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AN ETHICAL DILEMMA – STOPPING SEXUAL MATURITY IN CHILDREN
Drs Albanese and Hopper review the therapeutic options available to suppress menstruation in adolescents with severe learning disabilities. Gary Butler and Elaine Beadle comment on this paper and the American girl Ashley X. For reasons related to menstrual hygiene, pregnancy and vulnerability to sexual abuse, Drs Albanese and Hopper suggest that suppression of menstruation may be worthwhile. They discuss both medical and surgical options. This review is part of the debate in dealing with growth and sexual maturity in children with severe developmental disabilities. In October 2006, in a widely discussed, debated and quoted article in Archives of Pediatric and Adolescent Medicine, two physicians describe how Ashley X, a 6½-year-old girl with static encephalopathy, was treated in order to attenuate both growth and sexual development.1 High-dose oestrogen and surgery, and pretreatment hysterectomy, were used. Few medical articles in the past year have stirred such debate in the US. In both the article itself, and in an accompanying editorial,2 the ethics of such treatment are explored. Drs Butler and Beadle add their own thoughts regarding the justification of manipulating growth and puberty in children with severe disabilities. Advances in medicine have fuelled numerous ethical dilemmas. In child health, how to deal with infants and children who are profoundly delayed will be a continuing ethical dilemma.
See pages 567 and 629
IMMUNISATIONS – SHOULD PATIENTS BE “JABBED” EVERYWHERE
As the number of vaccinations grows, and the immunisation schedule becomes increasingly complex, a new debate has surfaced in healthcare. Should we leverage all healthcare encounters to ensure that children and adolescents are appropriately vaccinated—opportunistic immunisation. Let’s assume for the moment that a healthcare system has an information technology system that can provide accurate and up-to-date information about the immunisation history of an individual. Should children and adolescents receive vaccinations in A&E departments, at the end of their stay in a paediatric tertiary hospital, or after a subspecialty visit? Walton and colleagues discuss this issue in the context of their research report that describes missed opportunities to vaccinate approximately 30% of 225 inpatients who were incompletely immunised. As the vaccination schedule includes more jabs for adolescents, a group notoriously short of healthcare encounters, new strategies will have to be developed to ensure full vaccination. I suspect that schools will undoubtedly play a greater role in ensuring a completely immunised populace in the future.
See page 620
THE DECLINE IN ORAL ANTIBIOTIC USE – CAN WE DO BETTER?
Oral antibiotic use, which declined in the UK between 1995–1996 and 2000–2001, has since plateaued. Advice from government helped drive the reduction, with healthcare providers learning to restrain their prescribing. The change in our practice was also influenced by less parental pressure, and the knowledge that children were receiving conjugate H Influenzae Type B vaccine. In a study conducted in 18 Oxforshire general practices over four winters (2000–2004), Harnden and colleagues found that approximately 1/3 of 425 children aged between 6 months and 12 years with cough and fever were prescribed an antibiotic. In general, rate of recovery, as recorded by parental diary, was similar regardless of the infecting virus—human metapneuomovirus, influenza or respiratory syncytial virus. Children in the influenza group (n = 134) who did not receive antibiotics were significantly more likely to be febrile on day 7 than children who received antibiotics. Whether uncomplicated influenza infection, leading to secondary bacterial infection, is different than the other viruses would need to be explored in a larger study.
See page 594
FEEDING CHILDREN AT NIGHT
In a meticulously performed randomised crossover study from Birmingham, Evans and colleagues describe the impact on total daily oral energy, protein, fat and carbohydrate intake, of two isocaloric overnight feeds (1.0 kcal/m and 1/5 kcal/m) in 32 children aged 1–10 years receiving enteral feeding at home. They found that children consumed 20–30% more food when they received the lower nutrient density feed. The authors indicate that these results are different from those in adults in whom dilute foods appear to be more satiating. This study has important implications for clinicians who are trying to convert children from enteral to oral feeds. Many variables are in play, including bolus versus continuous feeds, caloric density, and the amount of enteral feeds.
See page 602
THIS MONTH IN FETAL & NEONATAL EDITION
A leading article by Harrison and Shaw describes the new oxygen service, including a step-by-step approach for ordering home oxygen, a description of the equipment and what to do when the family is on holiday. See page F241
Keeping preterm infants warm when they are transported is critically important. Meyer and Bold randomised 62 infants <28 weeks gestational age to either a radiant warmer or incubator transport. On arrival at the neonatal intensive care unit (NICU) their median axillary temperature was similar. See page F295
Morphine or remifentanil for intubation? Pereira e Silva et al conclude after completing a double-blind, randomised controlled study involving 20 preterm neonates that reminfentanil is superior. See page F293