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Highlights from this issue

2018-04-20T06:00:18-07:00

Spoilt for choice

One of the many pleasure inherent to my job, is seeing papers evolve from submission through the review process, and then appear in print. Writing this column (which I do about 6 weeks before the issues arrive in the post or appear on the website) is, therefore, one of the highpoints of my month. I am invariably spoilt for choice and left with difficult decisions as to what to feature. It has been particularly hard this time, the papers being of such quality and breadth, but exactly the sort of ‘problem’ I enjoy

Every few years, public attention is captured by a story so poignant, that it plays out in the full glare of the public eye. Such exposure is now, of course, heightened by social media, and where in the not-so-distant past, events would be relayed by newspaper or radio the following day, the...




Observations on the case of Charlie Gard

2018-04-19T01:30:34-07:00

The case of Charlie Gard, the English boy with mitochondrial DNA depletion syndrome who was at the centre of a high-profile legal case and died days before his first birthday, attracted worldwide attention.1 2 His condition deteriorated when he developed progressive encephalopathy and muscle weakness and he required artificial ventilation. His parents found a doctor in New York who had developed nucleoside therapy, which he had used for patients with a similar disease. However, the doctors taking care of Charlie at the Great Ormond Street Hospital (GOSH) for children in London felt that the new therapy was not suitable for Charlie and argued that he should receive palliative care in a hospice. The case ended up in The High Court of Justice, which covers England and Wales, and the European Court of Human Rights. Both agreed with GOSH that the new therapy was not in...




Response to 'When paediatricians and families cant agree

2018-04-19T01:30:34-07:00

Dr Wallis’ article1 is a plea for mediated settlements (rather than judicial decisions) to determine medical disputes in childhood. His reasonable proposal may underestimate both the similarity of his solution to the judicial status quo and the inherent difficulty of the arbitrator’s task; but nonetheless deserves consideration. Leaving that consideration to one side, this response offers an alternative explanation to his account of the role of English courts in providing clinicians with neutral judgements as to where children’s best interests lie.

Both medical and legal professions owe a fiduciary duty to their patients/clients; and (in the context of the Gardi litigation) have furtherance of the child’s welfare as their paramount duty. Equally, both use judgement to construct a conclusion, broadly reliant on preceding decisions or practice. Doctors and lawyers have much in common.

The goddess Lustitia (‘Lady Justice’) holds a set of scales to measure the...




Point-of-care C-reactive protein at triage for children in the emergency department

2018-04-19T01:30:34-07:00

Fever is a very common reason for consultation among children attending the emergency department. Most of these children have a self-limiting viral infection. Nevertheless, despite advances in vaccinations and antibiotics, serious infections remain significant causes of death of children. Early identification of children with serious bacterial infections is essential to initiate immediate antibiotic therapy. But, identification of these patients may be difficult, mainly in an overcrowded emergency department, in which most of the incoming patients appear well. In fact, a large number of children with an invasive bacterial infection are not identified at first contact.1

Different efforts have been made in order to identify children at low risk and high risk for serious bacterial infection. In this way, the appearance of the child, the vital signs and certain laboratory data are useful to identify these children.

In selected populations, complementary tests are helpful to identify children at high...




When paediatricians and families cant agree

2018-04-19T01:30:34-07:00

Recent high-profile cases have highlighted the difficulties that professionals caring for terminally ill or technology dependent children face.

I am a paediatrician. I see children with severe problems, often chronic and frequently without a cure, and I try as far as possible to help them and their families. Occasionally there is science and evidence behind the decisions we make, but not always. Medicine does have its black and white disciplines—it is either cancer or it isn’t; or you either need to have an operation or you don’t. But paediatrics is often a discipline of uncertainty dealing with many shades of grey.

Paediatricians learn to live with uncertainty and similarly have to support parents and young people to accept this uncertainty. Sometimes we have to wait for nature to reveal itself or for the future to unfold as it should. Herein lies the art of paediatrics: the ability to watch...




Family Integrated Care: changing the culture in the neonatal unit

2018-04-19T01:30:34-07:00

Introduction

Family Integrated Care (FIC) is a new model of neonatal care which supports parents to be primary caregivers, as partners with the clinical team.1

The inspiration for FIC comes from lower resource settings where families provide care through necessity rather than choice.2 3 This approach has been adapted for modern neonatal intensive care by pioneering FIC teams in Canada, Scandinavia and the UK. Trials in preterm infants have demonstrated improved rate of weight gain, reduced parental stress and shorter length of stay.4 5 By supporting and combining the benefits of breast feeding, kangaroo mother care (KMC) and parental presence, FIC may have even greater long-term benefits for infants and their families.6

FIC builds on the foundations of Family-Centred Care, a well-established approach with accepted standards supported by Unicef and the neonatal charity Bliss.7 8




Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study

2018-04-19T01:30:34-07:00

Objective

Acute infection is the most common presentation of children to hospital. A minority of these infections are serious, but early recognition and adequate management are essential. We aimed to develop improved tools to assess children attending ambulatory hospital care, integrating clinical features with point-of-care C reactive protein (CRP).

Design

Prospective observational diagnostic study.

Setting and patients

5517 acutely ill children (1 month–16 years) presenting to 106 paediatricians at six outpatient clinics and six emergency departments in Belgium.

Index test

Point-of-care CRP alongside vital signs and objective symptoms measurements.

Main outcome

Hospital admission for >24 hours with a serious infection <5 days after presentation.

Results

An algorithm was developed consisting of clinical features and CRP. This achieved 97.1% (95% CI 94.3% to 98.7%) sensitivity and 99.6% (95% CI 99.2% to 99.8%) negative predictive value, excluding serious infections in 36.4% of children. It stratifies patients into three groups based on CRP level: high-risk group with CRP >75 mg/L (26.8% risk of infection), intermediate-risk group with CRP 20–75 mg/L and at least one of seven clinical features (8.1%), and lower risk group with CRP <20 mg/L with at least one of the 11 features (3.8%). Children in intermediate-risk or low-risk groups with normal clinical assessment have 0.6% and 0.4% risk of serious infections, respectively.

Conclusions

Conducting a CRP test may first enable children to be stratified into three risk groups, guiding assessment of clinical features that could be performed by junior doctors or nurses. In one-third of acutely ill children, the algorithm could exclude serious infection. Prospective validation of the algorithm is needed.

Clinical trial registration

NCT02024282 (post-results).




Comparative analysis of the scope of European Union paediatric investigation plans with corresponding orphan designations

2018-04-19T01:30:34-07:00

Background

Market forces may not be sufficient to stimulate research and development of medicines for small patient populations, such as children and patients with rare diseases. Both the European Union Orphan and Paediatric Regulations were introduced to address the unmet public health needs of these smaller patient populations through the use of incentives, rewards and obligations. Developers for new medicines for rare diseases must agree a paediatric investigation plan (PIP) or waiver with the European Medicines Agency’s (EMA) Paediatric Committee (PDCO), and can also apply for an orphan designation (OD) from the EMA’s Committee of Orphan Medicinal Products (COMP). The scope of both the OD and the PIP (or waiver) is defined by the agreed condition.

Objectives

The aim of this study was to analyse the approach of PDCO and COMP in defining the appropriate condition for a PIP or OD, respectively, in order to investigate potential challenges in the paediatric development of orphan medicines which have to meet the requirements of both legislations.

Methods

A comparative analysis of PIP conditions and OD conditions was performed for medicines that have been reviewed by both Committees.

Results

We found that in the substantial majority of cases there is no divergence between the conclusions of COMP and PDCO with regard to the condition for which a medicine is to be developed.

Conclusion

These findings demonstrate that a collaborative approach allows both Regulations to work synergistically to foster pharmaceutical development for rare diseases in childhood.




Takeaway meal consumption and risk markers for coronary heart disease, type 2 diabetes and obesity in children aged 9-10 years: a cross-sectional study

2018-04-19T01:30:34-07:00

Objective

To investigate associations between takeaway meal consumption and risk markers for coronary heart disease, type 2 diabetes and obesity risk markers in children.

Design

A cross-sectional, school-based observational study.

Setting

85 primary schools across London, Birmingham and Leicester.

Participants

1948 UK primary school children in year 5, aged 9–10 years.

Main outcome measures

Children reported their frequency of takeaway meal consumption, completed a 24-hour dietary recall, had physical measurements and provided a fasting blood sample.

Results

Among 1948 participants with complete data, 499 (26%) never/hardly ever consumed a takeaway meal, 894 (46%) did so <1/week and 555 (28%) did ≥1/week. In models adjusted for age, sex, month, school, ethnicity and socioeconomic status, more frequent takeaway meal consumption was associated with higher dietary intakes of energy, fat % energy and saturated fat % energy and higher energy density (all P trend <0.001) and lower starch, protein and micronutrient intakes (all P trend <0.05). A higher frequency of takeaway meal consumption was associated with higher serum total cholesterol and low-density lipoprotein (LDL) cholesterol (P trend=0.04, 0.01, respectively); children eating a takeaway meal ≥1/week had total cholesterol and LDL cholesterol 0.09 mmol/L (95% CI 0.01 to 0.18) and 0.10 mmol/L (95% CI 0.02 to 0.18) higher respectively than children never/hardly ever eating a takeaway meal; their fat mass index was also higher.

Conclusions

More frequent takeaway meal consumption in children was associated with unhealthy dietary nutrient intake patterns and potentially with adverse longer term consequences for obesity and coronary heart disease risk.




Patterns of pain over time among children with juvenile idiopathic arthritis

2018-04-19T01:30:34-07:00

Objectives

Pain is a very common symptom of juvenile idiopathic arthritis (JIA). Disease activity alone cannot explain symptoms of pain in all children, suggesting other factors may be relevant. The objectives of this study were to describe the different patterns of pain experienced over time in children with JIA and to identify predictors of which children are likely to experience ongoing pain.

Methods

This study used longitudinal-data from patients (aged 1–16 years) with new-onset JIA. Baseline and up to 5-year follow-up pain data from the Childhood Arthritis Prospective Study (CAPS) were used. A two-step approach was adopted. First, pain trajectories were modelled using a discrete mixture model. Second, multinomial logistic regression was used to determine the association between variables and trajectories.

Results

Data from 851 individuals were included (4 years, median follow-up). A three-group trajectory model was identified: consistently low pain (n=453), improved pain (n=254) and consistently high pain (n=144). Children with improved pain or consistently high pain differed on average at baseline from consistently low pain. Older age at onset, poor function/disability and longer disease duration at baseline were associated with consistently high pain compared with consistently low pain. Early increases in pain and poor function/disability were also associated with consistently high pain compared with consistently low pain.

Conclusions

This study has identified routinely collected clinical factors, which may indicate those individuals with JIA at risk of poor pain outcomes earlier in disease. Identifying those at highest risk of poor pain outcomes at disease onset may enable targeted pain management strategies to be implemented early in disease thus reducing the risk of poor pain outcomes.




Outcomes following prolonged convulsions

2018-04-19T01:30:34-07:00

Convulsive status epilepticus (CSE) is one of the more worrying paediatric emergencies. It’s less common now because of more ready availability of rapidly-acting anticonvulsants such as buccal midazolam in the community; but there remain concerns about what might happen to the child once the acute fits have stopped. Some earlier work suggested that a high proportion develop problems, but a recent unselected population-based study is more reassuring.

London-based researchers undertook a study back in 2002–2004 identifying all 226 children presenting to 21 north London hospitals with CSE which lasted for at least 30 minutes (NLSTEPS study, Chin R et al. Lancet 2006. doi.org/10.1016/S0140-6736(06)69043-0). Of these 203 survived, and they were able to contact and follow-up 134, at a mean 9 years after the initial event (STEPSOUT study. Pujar S et al. Lancet Child Adolesc Health 2018. doi.org/10.1016/S2352-4642(17)30174-8). The long follow-up is important, since many will have had short-term cognitive impairment,...




Influence of early childhood burns on school performance: an Australian population study

2018-04-19T01:30:34-07:00

Objectives

To determine the influence of burn injuries on childhood performance in national standardised curriculum-based school tests.

Design

Birth and health records of 977 children who were hospitalised with a burn injury between 2000 and 2006 in the state of New South Wales, Australia, were linked to performance scores in the National Assessment Program: Literacy and Numeracy test, a compulsory nationwide curriculum-based test (CBT) and compared with children who were not hospitalised for burns and who were matched for birth year, gender, gestation and socioeconomic status.

Main outcome measures

Test scores in years 3 (ages 8–9), 5 (ages 10–11) and 7 (ages 13–14) in numeracy, writing, reading, spelling, grammar and punctuation.

Results

Mean age at first burn injury was 28 months (median: 20, range: 0–140). Children with burns were significantly more likely to have younger mothers (28.5 vs 29.6 years) (P<0.001), be indigenous (OR 2.5 (95% CI 2.1 to 3.1)) (P<0.001) and have siblings (OR 1.2 (95% CI 1.1 to 1.4)) (P<0.001). They were also less likely to meet national minimum standards in most domains of testing until year 5, even after adjustment for parental education levels, parental smoking, maternal age and indigenous status. Each 10% increase in total body surface area burnt was associated with a decrease in year 5 scores by 37.0% in numeracy and 71.9% in writing.

Conclusions

Most childhood burn injuries occur before the start of formal schooling. Children who are hospitalised for burns perform more poorly in CBT even after accounting for family and socioeconomic disadvantage. Rehabilitation of children with burn injuries must address school performance to decrease any long-term negative societal impact of burns.




An unusual unilateral breast enlargement in a prepubertal girl

2018-04-19T01:30:35-07:00

A girl aged 4 years and 3 months presented to our department for a right breast mass, slowly enlarging since the age of 6 months (figure 1). The mass was tender at the outer and harder at the medial quadrants to palpation, with apparently regular margins. The nipple over the mass was not altered.

MRI showed a diffuse thickening of the tissue above the right pectoral muscle, in part delimited by a thin capsule at the outer margin, hyperintense on T1 and T2 sequences, and hypointense on the sequence with fat suppression, typical of a benign adipose lesion.

Surgical excision of the mass, which presented an overt cleavage plane along the pectoral muscle, was performed, and the histopathological examination revealed proliferation of variably differentiated adipocytes and a small amount of stroma, consistent with a diagnosis of lipoblastoma of infancy.

Breast masses are rarely reported in the paediatric population, and are seldom composed by lipomatous...




Healthcare costs attributable to congenital cytomegalovirus infection

2018-04-19T01:30:35-07:00

Objective

Congenital cytomegalovirus infection (cCMV) can cause symptoms at birth as well as long-term impairment. This study estimates cCMV-related healthcare costs in the Netherlands in early childhood.

Design, setting and patients

In a nationwide retrospective cohort study, 156 children with cCMV were identified by testing 31 484 neonatal dried blood spots for cCMV. Use of healthcare resources in the first 6 years of life by children with cCMV and a matched cCMV-negative control group were analysed. Mean costs per child were calculated by multiplying healthcare resource use by its reference prices.

Exposure

Children with cCMV were compared with cCMV-negative children.

Main outcome measures

The average total healthcare costs per child were based on the average costs for hospital admissions and consultations by healthcare providers.

Results

Mean healthcare costs of children with cCMV (6113, n=133) were higher than children without cCMV (3570, n=274), although statistically not significant, with a mean difference of 2544 (95% CI -451 to 5538). The costs of children with long-term impairment were two times higher in children with cCMV (17 205) compared with children without cCMV (8332).

Conclusions

Children with cCMV, especially those with long-term impairment and those symptomatic at birth, accrue higher healthcare costs than cCMV-negative children in the first 6 years of life, although this is not statistically significant. This economic impact is of importance in the evaluation of preventive measures against cCMV.

Trial registration number

NTR3582.




Inter-rater reliability in the Paediatric Observation Priority Score (POPS)

2018-04-19T01:30:35-07:00

Objective

The primary objective of this study was to determine the level of inter-rater reliability between nursing staff for the Paediatric Observation Priority Score (POPS).

Design

Retrospective observational study.

Setting

Single-centre paediatric emergency department.

Participants

12 participants from a convenience sample of 21 nursing staff.

Interventions

Participants were shown video footage of three pre-recorded paediatric assessments and asked to record their own POPS for each child. The participants were blinded to the original, in-person POPS. Further data were gathered in the form of a questionnaire to determine the level of training and experience the candidate had using the POPS score prior to undertaking this study.

Main outcome measures

Inter-rater reliability among participants scoring of the POPS.

Results

Overall kappa value for case 1 was 0.74 (95% CI 0.605 to 0.865), case 2 was 1 (perfect agreement) and case 3 was 0.66 (95% CI 0.58 to 0.744).

Conclusion

This study suggests there is good inter-rater reliability between different nurses’ use of POPS in assessing sick children in the emergency department.




Diagnosis of sporadic neurofibromatosis type 2 in the paediatric population

2018-04-19T01:30:35-07:00

Objective

Onset of symptoms in severe sporadic neurofibromatosis type 2 (NF2) is typically within childhood; however, there is poor awareness of presenting features in young children, potentially resulting in delayed diagnosis and poorer outcome. We have reviewed presentation of sporadic paediatric NF2 to raise awareness of early features, highlighting those requiring further investigation.

Design

Patients diagnosed with NF2 at age ≤16 and seen between 2012 and 2015 were notified via the British Paediatric Neurology Surveillance Unit or identified through the English NF2 service.

Results

Epidemiological data estimate that 1 in 110 611 births are affected with childhood-onset NF2. Notes of 32 patients with sporadic NF2 were reviewed. Of those presenting under the age of 5, 89% (17/19) had ocular, 74% (14/19) dermatological and 58% (11/19) neurological signs; in 84% (16/19) features were multisystemic. Sixty-six per cent (21/32) had ≥1 atypical feature, including cerebellar hypoplasia in three cases (9%) and focal cortical dysplasia in five out of seven seizure-related presentations. Five cases presented with a sometimes transient or intermittent cranial nerve mononeuropathy. The mean delay to diagnosis was 3.16 years; in eight cases (25%) this exceeded 6 years. Most significant delay occurred in mononeuropathy, ophthalmological and/or seizure presentations, with a mean delay of 3, 4.5 and 6 years, respectively. Eighty-four per cent (27/32) of cases needed intervention in childhood.

Conclusions

All non-vestibular schwannoma NF2 presentations in childhood had significant diagnostic delay. We emphasise the importance of detailed assessment of skin and eyes in unusual presentations and propose an aide to prompt timely referral to specialist services.




Infant feeding practices among HIV-exposed infants less than 6 months of age in Bomet County, Kenya: an in-depth qualitative study of feeding choices

2018-04-19T01:30:35-07:00

Background

In children, HIV can be acquired from the mother during pregnancy, delivery and through breast milk. The WHO recommends exclusive breast feeding or exclusive replacement feeding for the first 6 months after birth for HIV-exposed infants. Barriers such as HIV-related stigma, inadequate resources, lack of access to safe water and negative cultural beliefs have been shown to influence infant feeding among HIV-exposed infants in some settings. In Kenya, there is limited literature on the barriers. The purpose of this study was to identify barriers to optimal feeding among HIV-exposed infants 0–5 months of age attending a mission hospital in Bomet County, Kenya.

Methods

A cross-sectional qualitative study was conducted at a referral mission hospital in Bomet County, Southwest Kenya. Four focused group discussions were conducted among mothers/caregivers of HIV-exposed infants aged 0–5 months in accordance with their infant feeding practices, while two key informant interviews were also held with healthcare workers. All sessions were audio recorded and later transcribed verbatim. Content analysis was performed, and conclusions were made based on identified themes.

Results

Factors influencing the infant feeding choices were: financial constraints, cultural beliefs and practices, HIV-related stigma and conflicting knowledge among mothers/caregivers and healthcare workers on the recommendations for feeding HIV-exposed infants 0–5 months of age.

Conclusions

Health worker retraining in and reinforcement of WHO guidance on feeding HIV exposed/infected infants will clarify misconceptions around feeding HIV exposed/infected infants, though there remain social and economic barriers to full implementation.




Countdown for UK Child Survival 2017: mortality progress and targets

2018-04-19T01:30:35-07:00

Background

The Countdown for UK Child Survival tracks recent UK child mortality trends and makes recommendations for improvement.

Methods

We used data from the WHO World Mortality Database to calculate mortality from 1970 to 2014 for 0–19 year olds in the UK and a comparable group of wealthy countries (the EU15+). We used Poisson regression models to assess the significance of apparent differences. We extrapolated model coefficients to estimate future disparites between the UK and the EU15+ to 2030. We proposed goals and intermediate indicators to track UK mortality in keeping with the UN Sustainable Development Goals.

Results

UK infant mortality continues to track in the worst decile of EU15+ mortality with 1–4 year mortality in the worst quartile. Annual reductions in total UK mortality have been significantly lower than the EU15+ since 1990 for infant, postneonatal and 1–4 year mortality. If current trends persist, by 2030 UK infant mortality and 1–4 year mortality could be respectively 180% and 145% of EU15+ median mortality. UK non-communicable disease (NCD) mortality among 1–4 years and 15–19 years persists in the worst quartile. UK injury mortality continues in the best quartile. A framework of goals and indicators for UK child survival and health is presented.

Discussion

UK mortality among under 10 years of age continues to diverge from the EU15+ median, and UK NCD mortality remains persistently poor. We propose a set of goals to improve UK childhood survival by 2030 and an annual Countdown mechanism to monitor progress towards these targets.




Individualised advance care planning in children with life-limiting conditions

2018-04-19T01:30:35-07:00

Introduction

In 2013, the Pediatric Association of the Netherlands launched an evidence-based guideline ‘Palliative care for children’. To promote implementation in daily practice and hereby improve quality of paediatric palliative care, we aimed to develop a functional individualised paediatric palliative care plan (IPPCP) that covers physical, psychological, spiritual and social functioning, with great emphasis on the guideline’s recommendations, advance care planning and patients’ and parents’ preferences and desires.

Methods

A Dutch working group (28 individuals) with a strong multidisciplinary character developed a draft IPPCP, which was piloted retrospectively and prospectively. In the pilots we completed, the IPPCPs for patients who were recently diagnosed with a life-threatening or life-limiting condition and evaluated completeness, usability and user-friendliness.

Results

The final IPPCP comprised five domains: (1) IPPCP data, (2) basics, (3) social, (4) psychosocial and spiritual and (5) physical care. Each domain covered various components. In both pilots, the IPPCP was considered a comprehensive document that covered all areas of paediatric palliative care and was experienced as an improvement to the present situation. However, the current form was regarded to lack user-friendliness.

Conclusion

We propose a set of essential components of a comprehensive IPPCP for paediatric palliative care with extra attention for advance care planning and anticipatory action. Patients’ and parents’ preferences and desires are included next to the recommendations of the evidence-based guideline ‘Palliative care for children’.




Children and young peoples versus parents responses in an English national inpatient survey

2018-04-19T01:30:35-07:00

Objective

Despite growing interest in children and young people’s (CYP) perspectives on healthcare, they continue to be excluded from many patient experience surveys. This study investigated the feasibility of, and additional information gained by, measuring CYP experiences of a recent hospital admission.

Design

Cross-sectional analysis of national survey data.

Setting

Inpatients aged 8–15 years in eligible National Health Service hospitals, July–September 2014.

Participants

6204 parents/carers completed the parent section of the survey. The CYP section of the survey was completed by CYP themselves (n=3592), parents (n=849) or jointly (n=1763).

Main outcome measures

Pain relief, involvement, quality of staff communication, perceived safety, ward environment, overall experience.

Analyses

Single-measures intraclass correlations (ICCs) were used to assess the concordance between CYP and parent responses about the same inpatient episode. Multilevel logistic regression models, adjusted for individual characteristics, were used to compare the odds of positive responses when the CYP section of the survey was completed by parents, by CYP themselves or jointly.

Results

The CYP section of the survey was completed independently by 57.8% of CYP. Agreement between CYP and parent responses was reasonably good for pain relief (ICC=0.61 (95% CI 0.58 to 0.63)) and overall experience (ICC=0.70 (95% CI 0.68 to 0.72)), but much lower for questions comparing professionals’ communication with CYP and with their parents (ICC range=0.28 (95% CI 0.24 to 0.32) to 0.51 (95% CI 0.47 to 0.54)). In the regression models, CYP were significantly less likely than parents to report feeling safe (adjusted OR (AOR)=0.54 (95% CI 0.38 to 0.76)), involvement in decisions (AOR=0.66 (95% CI 0.46 to 0.94)) or adequate privacy (AOR=0.68 (95% CI 0.52 to 0.89)).

Conclusions

Including CYP (8–15 years) in patient experience surveys is feasible and enhances what is known from parents’ responses.




Kangaroo mother care for the prevention of neonatal hypothermia: a randomised controlled trial in term neonates

2018-04-19T01:30:35-07:00

Objective

To test the hypothesis that kangaroo mother care (KMC) initiated either at birth or at 1 hour after birth reduces moderate or severe hypothermia in term neonates at (A) 1 hour after birth and (B) at discharge when compared with standard thermoregulation care.

Methods

Term neonates born at a tertiary delivery centre in Zambia were randomised in two phases (phase 1: birth to 1 hour, phase 2: 1 hour to discharge) to either as much KMC as possible in combination with standard thermoregulation care (KMC group) or to standard thermoregulation care (control group). The primary outcomes were moderate or severe hypothermia (axillary temperature <36.0°C) at (A) 1 hour after birth and (B) at discharge.

Results

The proportion of neonates with moderate or severe hypothermia did not differ between the KMC and control groups at 1 hour after birth (25% vs 27%, relative risk (RR)=0.93, 95% CI 0.59 to 1.4, P=0.78) or at discharge (7% vs 2%, RR=2.8, 95% CI 0.6 to 13.9, P=0.16). Hypothermia was not found among the infants who had KMC for at least 9 hours or 80% of the hospital stay.

Conclusions

KMC practised as much as possible in combination with standard thermoregulation care initiated either at birth or at 1 hour after birth did not reduce moderate or severe hypothermia in term infants compared with standard thermoregulation care. The current study also shows that duration of KMC either for at least 80% of the time or at least 9 hours during the day of birth was effective in preventing hypothermia in term infants.

Clinical trial registration

NCT02189759.




Are we giving too much IV fluid?

2018-04-19T01:30:35-07:00

The importance of prompt resuscitation with intravenous (IV) fluids in children with presumed sepsis or severe dehydration is well-known, and is emphasised in all resuscitation guidelines. But have we gone too far? The FEAST trial published in 2011 set alarm bells ringing (doi: 10.1056/NEJMoa1101549). In a sub-Saharan Africa setting, it showed that very ill, febrile children randomised to fluid boluses of either saline or albumin had a 3.3% higher mortality than those receiving only maintenance fluids. Those with gastro-enteritis were excluded. Since then questions have been asked about whether we might also be doing harm to less ill children in Western settings by overuse of fluids.

Two systematic reviews and meta-analyses have been published looking at different aspects of this dilemma. The first, by Canadian authors, looked for evidence linking fluid balance and outcomes in critically ill children on intensive care units (Alobaldi R et al doi: 10.1001/jamapediatrics.2017.4540). In these children,...




Non-operative management of appendicitis in children

2018-04-19T01:30:35-07:00

While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon’s knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.




The fastener that left its mark

2018-04-19T01:30:35-07:00

A 4-month-old baby was referred by children’s services for assessment of a lesion on her cheek to exclude a non-accidental burn. She was being treated for oral candidiasis. The family was receiving support from social services.

On examination, a single lesion consisting of two concentric, well-demarcated circles measuring 0.5 cm in diameter was found on her right cheek (figure 1). The skin was intact and blanched under pressure. A clean dummy attached to her clothes was noted to contain a plastic fastener consisting of firm concentric circles whose dimensions matched the lesion exactly (figure 2). Parents confirmed that she often slept in her cot with the right side of her face pressing against her dummy. She was discharged home after it was concluded that the lesion was likely to have been caused by pressure from the fastener. Parents were advised to complete her antifungal treatment. The...




Bone protective agents in children

2018-04-19T01:30:35-07:00

Evaluation of bone health in childhood is important to identify children who have inadequate bone mineralisation and who may benefit from interventions to decrease their risk of osteoporosis and subsequent fracture. There are no bone protective agents that are licensed specifically for the prevention and treatment of osteoporosis in children. In this review, we discuss the mechanism of action and use of bisphosphonates and other new and established bone protective agents in children.




Major bleeding disorders: diagnosis, classification, management and recent developments in haemophilia

2018-04-19T01:30:35-07:00

In this review, we outline the standard of care for children in the UK with the most common major bleeding disorder, haemophilia, and how exciting new developments in therapy have the potential for further improvements in quality of life and clinical outcome. The combination of comprehensive specialist medical care, safer factor concentrates, earlier introduction of prophylaxis and patient-specific education has allowed the current generation of patients with haemophilia to grow into adulthood with excellent joint function, pursuing full-time employment with a good quality of life. We are entering an exciting new phase in paediatric haemophilia as potentially life-changing products appear on the scene taking a step towards achieving better, easier and personalised prophylaxis.




Question 1: Is it safe to use ivermectin in children less than five years of age and weighing less than 15 kg?

2018-04-19T01:30:35-07:00

Scenario

You are working in a remote clinic in Northern Australia and see an 18-month-old girl (weight 10 kg) who presents with a pruritic rash on her extremities. She has a history of persistent scabies despite multiple treatments with topical permethrin 5%. You diagnose her with scabies and although you are aware that oral ivermectin is used for scabies in children over 5 years and weighing more than 15 kg, you consider whether it would be safe to use ivermectin for the treatment of scabies in this child.

Structured clinical question

In a child less than 5 years of age and less than 15 kg (patient), is oral ivermectin (intervention) a safe treatment option (outcome)?

Search strategy and outcome

In May 2017, the Ovid interface was used to search English-language articles in MEDLINE (1946 to current) and EMBASE (1974 to present). The following search terms were used: ivermectin AND...




Towards evidence-based medicine for paediatricians

2018-04-19T01:30:35-07:00

Signal, noise, chance and chancers

For those who hold to personalised medicine as the future of therapeutics, the case is made that it is about identifying the ones who will gain from the ones who do not. Separating the signal from the background noise. If we did a randomised trial of ‘antibiotics for fever’, we may come away believing they had no value; the benefit in significant bacterial infections swamped by the viruses, immune responses and dodgy thermometer readings that made up the noise. With this in mind, it makes sense to search within a potential heterogeneous group of patients to identify those who do gain some benefit from an intervention if it is—broadly—ineffective.

How we do this poses a problem though.

The issue of data dredging, P value fitting and ‘overprediction’ within the field of clinical decision rules and the like we have spoken of before.1 The same issues...




Question 2: Is there a role for Montelukast in the management of viral-induced wheeze in preschool children?

2018-04-19T01:30:35-07:00

Clinical setting

A 3-year-old girl presents to the emergency department with a severe wheeze and tachypnoea. Her mother reports that she experienced coryzal symptoms a few days prior to the onset of the wheeze and that she previously had three similar wheezing episodes that were also triggered by viral upper respiratory tract infections in the past year. Each wheezing episode lasts 2–4 days and have all been clinically severe, requiring medical attention. Between upper respiratory tract infections, she is asymptomatic with no wheeze, and she has no history of atopy.

She has viral induced wheeze (also known as episodic viral wheeze (EVW)) and is usually managed with an inhaled short-acting beta-2 agonist and inhaled or oral corticosteroids. Having heard that there are some concerns over corticosteroids causing stunted growth, her physician wonders if a leukotriene receptor antagonist (LTRA), such as Montelukast, which does not suppress growth, would be effective...




Understanding and improving the experience of paediatricians in training

2018-04-19T01:30:35-07:00

In recent years, postgraduate training has changed significantly, with further changes to the training pathway on the horizon.1 Tensions have been heightened due to significant rota gaps, recent contract negotiations, ongoing challenges with trainee retention and poor morale.2 Coupled with intense service pressures, there is a need to understand the impact of these on paediatricians in training and develop mechanisms to improve the training experience.

The General Medical Council is tasked with quality assurance through the national training survey (NTS) but lacks specific paediatric measures (eg, subspecialty and community domains) and historically has had poor uptake.3 The NTS begins surveying trainees only a few weeks into a post, generating suboptimal feedback, unlikely to be reflective of a 6-month period and with greater emphasis on identifying outliers.

These factors have driven us to produce a trainee survey, now approaching its sixth cycle. The survey...




Muscular dystrophy: Are we looking for subtle signs?

2018-04-19T01:30:35-07:00

Muscular dystrophy is a group of inherited genetic conditions. Gene mutations lead to defectivemuscular structural protein production, thus making the muscles weak, leading to poor function and disability. Early diagnosis is crucial, as treatment is aimed to halt disease progression. Although newer treatments are currently available, time taken to reach diagnosis has still not improved.1

Here are two case reports of children who were referred for different concerns to neurodevelopmental clinic run by Community Paediatrics. The children had a diagnosis of muscular dystrophy.

The aim of this letter is to increase awareness of suspecting muscular dystrophy in children who present with subtle signs.

Case 1

A 5-year-old boy was referred for behavioural concerns and learning difficulties. His school had noticed that the child walked with wide-based gait, but his mother was not worried. The child’s birth, medical and family history were unremarkable.

The boy said he...




Investigation of developmental delay

2018-04-19T01:30:35-07:00

In November 2017’s issue of Archives there were a number of articles addressing the important area of the clinical approach to children with developmental delay. The investigations performed are very variable across the UK and this is a key area where the clinical and cost-effectiveness of every laboratory investigation needs to be further evaluated. Hart et al1 suggest a very limited metabolic screen for children with developmental delay without additional features, whereas Mithyantha et al2 suggest more extensive metabolic screening.

We cannot agree with the very limited metabolic screen proposed by Hart et al1 for children with developmental delay without additional features. We agree that investigations can be more targeted after a thorough clinical assessment. However, a large number of children will have no additional features, and not performing a more extensive screen would be a disservice.

It is important to consider the reasons...




Correction: The Little Prince: is not a glimpse into the world of autism

2018-04-19T01:30:35-07:00

Burgio E, Leo I, Lucangeli D. The Little Prince: is not a glimpse into the world of autism. Arch Dis Child 2018;103:405.

There was an error in the reference list in in this letter. Reference 3 should have read: Lemay J, Eastabrook G, MacKenzie H. The Little Prince: a glimpse into the world of autism? Arch Dis Child 2018;103:389–92.




Highlights from the literature

2018-04-19T01:30:35-07:00

High fever and serious infection

Parents worry when their child has a very high fever, but as paediatricians we are often more relaxed; we assume that such high temperatures in otherwise healthy children are more likely to be due to viral infection, while those with serious sepsis often have only a mild fever. Is our assumption justified? Researchers from Israel did a systematic review (Rosenfeld-Yeoshua et al. Eur J Pediatrics doi.org/10.1007/s00431-018-3098-x). They looked for studies comparing rates of serious bacterial infection (SBI) depending on the child’s presenting temperature. They found 11, and distinguished those looking at hyperpyrexia (> 41°C) and high fever (>40 °C). The two hyperpyrexia studies showed a significantly higher risk of SBI at all ages (pooled OR 1.96; 95% CI 1.3 to 2.0), but both studies were old (1976 and 1990) and pre-dated routine vaccination against H. influenza B, pneumococcus and meningococcus. Five studies looked at otherwise...