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Highlights from this issue
  1. R Mark Beattie, Editor-in-Chief

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Children's and young people's experience of the NHS

The ‘new’ NHS has consultation and patient experience at its core, although there is very little data on it particularly in children and young people. Hargreaves and Viner review the inclusion of children and young people in the 38 national surveys of patient experience in the NHS carried out between 2001 and 2011. Patients under age 16 years were included in just 1 of the 38, representing just 0.6% of recipients, although inclusion of 16–24 year olds was better. The results are discussed and although satisfaction was generally good it was ‘less good’ in the 18–24 year olds than older adults. The authors highlight the Kennedy report (2010) recommendation to improve health services for children and young people to the satisfaction of patients, carers and staff and rightly call for greater inclusion of children and young people when feedback is sought. See page 661

New therapies for asthma

Most children with asthma respond to standard therapies although a small proportion with the most severe disease require long term treatment with oral prednisolone. Brodlie et al report the outcome of 34 children (15<12 years) with steroid dependant asthma treated with Omalizumab in a tertiary referral clinic. Omalizumab is a monoclonal anti-immunoglobulin E antibody that has emerged as a therapeutic option in IgE mediated asthma with the majority of previous studies in adults and although there is some efficacy data in children there is controversy regarding its use. In the cohort studied treatment was by 2–4 weekly subcutaneous injection for 16 weeks. Median oral steroid dose reduced from 20 mg to 5 mg during the study period with improved asthma control and quality of life. Efficacy was similar across the age range. No major adverse effects were seen. The authors are clear that a randomised controlled trial is needed although this dataset does provide further evidence for this as a therapeutic option in chronic severe asthma resistant to conventional treatment approaches. See page 604

Meeting standards

Standards have been developed for the inpatient care of children with diabetes (Department of Health 2007, 2008) and it is crucial, as with all standards, to audit their implementation and effectiveness. Edge et al report on their experience across 27 services by surveying units and reporting progress with each standard. In general compliance is good and provides a benchmark for service development and further audit. In particular there is good availability of protocols, link nurses on the wards and diabetes specialist nurses are well integrated into the acute service. Less good are issues like access to dietetic advice and liaison with the diabetes team (which may be small) within 2 h of admission (daytime) and out of hours. The issue of out of hours speciality cover is not straightforward and nationally debated. The authors discuss these issues in detail including the reality that the standards may need to be revised to closer match what is realistically available. See page 599

Life style intervention

The health care and social impact of reduced physical activity and increased sedentary behaviour is well known. Strategies to impact on this and evidence for efficacy is less clear. Breslin et al report a non randomised controlled trial involving 416 children from 24 schools. The intervention was a 12 week programme based on social cognitive theory (essentially a series of sessions delivered with the purpose of increasing knowledge and understanding of the benefits of regular participation in physical activity and sport and the importance of eating a healthy balanced diet with an Olympic event at the end). Although within the 12 weeks period there was no impact on anthropometric markers children in the intervention group were more active and less sedentary at the end of the study than those in the non intervention control group. Implementation of strategies like this, particularly if sustained, could potentially impact on lifestyle and behaviour long term. See page 618

Basic clinical skills

The importance of basic clinical skills is highlighted by two papers in this issue which discuss musculoskeletal (MSK) history taking and examination, the latter now being a common short case in the paediatric membership exam. Gill et al reviewed the case records of 100 consecutive patients admitted and found that only 9% had had a routine musculoskeletal examination, increasing to 32% after targeted training. The authors highlight the availability of screening systems such as pGALS (paediatric gait, arms, legs and spine) and the important diagnostic potential of a careful and thorough clinical examination. Goff et al report on a prospective cohort of children attending a paediatric rheumatology clinic (45) or general paediatric assessment unit (50). All had a proforma history taken recording abnormal joints followed by MSK examination. History taking failed to identify joint abnormalities subsequently identified on examination. The history is clearly of key importance but this second dataset further highlights the importance of the clinical examination. The authors also highlight the importance of tools such as pGALS as a screen followed by a more detailed joint examination as appropriate. See page 641 and 644

In FNN this month

In an excellent guideline review the new recommendations from the Centres for Disease Control and Prevention (CDC) on the prevention and management of early onset group B streptococcal sepsis are discussed with a clear summary including what's new. The recommendations are compared with the guidance from the Royal College of Obstetericians and Gynaecologists (RCOG) and helpful tables and algorithms for management provided.

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