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Archives of Disease in Childhood - Education and Practice recent issues

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Highlights from this issue


Welcome to a slightly different issue of E&P. There are a lot of additional considerations for editing when you decide you’re going to ask authors to aim for a more quirky edition. I’ll tell you the two main ones. The first is whether the authors of the more serious papers are going to take offence at being included alongside slightly lighter hearted ones. I have to tell you that I’ve not contacted all of the authors here to check that they’re OK with this; what I was able to do instead was ensure that the quirkier papers we did have were good enough to stand alone—I hope you agree. I do hope the non-quirky authors are OK with this.

The second important consideration was: What makes a good quirky paper? Our much bigger sibling, the BMJ, has a seasonal edition, but I don’t think I’ve ever seen a formal...

I sit in the Diabetic Clinic



The extract below is an edited version of Dr Lindsay’s presidential address—entitled ‘Listening and Reflecting’—to the paediatric section of the Royal Society of Medicine in October 1989. Mary Lindsay qualified in medicine in 1951 and, as Dermod MacCarthy’s paediatric registrar, appeared in James Robertson’s influential film ‘Going to hospital with mother’.1 2 Later, as a consultant child psychiatrist, she worked again with Dr MacCarthy and his patients, pioneering the model of liaison work described in this lecture. In 1976, Dr Lindsay, although a child psychiatrist working in the home counties, was elected to the British Paediatric Association, and in 1993 elected FRCP, something of an honour. In 1974, she and Dr MacCarthy started the celebrated child psychiatry/paediatric meetings at the postgraduate centre at Stoke Mandeville Hospital, which took place three times a year and continued for 18 years.

Mary Lindsay has been a distinguished...

The team that plays together stays together: the effect of departmental Christmas party attendance on team cohesion within a healthcare setting



To understand the effect of attendance at departmental Christmas parties on cohesion and teamwork within the healthcare setting.

Method (design/setting/participants/interventions/outcome measures)

We used the ‘Team Development Measure’ questionnaire to assess team cohesiveness among healthcare professionals before and after departmental Christmas parties took place. A pooled mean score (PMS) of responses was used to compare between groups.


There were no significant differences in perceived measures of team cohesion when comparing responses before (PMSbefore=1.86±0.20) and after (PMSafter=1.91±0.22) the departmental Christmas party (p=0.37), nor was there a significant difference when comparing responses from attendees (PMSbefore=1.83±0.23, PMSafter=1.89±0.24, p=0.52) or non-attendees (PMSbefore=1.84±1.47, PMSafter=1.83±0.15, p=0.91). No difference was observed between professional groups (PMSdoctors=1.85±0.23, PMSnurses=1.95±0.18, p=0.064).


Attendance at departmental Christmas parties does not seem to result in improved team cohesion.

Christmas Connections


This collection of cases has a Yuletide theme; think winter weather and the nativity story with a dose of lateral thinking to link the imaging findings with a Christmas themed paediatric radiology sign.

Answers to the questions can be found on page 291



A chest X-ray (figure 1) was taken to assess this term baby with respiratory distress at 4 hours of age. What celestial sign is demonstrated and why does it occur?


What evergreen entity is seen on this cystogram image (figure 2) taken during urodynamic bladder assessment of a an 11-year old girl with spina bifida? What causes it?


An 8-year old girl known to the paediatric orthopaedic surgeons presented to the emergency department with leg pain and subsequently had surgery to stabilise her left femur. Her preoperative and postoperative radiographs are shown in figure 3a and

Uses and abuses of snack foods in child health


Snack foods, though regarded as unhealthy, are widely eaten by children, particularly those with eating and feeding difficulties. This article outlines the ways in which paediatricians have traditionally made use of snack foods as incentives and then reviews the key nutritional and practical characteristics of commonly eaten snack foods, to allow practitioners to evaluate their role in the child’s diet. Generally savoury snacks are preferable to sweet, while dry foods are preferable to drinks or semiliquid desserts. Many ostensibly healthy snacks are also rich in sugar or fat. Eaten in addition to other meals, snack foods may lead to obesity or else displace family foods, but the instant appeal of snack foods can be exploited to introduce young children to otherwise aversive sensations and tastes and can prove a useful path towards a more diverse future diet. If a reasonable variety of snack foods are taken, this will still form a fairly balanced, if non-ideal, diet.

Fifteen-minute consultation in the normal child: Challenges relating to sexuality and gender identity in children and young people


Lesbian, gay, bisexual and transgender (LGBT+) young people face several challenges in their daily lives, including specific healthcare inequalities. Negative societal attitudes towards sexual and gender minorities, and the effects of regular experiences of bullying and homophobia/transphobia exacerbate the normal trials and tribulations of childhood and adolescence. Barriers to accessing healthy activities, such as sport, are created by perceived stigma and real-life experiences. Healthcare environments are by default heteronormative and contribute to the isolation and exclusion of LGBT+ young people. Paediatricians are well placed to act on these healthcare inequalities and to advocate for LGBT+ youth, through simple changes to individual practice as well as system-wide improvements.

Fifteen-minute consultation--the child with a developmental disability: is there an ocular or visual abnormality?



To present a structured approach for an outpatient consultation for a child with developmental disability who may have an ocular or visual disorder.


Review of relevant literature and description of the approach to ocular and visual assessment which could be used by any paediatrician.


A systematic approach to history, observation and examination of a child with a developmental disability will assist in identifying a possible visual problem. A structured referral letter will ensure that the child will receive the most appropriate assessment to clarify the problem and appropriate management in the eye clinic.

Thinking outside the box in clinical practice


During difficult times we forget that as healthcare practitioners we are immensely privileged. We have a job, with regular work and generally don’t have to worry about putting food on our families’ table. But from a humanities perspective, we also have front row seats on the drama of life and no two days can be the same. Yet as we struggle to master our profession, the day to day realities of the job itself struggles to master us. If we become ‘too hard’ we may be fully competent yet fail to discharge our duties properly; however, should we become ‘too soft’, we may find ourselves not being able to discharge those duties at all. Striking that ‘happy’ balance is a decision we each make for ourselves every day during our decades of practice. For me, it has been necessary from the outset to include medical humanities within the clinico-medical perspective of daily practice. My definition of Medical Humanities will not only include medical history but also, stories, films and plays. This article relates some practices which I have found useful.

How to use nasal nitric oxide in a child with suspected primary ciliary dyskinesia


Measuring nasal nitric oxide (nNO) is increasingly used as part of testing for primary ciliary dyskinesia (PCD). The diagnosis of PCD is often delayed until after bronchiectasis is established and auditory damage has occurred. It is important that all paediatricians are aware of clinical features that are suggestive of PCD that should prompt diagnostic testing. nNO levels are recognised to be low in people with PCD and results generated by static chemiluminescence analysers using velum closure technique in older children have good sensitivity and specificity. However, to conclusively rule PCD in or out, further tests of ciliary function are required and assessment of cilia ultrastructure, immunohistochemistry studies and genotyping may also be indicated. These tests are more complex, invasive and expensive than nNO. nNO is less well studied in younger children where tidal breathing measurements are required. Portable nitric oxide analysers are also increasingly used in practice. This paper discusses when to consider PCD as a possible diagnosis in a child along with the indications, physiological and technical background and clinical utility of nNO as a test for PCD in children.

How to use tests for disorders of copper metabolism


In paediatrics, one of our main aims in the diagnostic process is to identify any treatable conditions. The copper metabolism disorder Wilson’s disease (WD) is one such condition that is caused by mutations in the ATP7B gene. Delay in treatment could result in irreversible disability or even death. Although liver disease is the most common presenting feature in children, some children may initially present with a subtle neurological presentation only. In patients presenting with dystonia, tremor, dysarthria or with a deterioration in school performance, there should be a high index of suspicion for WD. However, the differential of these clinical presentations is wide and exclusion of WD is difficult. No single diagnostic test can exclude WD and each of the biochemical tests has limitations. In this article, we discuss copper metabolism disorders including WD and Menke’s disease. We then discuss the available diagnostic tests and how to investigate children for these rare disorders.

Intravenous fluid therapy in children and young people in hospital N29


Information about the current guideline

The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal. Errors in prescribing or administration can increase morbidity, with inadequate provision causing hypovolaemia and poor organ perfusion, and excessive fluids leading to overload and cardiac failure. Failing to correct electrolyte imbalances can result in neurological sequelae and even death.

In December 2015, the National Institute for Care Excellence (NICE) addressed the lack of guidance by publishing ‘Intravenous fluid therapy in children and young people in hospital NG29’1. Endorsed by the Royal College of Paediatrics and Child Health, its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.

Previous guidelines

Although there is no previous national consensus for intravenous fluid prescription...

Amitriptyline and topiramate are no better than placebo for childhood migraine


Study question

Setting: 31 sites in the USA.

Patients: Children and adolescents aged 8–17 years with a diagnosis of migraine plus Pediatric Migraine Disability Assessment Score (PedMIDAS) indicating mild to severe disability and four or more headaches over the initial 28 day baseline period.

Intervention: 1 mg/kg/day amitriptyline versus 2 mg/kg/day topiramate versus placebo. There was a 28-day period initially before medication started to monitor baseline migraine frequency, the active medication was started and dose slowly increased for 8 weeks with 16-week maintenance period, to complete 24 weeks in total.

Outcomes: Primary outcome was relative reduction of 50% or more in number of headache days between the initial 28-day baseline period and the last 28-day period of the trial.

Secondary outcomes included headache disability (change in PedMIDAS score), reduction in the number of days with headache, number of people who completed the 24-week treatment period and the serious adverse events.

Main results...

Introduction of allergenic foods from 3 months of age reduces incidence of food allergy in breastfed infants


Study question

Patients: 1303 exclusively breastfed, well, singleton infants, aged 13–17 weeks recruited from the general population in England and Wales.

Early introduction group: Introduction of six allergenic foods: cow’s milk, peanut, hen’s egg, sesame, whitefish and wheat. Minimum amounts defined as 3 g once a week of at least five of the foods for 5 weeks between 3 and 6 months of age.

Standard introduction group: Continue to breast feed until 6 months of age, compliance defined as no consumption of allergenic foods including less than 300 mL of formula per day.

Outcomes: Challenge-proven food allergy to one or more of the six early introduction foods at age 1–3 years.

Analysis: Intention-to-treat (ITT) analysis and per-protocol analysis (PPA). In PPA, infants who were not compliant with their diet using the above definitions were excluded from the analysis.

Follow-up period: Until 3 years of age.

Main results

When analysed by...

Gradual withdrawal of desmopressin in patients with enuresis leads to fewer relapses than an abrupt withdrawal


Study question

In children with enuresis, does gradual reduction of desmopressin compared with abrupt cessation result in less relapses?

Study inclusion criteria: RCTs with a control group comparing gradual with abrupt cessation of desmopressin.

Data source: Two independent reviewers searched Medline, Embase, ScienceDirect, Ovid, Google Scholar and Wiley Online Library for ‘desmopressin’ and ‘enuresis’. They searched for unpublished trials by contacting the authors. Risk of bias was assessed using recommendations from the Cochrane Collaboration. Four articles remained for meta-analysis and a further 18 were used in a systematic review.

Outcome: Rate of sustained response (ie, no incidences of wetting) at ≥1 month after withdrawal from desmopressin. Subgroup analysis separated the gradual withdrawal group into either dose dependent (by reducing the dose) or time dependent (increasing the time between each dose).

Main results

Structured withdrawal significantly reduced the number of wetting incidents in the month following cessation...

Azithromycin for episodes with asthma-like symptoms in young children aged 1-3 years


Setting: Birth cohort of general population of Zealand region, Denmark.

Patients: At the age of 1 week, 700 infants were recruited and observed via daily parental diaries until the age of 3 years. Included in the trial were children who developed recurrent troublesome lung symptoms, defined as: 5 episodes in 6 months of cough, dyspnoea or wheeze severely affecting the well-being of the child; 4 weeks of continuous symptoms; severe episode requiring admission or treatment with oral steroids. Three months of inhaled fluticasone was given at the diagnosis of recurrent troublesome lung symptoms and continued for another 6 months if symptoms recurred.

Intervention: Children older than 1 year of age were assessed by a study physician at each acute episode (≥3 consecutive days of cough, dyspnoea or wheeze severely affecting the well-being of the child) and randomly allocated to azithromycin (10 mg/kg/day for 3 days) or placebo. Hypopharyngeal aspirates...

Critically ill children did not benefit from tight glycaemic control


Study design

Design: Randomised controlled trial.

Allocation: Computer generated block design.

Study question

Setting: Thirty-five paediatric intensive care unit (ICU) centres.

Patients: Three hundred and sixty patients (median age 5.5 years, IQR 1.4–12.5 years) in the lower target group; 353 patients (median age 6.7 years, IQR 1.7–12.8 years) in the higher target group.

Intervention: Randomisation to low target glycaemic control group (80–110 mg/dL (4.4–6.1 mmol/L)) or higher target glycaemic control group (150–180 mg/dL (8.3–10 mmol/L).

Outcomes: Primary outcome: number of ICU-free days to day 28. Prespecified secondary outcomes: 90-day mortality, severity of organ dysfunction, the number of ventilator-free days to day 28, incidence of healthcare-associated infection and incidence of hypoglycaemia.

Patient follow-up: Patients were followed up for 90 days. Recruitment stopped at 50% due to low likelihood of benefit and potential of harm.

Main results

The key results from this study are summarised in Table 1. There was no change in 90 day hospital mortality or...