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Preview: Archives of Disease in Childhood - Education and Practice current issue

Archives of Disease in Childhood - Education and Practice current issue



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Highlights from this issue

2018-01-18T08:40:28-08:00

I’ve been following, with interest, the developments in artificial intelligence (AI) over the past few years. Depending on which author you read, we’re either a few years, or a lifetime away from, or several lifetimes from being replaced in all we do. There are some really interesting examples of how specific AI—where the software learns a very precise task—is nearly as good as, or perhaps better than humans at some things. Driving a car is  one attracting much attention, and the recent examples of programs beating humans at board games seem to be the start of this. However, general AI appears to be further off. We might, quite soon, trust software to drive us down a motorway, but that exact same software will likely be rubbish at making a good cup of tea.

While we’re still in the phase where we need to use wetware—our brains—in meatspace—the physical world—it...




Fifteen-minute consultation: Pain relief for children made simple--a pragmatic approach to prescribing oral analgesia in the postcodeine era

2018-01-18T08:40:28-08:00

What are the most effective doses of simple oral analgesics such as paracetamol and ibuprofen for pain relief in children? Why can’t I prescribe codeine phosphate for children anymore? Is oral morphine really a safe alternative to codeine phosphate, and if so what dose should I prescribe? These questions are frequently asked by clinicians who wish to give analgesics to children for pain relief. In this article I will address these questions and describe a pragmatic approach for pain relief using oral analgesics based on the best evidence available and my experience as a consultant paediatric anaesthetist.




Fifteen-minute consultation: An evidence-based approach to the child with preschool wheeze

2018-01-18T08:40:28-08:00

Preschool wheeze is very common and its prevalence is increasing. It consumes considerable healthcare resources and has a major impact on children and their families due to significant morbidity associated with acute episodes.History taking is the main diagnostic instrument in the assessment of preschool wheeze. Diagnosis and management is complicated by a broad differential and associations with many other diseases and conditions that give rise to noisy breathing, which could be misinterpreted as wheeze. Several clinical phenotypes have been described but they have limitations and do not clearly inform therapeutic decisions. New insights in aetiopathogenesis modify treatment options and lay foundation for further research. An understanding of the approach and available evidence to assess and manage wheeze informs best patient care and use of resources.Our objective is to demonstrate a focused history, examination and management options in a preschool child with wheeze.




Fifteen-minute consultation: Communicating with young people--how to use HEEADSSS, a psychosocial interview for adolescents

2018-01-18T08:40:28-08:00

Adolescents undergo a period of biological, social and psychosocial development, and each of these domains impacts each other. Psychosocial areas of concern often emerge over the adolescent period (such as mental health conditions, drug use and risky sexual behaviour); those with chronic illness being at higher risk. The paper aims to guide health practitioners on when and how to approach the psychosocial interview with young people and assess areas of risk or concern. This will include putting them at ease, developing rapport, seeing them alone and explaining confidentiality before commencing the assessment. Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) is a recognised psychosocial interview framework that allows a better understanding of the young person’s situation and what their specific needs may be. By exploring each section in turn briefly or more fully, it gives the professional an overall impression of the young person’s life and any risky behaviours or concerns. This systematic structure should develop an easily accessible approach to adolescents as a group of patients whatever their developmental stage.




Bilateral hydroureters and hydronephrosis in a neonate

2018-01-18T08:40:28-08:00

A newborn boy was diagnosed antenatally with bilateral hydronephrosis. Postnatal renal ultrasound scan (USS) measured a renal pelvic anteroposterior diameter (APD) of 12 mm on the left side and 7 mm on the right side. The baby had good urine stream. Parents missed the repeat USS at the age of 1 week. An ultrasound done at 4 weeks revealed progressive hydronephrosis, bilateral hydroureters, with increased renal echogenicity. Normal bladder wall thickness was noted but two intravesical lesions were seen (figures 1 and 2). The APD was 13.5 and 11 mm on the left and right side, respectively.

Figure 1

Renal ultrasound scan of (A) left kidney (LT) and (B) right kidney (RT) showing bilateral hydronephrosis (white arrows) and hydroureters (red arrow). Increased renal echogenicity is not shown in the figure.

Figure 2

Showing normal bladder wall thickness but two intravesical lesions were seen (white arrows).

Question

  • How would you describe the intravesical lesions in figure 2?

  • Bilateral ureteroceles

  • Bilateral vesicoureteral reflux (VUR)

  • Bilateral pelvi-ureteric junction obstruction

  • Posterior urethral valves (PUVs)

  • Which complication(s) may you expect in such cases?

  • Urinary tract infection (UTI)

  • Obstructive voiding symptoms

  • Failure to thrive

  • Ureteral calculus

  • All of the above

  • How would you treat this problem?

  • Endoscopic puncture

  • Deflux surgery

  • Pyeloplasty

  • Vesicostomy

  • Answers are on page




    An adolescent with acute abdominal pain and bowel wall thickening

    2018-01-18T08:40:28-08:00

    A 15-year-old girl was admitted with acute crampy abdominal pain and repeated vomiting over the preceding 2 hours; no fever, diarrhoea or abdominal trauma was reported. She had started oestrogen–progestin contraception 3 months ago. She had sought medical advice twice in the previous weeks for self-limiting episodes of right hand swelling, without urticaria. On examination, she was unwell and in pain, with severe tenderness in the right lower quadrant, without guarding or rebound tenderness. Bowel sounds were diminished. Blood tests were unremarkable. Two hours after admission, an abdominal ultrasound scanning showed an impressive wall thickening (>1 cm) of the terminal ileum, caecum and ascending colon (figure 1). Abundant free intraperitoneal fluids in the pelvis and in the hepatorenal recess were present.

    Figure 1

    Marked caecal wall thickening evidenced at the ultrasound scanning.

    Questions

  • Which of the following is the most likely diagnosis in this patient?

  • Ileocolic intussusception

  • Gastrointestinal manifestation of Henoch-Schönlein purpura

  • Abdominal attack of hereditary angioedema (HAE)

  • Acute pancreatitis

  • Which of the following blood tests may help to confirm the diagnosis?

  • Erythrocyte sedimentation rate

  • C4

  • Serum amylase: 36 IU/L

  • C1-inhibitor

  • How should this patient be evaluated and treated?

    Answers are on page .




  • What is that rash?

    2018-01-18T08:40:28-08:00

    Case history

    A healthy 15-month-old girl presented to the emergency department with a 24-hour history of fever and rash. The initial blanching rash developed into non-blanching areas with associated leg swelling. She had received no recent medications, had no known drug allergies and no unwell contacts.

    On examination, she was feverish at 38.6°C, capillary refill time was <2 s with warm peripheries, heart rate 169 bpm and blood pressure 94/59 mm Hg. A palpable purpuric rash was evident on all four limbs and face (figure 1) although the trunk was spared. Her legs were tense and oedematous to the knee.

    Figure 1

    Rash at presentation.

    Initial investigations:

  • Haemoglobin level: 131 g/L, white cell count: 16.6x109/L, neutrophils: 11.1x109/L and platelets: 407x109/L

  • Coagulation screen: normal

  • C reactive protein level: 20 mg/L

  • Lactate level: 1.7 mmol/L

  • Intravenous ceftriaxone was commenced following blood culture and meningococcal PCR. The following day, while remaining systemically well, she developed a vesicular rash on her trunk and back (figure 2).

    Figure 2

    Vesicular rash.

    Questions

  • What is the diagnosis?

  • Henoch-Schonlein purpura (HSP)

  • Meningococcal septicaemia

  • Acute haemorrhagic oedema of infancy (AHOI)

  • Vasculitic urticaria

  • Gianotti-Crosti syndrome

  • What further investigation is required?

  • Check viral serology including Epstein-Barr virus and hepatitis B virus

  • Complement levels and autoimmune screen

  • Skin biopsy

  • Lumbar puncture and audiology

  • No further investigation

  • How should this child be managed?

  • Complete 7 days of ceftriaxone treatment

  • Oral aciclovir

  • Oral steroids

  • Regular follow-up with urinalysis and blood pressure monitoring

  • Stop antibiotics if cultures were negative at 48 hours and discharge

  • Answers are on page




    The right care, every time: improving adherence to evidence-based guidelines

    2018-01-18T08:40:28-08:00

    Guidelines are integral to reducing variation in paediatric care by ensuring that children receive the right care, every time. However, for reasons discussed in this paper, clinicians do not always follow evidence-based guidelines. Strategies to improve guideline usage tend to focus on dissemination and education. These approaches, however, do not address some of the more complex factors that influence whether a guideline is used in clinical practice. In this article, part of the Equipped Quality Improvement series, we outline the literature on barriers to guideline adherence and present practical solutions to address these barriers. Examples outlined include the use of care bundles, integrated care pathways and quality improvement collaboratives. A sophisticated information technology system can improve the use of evidence-based guidelines and provide organisations with valuable data for learning and improvement. Key to success is the support of an organisation that places reliability of service delivery as the way business is done. To do this requires leadership from clinicians in multidisciplinary teams and a system of continual improvement. By learning from successful approaches, we believe that all healthcare organisations can ensure the right care for each patient, every time.




    How to use... Hip examination and ultrasound in newborns

    2018-01-18T08:40:28-08:00

    Developmental dysplasia of the hip (DDH) ranges from a clinically detectable dislocation of the hip to radiologically diagnosed hip abnormalities. It is caused by both antenatal and postnatal factors. The Neonatal and Infant Physical Examination Screening Programme recommends that newborns should undergo a hip ultrasound (USS) when risk factor or clinical features suggestive of DDH are present. The aim of hip ultrasonography is to detect DDH early and prevent late complications through early treatment. Here, we discuss how to use hip examination and USS in newborns.




    Introducing routine enquiry about domestic violence in a paediatric setting

    2018-01-18T08:40:28-08:00

    Implementation of routine enquiry (RE) about domestic abuse in the multidisciplinary Evelina London Guys and St. Thomas Trust (GSTT) Community Health Services (CHS).




    What is oncolytic virotherapy?

    2018-01-18T08:40:28-08:00

    Overview

    It has long been hypothesised that viruses may have a role in treating cancer. From the mid-1800s, there has been documentation of patients undergoing spontaneous cancer remission following severe infection, and by the start of the 20th century, a temporary complete remission of acute leukaemia was observed in a patient suffering from influenza.1 Over the course of the last century, rodent cancer models have demonstrated tumour regression following virus treatment,1 2 and these promising results led to clinical trials in the 1960s–1970s using ‘anti-cancer’ viruses, which were unfortunately somewhat hampered by their high rate of infectious complications secondary to wild-type virus use.1 2 Over the past three decades, the introduction of genetically engineered viruses that can specifically target cancer cells while leaving normal cells unharmed has opened up an exciting new era of oncolytic virotherapy (the use of...




    UK recommendations for combating antimicrobial resistance: a review of 'antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (NICE guideline NG15, 2015) and related guidance

    2018-01-18T08:40:28-08:00

    Background

    Antimicrobial resistance (AMR) is a major health threat. In 2011, the UK’s chief medical officer’s annual report described AMR as an ‘apocalyptic scenario’1 in which common infections would become untreatable, and young children, arguably the most susceptible to infectious disease, would bear the burden.

    The problem is caused by overuse and misuse of antibiotics resulting in the survival and spread of resistant bacteria. A recently published review on AMR (2016), outlines the enormity of the problem: ‘by 2050, 10 million lives a year... are at risk due to the rise of drug-resistant infections if we do not find proactive solutions now. Even today, 7 00 000 people die of resistant infections every year’.2

    The clinician plays a major role in one of the identified solutions: antimicrobial stewardship to preserve drug effectiveness (box 1). This can be a particular challenge in paediatrics: a feverish child may...




    Public health for paediatricians: promoting good health for children in the early years

    2018-01-18T08:40:28-08:00

    The foundations that are laid through pregnancy and the first years of life have a profound influence on health both through childhood and into adult life. Public health approaches—those that seek to promote good health and prevent ill health—which, for example, effectively support poverty reduction, immunisation, good nutrition, safe sleeping and nurturing parenting—have had a considerable impact on reducing poor health outcomes. They continue to be critical to tackling preventable ill health in children and reducing inequalities. Alongside their role in treating child ill health, paediatricians can play a key role in promoting primary prevention efforts, aimed at preventing ill health from occurring in the first place, and secondary prevention or early intervention, identifying issues early on and addressing them before they have had more lasting impact. Paediatricians’ role can be as powerful advocates across the public system arguing for policy change, as local professionals working hand-in-hand with a...




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

    2018-01-18T08:40:28-08:00

    Dalrymple RA, Makwana N. Introduction of allergenic foods from 3 months of age reduces incidence of food allergy in breastfed infants. Arch Dis Child Educ Pract Ed 2017;102:335.

    The structured abstract of this Picket paper was written by Dr Kate C Harvey, affiliated with Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK. The authors would like to apologise for this omission.




    Comparing family-based treatment with parent-focused treatment for adolescent anorexia nervosa

    2018-01-18T08:40:28-08:00

    Study question

    Setting: A specialist multi-disciplinary outpatient eating disorders centre in Australia.

    Patients: Adolescents aged 12-18 years with a diagnosis of anorexia nervosa (AN) or partial AN based on DSM-IV criteria (excluding amenorrhoea) living with at least one parent. Those who presented with severe medical or psychiatric comorbidity were excluded. Those who had previously received family-based treatment (FBT) were also excluded.

    Intervention: Manualised outpatient treatment delivered as 18 sessions over 6 months. FBT which included the entire family and the adolescent in treatment sessions was compared with PFT. This involved sessions with the same focus as FBT but attended by the parents only, without the adolescent or siblings present.

    Outcomes: Remission was defined as increase in weight to >95% median BMI at the end of treatment and Global Eating Disorder Examination (EDE) within 1 SD of community norms. Follow-up period: Participants were assessed at baseline and end of...




    Use of high or low FiO2 during initial resuscitation did not impact survival or neurodevelopmental outcomes of preterm infants

    2018-01-18T08:40:28-08:00

    Study design

    Design: Randomised controlled trial.

    Allocation: Randomised using computer-generated list.

    Blinding: Double-blind.

    Study question

    Setting: Three hospitals in Spain and the Netherlands.

    Patients: Infants born before 32 weeks completed gestation.

    Intervention: Initial resuscitation with low (0.3) or high (0.6/0.65) FiO2 immediately after delivery.

    Outcomes: Prevalence of cerebral palsy and disability severity according to Bayley-III developmental scores at 24 months corrected age.

    Follow-up period: Until 24 months corrected age.

    Main results

    Prevalence of mild, moderate and severe disability according to Bayley-III developmental scores at 24 months corrected age is summarised in Table 1.

    Conclusion

    In preterm infants who survived to 24 months corrected age, neurodevelopmental outcomes were not significantly impacted by the use of low or high FiO2 during initial resuscitation.

    Abstracted from:

    Boronat N, Aguar M, Rook D, et al. Survival and neurodevelopmental outcomes of preterms resuscitated with...




    The INSIGHT responsive parenting intervention reduced infant weight gain and overweight status

    2018-01-18T08:40:28-08:00

    STUDY DESIGN

    The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) study randomised primiparous mothers and their newborns. Randomisation was completed by telephone at 10–14 days postpartum, using permuted blocks and stratified on birth weight for gestational age. The intervention group received responsive parenting (RP) training; focusing on sleeping, soothing and feeding. The control group received dose-matched information about home safety.

    STUDY QUESTION

    Setting: One maternity ward in Pennsylvania with follow up visits at home by the health visitor.

    Patients: Full term singleton newborns and their mothers who were English-speaking, primiparous women over 20 years old. 145 randomised to the intervention group and 146 randomised to the control group.

    Intervention: The INSIGHT RP intervention addressed 34 infant behaviours; drowsy, sleeping, fussy and alert. Home visits were conducted at 3 to 4 weeks, 16 weeks, 28 weeks and 40 weeks. At each visit intervention related to...