist to guide nurses' minimal actions based on the PEWS score. Guided by 3 adult learning theories (Knowles, Kolb, and Bandura) and 1 evaluation model (Kirkpatrick), this staff education project sought to educate pediatric nurses on a PEWS action algorithm and determine whether this project improved nurses' knowledge, situational awareness, and attitude toward activating PRRT alerts. A convenience sample of 30 pediatric nurses completed a preeducation knowledge survey (EKS), attended an interactive PEWS education class, and completed a postEKS. After participating in the class, correct responses on the EKS increased from 43% to 82% and, using the Wilcoxon-signed rank test, a significant increase was noted in nurses' responses to questions related to self-efficacy, factual knowledge, and application. The overall increase in the nurses' self-efficacy and knowledge about the PEWS might enhance critical-thinking skills, foster identification of patients at risk for clinical deterioration, and empower nurses to follow the PEWS action algorithm including activation of PRRT alerts when indicated. This project has the potential to effect positive social change by supporting nurses' actions designed to improve pediatric patient outcomes.

Emergence delirium (ED), also known as emergence agitation, is a postoperative condition characterized by aberrant cognitive and psychomotor behaviors following general anesthesia. The incidence of ED is 3 to 8 times higher in children 5 years of age or less. There is no standard of nursing practice for managing ED symptoms in the pediatric surgical population. The purpose of this quality improvement project was to address a gap in knowledge needed to inform clinical decision-making when managing ED in the postoperative setting. Using an educational presentation for post anesthesia care unit (PACU) nurses, this project introduced the use of non-pharmacological interventions to mitigate symptoms of ED in the pediatric population as inspired by The Green Star Initiative, an Army program at Fort Carson. The project aim was to describe the effectiveness of ED-specific interventions from the nursing perspective. Using tenets of the Iowa model, this quality improvement project included a needs assessment survey, PowerPoint presentation, parent education leaflet, ED cheat sheet, and a post-intervention survey. Applying the context, input, process, product model for evaluation, this project increased knowledge of ED-specific interventions used by nurses that demonstrates a change in clinical decision-making. PACU nurses rated the interventions 43% effective on pediatric patients. This project addressed the gap in practice by providing structured education on ED, inspiring the use of ED-specific interventions, and promoting readiness to care for the pediatric surgical population. Outcomes add to the nursing literature by introducing ED-specific interventions to manage pediatric ED in facilities nationwide. A social implication of this project is to improve the care of pediatric surgical patients.

Background & aims: The inflammatory bowel diseases (IBD), Crohn‟s disease (CD) and ulcerative colitis (UC), are common causes of chronic gastrointestinal morbidity, affecting up to 1 in 250 of the general population in Northern Europe. Up to 25% of IBD is diagnosed during childhood or adolescence. The aims for this thesis were to study the epidemiology, natural history and novel genetic determinants of childhood onset IBD in Scotland. Methods: The existing repository of childhood onset and adult onset IBD patients, established at the Western General Hospital in Edinburgh, was used and expanded. Thus, anatomical location and behaviour of disease were assessed in 416 childhood onset (276 CD, 99 UC, 41 IBDU diagnosed before 17th birthday) and 1297 adult patients (596 CD, 701 UC) using the Montreal classification. Additional phenotypic (at diagnosis and at regular follow-up intervals) and epidemiological data were gathered. In this cohort, genotyping of germline variants in putative susceptibility genes (NOD1/CARD4, IL23R, ATG16L1, IRGM, FLG) was performed to enable single variant and haplotype-tagging association studies. Genotypic data of population-matched healthy controls were obtained locally (n=342) and from the Wellcome Trust Case Control Consortium (n=2937). Results: Compared with adults, childhood-onset CD was characterized by a more extensive, “panenteric” phenotype (ileocolonic plus upper GI; p<0.0001 OR23.3; 95% CI (13.4–40.6) with less isolated ileal (p<0.0001 OR 0.06 (0.03–0.1) or colonic disease (p<0.0001, OR 0.3 (0.2–0.5)). In 39%, the anatomic extent increased within 2 years. UC was also more extensive in children at diagnosis vs adults (p<0.0001 OR 5.1 (2.7–9.4)). In population-matched and age, sex and postcode-matched case-control analysis, childhood onset IBD and CD was associated with asthma (p<0.0001 OR 1.7 (1.3-2.1) and (p=0.005 OR 2.5 (1.3-4.8), respectively). Inherited variation of NOD1/CARD4 was not a strong determinant of disease susceptibility in the Scottish population (both in single marker and haplotype-tagging studies, all p>0.05 after Bonferroni correction). We found that the allelic frequency of rs11209026*A located within the IL23R gene, differed significantly between IBD/CD cases and controls (p=0.01 OR 0.51(0.3-0.9) and p=0.04 OR 0.5 (0.3-0.98)). Using a gene-wide haplotype-tagging strategy, we demonstrated that the multiple association signals of the IL23R locus are independent of rs11209026 in childhood onset IBD and CD. In Scottish children, the effect of germline variation of ATG16L1 and IRGM on CD susceptibility was relatively small (OR< 1.4), and appeared less than in adult disease. Genotype–phenotype analysis demonstrated an association of pure ileal disease with the ATG16L1 rs2241880G-allele (p=0.02 OR 1.3 (1.03–1.7)). Using binary logistic regression analysis, we confirmed the effect of rs2241880 genotype (GG) on ileal disease versus colonic disease (p=0.03 OR 2.4 (1.05–5.6)). Null alleles of the epithelial barrier protein FLG have no important effect on IBD susceptibility (p>0.4), but contribute to the high prevalence of atopy, notably co-existent eczema and food allergy (p=0.0003 OR 3.3 (1.7–6.6) and p=0.0001 OR 4.5 (2.0–10.0), respectively). Conclusion: Childhood onset IBD is characterised by extensive intestinal involvement and progression of disease after diagnosis. Genetic association studies in childhood and adult IBD have provided evidence for a large number of new genomic loci. These loci encode genes involved in a number of homeostatic mechanisms: innate pattern recognition receptors, the differentiation of Th17-lymphocytes, autophagy, maintenance of epithelial barrier integrity and the orchestration of the secondary immune response.