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Community child health and accident & emergency

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G54. A SURE START INITIATIVE TO REDUCE ACCIDENT AND EMERGENCY ATTENDANCES: ADULT EDUCATION HELPS PARENTS MANAGE COMMON CHILDHOOD ILLNESS

T.C. Kilgour, A.F. Mellon.

Sure Start Thorney Close, Sunderland; University of Leeds

Aims: Studies have suggested that professionals have considerable potential to empower parents to look after their own children when they have an acute illness by sharing knowledge and skills. The aims of this study were to develop a training package on common childhood illnesses for delivery to parent groups by a health professional and to undertake an initial evaluation of its effectiveness.

Methods: A group of ‘Sure Start’ parents identified their concerns when their children had an acute illness. They felt that anxieties might be reduced if they were knowledgeable about these illnesses and requested group teaching. A training package was developed and delivered to six successive groups. The final package consisted of six sessions of two hours, held over consecutive weeks. The package was evaluated using Kirkpatrick’s hierarchy of levels of evaluation of an educational intervention. Outcome measures used were parental satisfaction, knowledge gained and attendance at A&E and GP surgeries.

Results: 44 parents registered for the course. Attendance rates were high with 66% attending at least five of the six sessions. Qualitative and quantative analysis of the data provided strong evidence of the value of the course in terms of parental satisfaction and knowledge gained. There were 170 sessional response sheets completed. Parents indicated high levels of satisfaction; 298 positive and 39 negative responses. The difference in knowledge test scores between intervention and control groups was highly significant. Mean for the control group = 22.19 v intervention group = 29.44 (p<0.0005). Within the timescales and limitations of the study it could not be shown that attending the course changed consulting behaviour.

Conclusion: Initial evaluation has shown that an effective training package has been developed to address parental concerns and increase parental knowledge. Future research needs to focus on more effective ways of evaluating the higher levels of Kirkpatrick’s hierarchy.

G55. ETHICS APPROVAL—WHO NEEDS IT?

G.J. Laing, M.C.J. Rudolf, S. Logan.

Annual Meeting of the Community Paediatric Research Group: 2002

Authors submitting abstracts to the annual meeting of the RCPCH are required to state whether ethics consent has been sought. Last year, assessors for the community child health sessions were surprised that relatively few authors had sought approval but disagreed over when approval was required. They became concerned that the RCPCH might be a forum for presenting research where the ethics was in doubt. Using the community papers as a sample, this study aimed to examine the extent of agreement between a large group of paediatric researchers as to when studies should be submitted for approval, to describe the variation in agreement for different types of research and to determine the level of agreement between researchers and authors.

Methods: Following agreement from authors, abstracts submitted to the community sessions in 2002 were distributed to participants attending the Community Paediatric Research Group (CPRG) summer meeting. They recorded independently whether they thought ethics approval was required. Members were divided into 4 groups of five and allocated one quarter of the abstracts. They attempted to reach a consensus about the need for approval and used a pre-defined scheme to categorise study type.

Results: 84/86 abstracts were included. 32 (38.1%) had obtained ethics approval. Prior to discussion, the CPRG members agreed on the need (or not) for approval in only 26 (30.9%) abstracts. Following discussion, complete agreement was obtained for 48 (57.1%) abstracts. There was poor agreement between authors’ actions and the research group consensus (kappa 0.42). CRPG members suggested that 47 (55.9%) studies should have sought approval of which only 27 had done so. Agreement was particularly poor for research involving case note reviews and use of existing datasets.

Conclusion: Amongst researchers, there is a marked variation in practice and considerable dissension about the need to seek approval from ethics committees. We suggest that there is a need for wider debate.

G56. ROAD-RELATED DEATHS AND INJURIES IN IRISH CHILDREN—WHAT LESSONS SHOULD WE LEARN FROM OUR FELLOW EUROPEANS?

A. Waters1, F. Trace2, A.J. Nicholson1.

1 Paediatric Department, Our Lady of Lourdes Hospital, Drogheda; 2 National Roads Authority (NRA), Waterloo Rd, Dublin 4

Background: For road-related accidents, mortality rates in under 15 year olds per 100 000 in Sweden (2.32) and the UK (2.54) are much lower than Portugal (8.03)and Ireland (3.61).

Aims: To study all road-related deaths and injuries in under 15 year olds in Ireland over a 5 year period (1996–2000) and to assess what enforcement measures could be suggested to reduce this road toll.

Methods: For pedestrian injuries or road traffic accidents, police assistance is required and at the time a detailed form is completed by the attending officer and sent to the NRA for analysis. Details re the severity of injury, light and road conditions and safety measures such as seat belts and seat position were collected. Injuries were sub-classified as fatalities, serious (detained in hospital, fractures, severe head injury, severe internal injuries or shock requiring treatment) and minor. All data was entered into an SPSS database.

Results: Of 6045 childhood road-related injuries, 155 (2.5%) were fatal, 731(12%) were serious and the remainder were minor. The age group 13–15 years had the highest mortality (p <0.001*) and the age group 0–3 years had the lowest injury rates and mortality. Of all road-related injuries, cyclists accounted for 10%(n=607), pedestrians 28.4% (n=1719), and car-occupants 61.5% (n=3719). Of car-occupant fatalities (n=69), 5 were drivers (7.2%), 22 (32%) were front seat passengers and 42 (61%) were rear-seat passengers. Seat belt wearing was documented in only 23% (n=16) of car-occupant fatalities and only 15% (n=53) of those injured seriously. Pearson chi-squared tests confirmed a significant relationship between seat belt use and the severity of injury (p<0.001*). For pedestrian injuries (n=1719), 61 (3.5%) were fatal and 261 (15.2%) were serious. The age group 13–15 had the highest prevalence and severity of pedestrian injuries. Of 607 bicycle injuries, 25 (4%) were fatal and 117 (19%) were serious. Only 26 children (4.3%) wore a helmet at the time of injury and just 1 of 25 fatalities had documented helmet use.

Conclusions: The above figures indicate that child passenger restraint, seat belt and bicycle helmet use are unacceptably low in Ireland. We need to adopt approaches found to be successful in the UK and Sweden to reduce this terrible toll.

G57. AETIOLOGY OF BURNS IN ADOLESCENTS ADMITTED TO A PAEDIATRIC BURNS UNIT

A. Kelly, A. Young.

Paediatric Burns Unit, Frenchay Hospital, Bristol

Background: Literature searches reveal little regarding adolescent burn injuries in comparison to younger paediatric patients who usually sustain scalds.

Aims: To identify the aetiology of burns in the age group 10–17 years.

Method: Retrospective collection of information from case notes of patients admitted during five years from 1 January 1997–1 January 2002 to our burns unit.

Results: Case notes of 93 patients were studied. There were 74 (80%) males and 19 (20%) females. Medical attention was sought within 1 hour by 49 (53%) and within 3 hours by 71 (76%) after the injury. 82 (88%) presented to the Accident and Emergency department. Most burns were less than 10% of total body surface area (87, 94%). 39 (42%) involved a flammable substance, 23 (25%) with petrol. A bonfire was involved in 20 (22%) cases and 16 of these also involved a flammable substance. Burns caused by flammable substances affect males almost exclusively (38 of 39 cases). There were no cases of female burns caused by petrol. 21 (23%) of burns were caused by hot water scalds. 8 of these were due to hot drinks and 3 due to kettle spillage. Two involved bath water and both of these had chronic medical conditions. 9 (10%) of burns were due to cooking with hot fat. Other causes included 4 cases due to candles, two cases of electrical burns and two due to burns on car exhausts. There was only one case of a burn caused by fireworks.

Conclusion: Burns in adolescents are usually caused by flammable substances and affect males predominantly. Accident prevention would be best directed towards this group.

G58. MEASURING QUALITY OF LIFE AFTER TRAUMATIC BRAIN INJURY IN CHILDREN: HOW DOES THE HEALTH UTILITIES INDEX (HUI) COMPARE TO THE PEDIATRIC QUALITY OF LIFE MEASURE (PedsQL)?

A.L. Curran, H. Miller, R. McCarter, P.M. Sharples, and the Kids Head Injury Study Group.

Bristol

Introduction: Cognitive and behavioural deficits after traumatic brain injury (TBI) are well recognised but few data exist concerning their impact upon functional health status. There is no general agreement concerning which quality of life measure is most sensitive to the effect of TBI in children.

Aims: To measure functional health status 6 months after TBI in children using the Health Utilities Index Mark 3 (HUI3) and the Pediatric Quality of Life Measure (PedsQL) and to compare these two outcome measures.

Methods: Longitudinal prospective follow up study of a cohort of children admitted to hospital for TBI compared to normal uninjured controls. The Glasgow Coma Score (GCS) on hospital admission was used to classify TBI children into severe (GCS 3–8), moderate (GCS 9–12) and mild (GCS 13–15) categories. Functional health status was measured by maternal report using the HUI3 and the PedsQL.

Results: 42 TBI children and 21 non-injured controls were recruited. At 6 months from injury the HUI3 results were as follows (control subjects in brackets): 25% (0%) were perceived by their parents to have impaired cognition and emotional health, 12.5% (5.6%) had problems with pain, 12.5% (0%) problems with vision, 10.5% (0%) problems with selfcare, 8.4% (0%) problems with speech and 4% (0%) problems with dexterity. Results of the PedsQL, administered at the same time to the same group, showed that 77% (24%) had problems with emotional functioning, 42% (0%) problems with physical functioning, 48% (14%) problems with school, and 59% (10%) problems with social functioning.

Conclusion: Measuring functional health status in children is still in its infancy. Our data suggest that both the HUI3 and PedsQL differentiate between TBI children and uninjured controls but that the PedsQL is more sensitive to change in functional health status following head injury than the HUI3.

G59. MANAGEMENT OF ADVERSE VACCINE EVENTS IN CHILDREN IN ENGLAND AND WALES

N. Sherwood1, D. Baxter1, E. Miller2.

1 Evidence for Population Health Unit, School of Epidemiology and Health Sciences, University of Manchester; 2 Immunisation Division, PHLS Communicable Disease Surveillance Centre, London NW9 5EQ

Aims: To evaluate management of adverse vaccine events in children.

Methods: Specialists were identified by asking all District Immunisation Coordinators (DICs) (192) in England and Wales to name their Local Expert Advisor (LEA) for adverse vaccine events in children.

All identified LEAs (220) were sent a 2-part questionnaire:

i) 4 case scenarios: each describing a specific adverse event (local reaction, fever, convulsion, collapse) temporally related to routine administration of DTP/Hib, Men C, and Polio vaccines, followed by questions on management of further vaccinations and likelihood of causality.

ii) workload questionnaire: covering frequency of vaccination queries, source of queries, and provision of specialist clinics.

Results: 85% (163) of DICs responded, identifying 220 LEAs. 61% (134) of LEAs responded. The highest concordance in management was reached for the case scenario of a local reaction, 57% of respondents opting for acellular pertussis (Pa); least concordance was seen in the case of a collapse/hypotonic-hyporesponsive episode, where 38% opted for Pa and 27% for omitting pertussis. The 2 most popular options throughout were Pa or continuing vaccinations as normal, but significant numbers (= 25% for all scenarios) opted for other management such as omitting pertussis, delaying vaccines, or giving vaccines at separate sites. There were also divergent views on whether the event was related to the vaccination. Local service arrangements varied widely, particularly regarding provision of specialist immunisation clinics.

Conclusions: Consensus on how to manage adverse vaccine events is lacking. Further work is needed to gather evidence on outcomes of different modes of management, to determine case definitions of adverse events and consensus management plans, and to establish the best means of service delivery for these children.

G60. CHILD HEALTH INDICATORS OF LIFE AND DEVELOPMENT (CHILD2000)—A FRAMEWORK FOR THE MEASUREMENT OF CHILD HEALTH IN EUROPE

M. Blair, L. Kohler, R. Mechtler, M. Rigby.

Imperial College, London, Nordic School of Public Health, Sweden, Johanes Keppler University, Linz, Austria and Keele University UK

Aim: To develop a set of child focussed and child centric indicators in order to compare the health of children in Europe and inform child public health policy.

Background/methods: There are 70 million children under 18 living in the EU. Some comparative data exists but this is not readily available and visible to policy maker. Health status, process, and determinants were considered by an international panel from 17 countries in relationship to burden load, vulnerability, and evidence based interventions using specified technical criteria for indicator inclusion through a process of literature search, iterative consensus, and external expert peer review.

Results: 38 indicators were developed; 5 demographic and socioeconomic, 11 child health status and wellbeing (mortality, morbidity, injuries, mental health), 12 health determinants, risks and protective factors (parental, child lifestyle, other) 10 health system and policy (quality, social policy and physical protection). Statistical offices in at least 4 countries are now compiling sample data sets based on these. Data items will become mandatory as part of wider EU health monitoring policy. It is clear that a number of indicators can only be collected as part of existing and new survey methods.

Conclusion: A consensus was reached and a framework developed for the measurement of child health. Implications for child health in the UK are discussed.

G61. AN EVALUATION OF THE PERSONAL CHILD HEALTH RECORD TRANSLATED INTO TURKISH

R.E. Klaber, S. Cadzow, D. Hodes.

Department of Child and Adolescent Services, City and Hackney Primary Care Trust, London

Introduction: Research indicates that parent-held Personal Child Health Records (PCHR) are well-accepted and liked by both parents and health professionals, have retention rates in the order of 90%, and are more thoroughly completed than clinic records. Cross-cultural issues that may impact on their effectiveness have not previously been examined. From 1994 to 1997 a directly translated Turkish edition of the PCHR was available to families in City and Hackney, but was not re-printed on the grounds of cost. This study sought to evaluate the acceptability, educational value and usefulness of this Turkish language PCHR as reported by parents.

Methods: A Turkish interviewer carried out a semi-structured interview with 65 Turkish and Kurdish parents. This covered topics on feeding, immunisation, child safety and sleeping position from the PCHR, background information about the participants, and their views on how to improve the PCHR.

Results: 68% preferred the Turkish edition, and a further 28% wanted a combined Turkish and English version. Written information about feeding and immunisation were understood by 11% to 69% of parents. Pictures, detailing child safety information, were understood by 48% to 60%. For the “sleeping position” pictures, 3% thought that it showed that their baby had to sleep prone and a further 5% did not know. 43% volunteered ideas to improve the PCHR, including guidance about acute illnesses, feeding, and other parenting issues. 17% were unable to read or write.

Conclusions: The Turkish language PCHR was extremely popular with parents. They felt it should be reintroduced. Pictures, with minimal text, were the more effective means of communicating simple educational messages, but, in the current form, are open to some concerning misinterpretations. The literacy levels within a community in question are an important consideration when introducing translated materials.

G62. MATERNAL AND CHILD RISK FACTORS FOR FAILURE TO THRIVE: WHICH ARE MOST IMPORTANT?

C.M. Wright1, K.N. Parkinson.

Department of Child Health, University of Newcastle upon Tyne; 1 Department of Child Health, University of Glasgow

Aims: The Millennium Baby Study recruited 1011 mothers of 1029 infants shortly after birth to study the respective influences of child and maternal factors on the incidence of weight faltering (failure to thrive).

Methods: Parents received 5 self completion questionnaires over the first year which each included a core group of questions used to generate scores of the child’s appetite, oro-motor dysfunction and aversive feeding behaviour, as well as maternal feeding anxiety and feeding promotion. Data were also collected on maternal education, deprivation, life events and eating attitudes (Dutch scale). Routinely collected weights and the Edinburgh post natal depression score (EPDS) completed at 3 months by the health visitor were also forwarded to the project office. Weight faltering was defined as weight gain (Thrive Index, TI) below the 5th percentile from birth to any one age; sustained weight faltering was defined as two or more TI below the 5th percentile over the first year.

Results: 73% mothers returned at least one questionnaire and two or more weights were available for 87%. EPDS scores were available for 77% mothers, of whom 98 (13%) had scores >12. Infants of these mothers were 3 times more likely to falter at 3 months (p=0.004) this effect persisted as a non-significant trend at 6 months, but not at a year. No other maternal psycho-social factor related to risk of weight faltering at any age. At 6 weeks only low appetite and oro-motor dysfunction independently predicted weight faltering (odds ratio (OR) 2.7 p=0.002 and OR 2.1 p=0.02 respectively). Low appetite at 6 weeks was also the strongest independent predictor of sustained weight faltering (OR 2.4 p=0.007) with only high maternal promotion of feeding also a significant predictor (OR 1.6 p=0.046).

Conclusions: Faltering infant weight gain in the UK seems to relate more to intrinsic features in the infant or the feeding relationship than maternal psycho-social factors.

G63. THE COGNITIVE SEQUELAE OF FAILURE TO THRIVE IN INFANTS AND YOUNG CHILDREN: A SUMMARY OF EVIDENCE FROM CONTROLLED STUDIES TAKING INTO ACCOUNT SELECTION BIASES AND WASH-OUT EFFECTS

R.F. Drewett, S.S. Corbett.

University of Durham

Aims: To determine the extent to which failure to thrive in infancy is associated with adverse cognitive outcomes.

Methods: Published controlled studies were classified into those in which the cases were identified in hospital or other specialist clinics, and those in which they were identified in primary care or by whole population screening. Effects were summarized using D statistics for the principle cognitive outcome measure.

Results: In studies with cases identified in hospital or other specialist clinics (52 cases, 36 controls), the pooled effect size (weighted standardized mean difference) for cognitive outcomes was −0.85 (95% CI −0.40 to −1.30). In studies with cases identified in primary care (652 cases, 539 controls), it was −0.30 (95% CI −0.18 to −0.42). In longitudinal studies the effect size was smaller when the children were older. Data from studies in which cases were identified in primary care, and restricted to IQ scores in older children (512 cases, 489 controls), were used to obtain an overall estimate of the long term cognitive outcome of failure to thrive. The weighted mean difference was –0.29 (95% CI −0.17 to −0.42), equivalent to 4 IQ points (95% CI 2 to 6).

Conclusions: Evidence from reasonably well controlled studies indicates that failure to thrive in infancy is associated with adverse intellectual outcomes sufficiently large to be of importance at a population level.

G64. AN AUDIT OF MISSED FRACTURES IN A PAEDIATRIC ACCIDENT & EMERGENCY DEPARTMENT

B. Cheema.

Paediatric Accident & Emergency Department, Royal Liverpool Children’s Hospital Alder Hey, Liverpool

Introduction: Few studies of radiograph misinterpretation have been conducted in a Paediatric A&E department. This audit aimed to quantify the number and type of missed fractures in a busy paediatric A&E, as well as sources of delay in identification of missed fractures, grades of doctors missing fractures and any potentially serious missed fractures.

Method: A 3-month prospective casenote audit. A&E senior doctors listed any potential cases of missed fractures (i.e. discrepancy between radiologists report and initial A&E diagnosis) when signing radiology reports in A&E. Notes were then obtained and analysed.

Results: During this period a total of 10 153 bone radiographs were taken and 1204 patients were diagnosed as having bone fractures in A&E. 78 cases of possible missed fracture were identified. 35 (45%) female and 43 (55%) male. 9 (12%) patients were aged < 5 years, 19 (24%) were aged 5–9 years and 50 (64%) were aged 10– 15 years. 68 (87%) of radiologists reports were received within 7 days. 52 (76%) of these were identified as possible missed fractures by A&E within 7 days. Attempts were made to recall all possible cases. Of the 65 patients who did attend for review 43 (66%) were seen within 14 days of initial attendance at A&E. 40 of the 78 initially identified cases had signs and/or symptoms that correlated with a missed fracture. This gives a missed fracture rate of 3.3%. The commonest sites for missed fractures were distal radius 10 (25%); phalanges of the hand 8 (20%) and lateral malleolus 8 (20%). The commonest types of fractures were: linear 19 (47.5%); avulsion 8 (20%) and buckle 7 (17.5%). 22 (55%) had been seen in A&E by a senior house officer and 11 (27.5%) by a specialist registrar. 21 (52.5%) patients required no additional treatment and 17 (42.5%) required only temporary immobilisation. 2 potentially serious cases of missed fracture were identified (linear occipital skull fracture and tibial plateau fracture).

Conclusion: Missed fractures do occur in paediatric A&E—but the vast majority are minor fractures that have no long-term significance.

G65. CHILDREN LIVING WITH DOMESTIC VIOLENCE; AT RISK, IN NEED, AND INVISIBLE

T.L. Josty, J. Shankleman, R. Brooks, E.V.J. Webb.

Department of Child Health, University of Wales College of Medicine, Cardiff

Introduction: Domestic violence is a common and serious public health problem. Children are harmed by living with domestic violence, both by direct physical abuse and by the adverse effects of witnessing violence. Despite this we have little information on whether children exposed to domestic violence are known to statutory child protection services.

Aims: To investigate whether children passing through domestic violence refuges are known to local social services.

Method: The details of 257 children passing through 5 domestic violence refuges in a UK city over a 10 month period were cross checked with databases held by Social Services.

Results: Adequate details for cross-checking were available on 234 children; 50% male, age range 12 days–16 years. 131 had fled a local address of which 60% were known to local social services at refuge entry. Only 16% of these 131 had cases ‘open’ to social services. Less than 5% were on the local Child Protection Register, and at the end of the study only 12% had allocated social workers. A child entering a refuge for minority ethnic families was significantly less likely to be known to social services than was a child entering a general refuge (28% v 65%; p <0.01). Children from outside the locality were less likely to be known to local Social Services than local children (27% v 66%; p <0.0001).

Conclusions: Despite the risk of harm these children face, many are unknown to local child protection services. Children from ethnic minority families are significantly less likely to be known. Health professionals must not presume that children living with domestic violence are already receiving support or protection from social services.

G66. LUMBAR PUNCTURE IN INFANTS WITH SIMPLE FEBRILE CONVULSION—A RETROSPECTIVE CASE REVIEW

C. Bevan, T. Sajjanhar.

Paediatric Emergency Department, University Hospital Lewisham, London SE13 6LH

Introduction and aims: Infants presenting with febrile convulsions often undergo lumbar puncture to exclude occult meningitis, although this management is being questioned.1 This study reviewed the management and discharge diagnoses of such infants, to support the hypothesis that simple febrile convulsions may be managed without a mandatory lumbar puncture.

Method: Cases of all infants aged 6 to 12 months presenting with a febrile convulsion between January 1999 and May 2002 were identified by searching Emergency Department (ED) and inpatient discharge diagnosis under the following headings: febrile convulsion, epilepsy, seizures, encephalitis, baby seizures, and meningitis. Case notes were analysed for demographic data, clinical features, seizure characteristics, investigation results, and final diagnosis. Those with a simple febrile convulsion (generalised seizure less that 15 minutes, no meningism) were further analysed.

Results: 196 case notes were reviewed; 75 relevant cases were identified. Excluding 4 infants with prolonged seizures, mean seizure time was 7 minutes. Lumbar puncture was performed in only 39 patients; none had a positive CSF. No lumbar puncture was performed in 32 patients. Of these, 27 were admitted and observed, none had a subsequent diagnosis of meningitis. The remaining 5 patients were discharged home from the ED after a period of observation. Discharge diagnoses were upper respiratory tract infection (48 infants), urinary tract infection (8), chest infection (3) and other (12).

Conclusion: Infants with simple febrile convulsions need careful evaluation for the possible cause of the fever. A period of observation is often useful. In the absence of other features of meningism a lumbar puncture is not mandatory but should be considered where dictated by the clinical condition of the child.

1

G67. COULD PROCALCITONIN (PCT-Q) BE A VALID POINT-OF-CARE TEST FOR INVASIVE BACTERIAL INFECTION IN CHILDREN PRESENTING TO PRIMARY OR SECONDARY CARE?

K. Brent, S. Hughes, S. Kumar, A. Gupta, A. Trewick, S. Rainbow, R. Wall, M. Blair.

Northwick Park Hospital, Harrow; Imperial College, London

Background: Rapid identification of invasive bacterial infection (IBI) in children remains difficult and a source of great concern. Procalcitonin (PCT) has been proposed as an early specific marker of IBI. PCT-Q is a recently developed bedside test for the semiquantitative detection of PCT. It can be performed in a general practice, A&E or ambulatory care unit.

Aim: To determine whether PCT-Q might be a useful test for IBI in children presenting to general practices, A&E or ambulatory units.

Methods: Children were classified according to clinical and laboratory data. Data described in table 1 is for 31 cases analysed to date.

Abstract G67, Table 1

Results: PCT concentrations can be identified within the ranges <0.5ng/ml, 0.5–2ng/ml, 2–10ng/ml or >10ng/ml. The capacity of PCT-Q to distinguish IBI from other causes is examined in table 2.

Abstract G67, Table 2

Conclusions: PCT-Q might be very useful for differentiating severe bacterial disease from other infection in infants and young children. The test can be performed at the bedside, making it available for use in general practice.

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