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Diving to death
Children often present either acutely or to clinic with an episode that might be a seizure, might be a faint, might be something else, so I found the paper by Albertella et al a riveting and highly educational read. The simple message is: if you get a history of ‘episodes’ in relation to water, think long QT syndrome (LQTS). The fact that LQTS is not that common is dwarfed by the seriousness of the situation for an affected child, and the large amount of good that can be done by investigating the family and treating those at risk.
Predicting the serious infection
Last month we published three papers with a similar thrust: one examined the criteria for admitting infants with bronchiolitis, another the performance of the Manchester triage system (MTS), and the third the effectiveness of emergency care practitioners. Not to be deflected from these important clinical questions, this issue carries two similar papers: one by Blacklock et al focusing on those features that identify serious respiratory infections, and the other by Nijman et al that examines the performance of the MTS in detecting serious bacterial infections (a topic we also addressed in April). From the first, I was surprised to learn that tachypnoea was not found to be as valuable a sign in an English population as it has proved to be in resouce-poor settings; but more importantly, the fact that mothers' accounts did not give good concordance with nurse evaluations undermines one of the central assumptions of triage over the phone. From the second, it seems that the MTS does not perform particularly well in identifying those children with serious bacterial infection, which implies that other clinical decision guides need to be used in parallel in some circumstances.
There are probably three ways in which complementary therapies can harm children. The first is that they can have direct adverse effects, just like conventional therapies can. The second is that in choosing an ineffective complementary therapy, a child might be deprived of an effective treatment: for most treatments this will matter little while for a few it is the difference between life and death. Finally, a child who is caught up in a strong parental ‘alternative’ ideology may be subjected to fanciful diets and may not be immunised. It therefore matters to all of us that we understand the degree to which complementary and alternative therapies may happily co-exist alongside evidence based conventional therapy, as well as their potential for harm. However, the paper by Hunt and Ernst shows that even the systematic reviews of the evidence are seriously flawed, especially in capturing and reporting rates of adverse events. Above all it is ironic that at a time when greater rigour is being brought to bear on the study and application of conventional medicines in children, no such framework exists for the substances that may actively heal or harm children when extracted from plants: call them ‘herbal’ and everyone is happy, but call them a soup of untested chemicals and you lose the magic.
Fat sleep, thin evidence
There has been enormous interest recently in linking sleep patterns with childhood obesity, driven perhaps by a belief that here at last is a factor that might be more amenable to intervention than getting children to eat less and exercise more. Hiscock et al present some powerful longitudinal data from an Australian cohort that pour a bucket of cold water on this idea. However as the randomised controlled trials testing the hypothesis that sleep modification might lead to improvements in obesity are already underway, all we can do is await their outcome with interest. But don't hold your breath.
E&P goes F&N
There is a neonatal theme to our Education and Practice section this month, but the salient topics are very much aimed at the generalist rather than just neonatologists. There are reviews of the NICE guideline on neonatal jaundice, and on the management of the near-term baby with respiratory distress. There is a paper that examines the emerging problem of infection with multi-resistant bacteria, many of which are to be found in the community rather than in hospitals. The section leads off with an unusual case that happens to be neonatal, but the lessons in diagnostic thinking are generic. Moving away from neonates, we have a thought provoking education paper examining the opportunities for getting medical students exposed to paediatric teaching in ambulatory care settings; and a paper on the use and meaning of α-fetoprotein measurements which relate to practice in pregnancy and childhood, not just the preserve of the oncologists.