Recovery position associated with reduced rate of admission

Loss of consciousness is often seen but the response of care givers has been poorly investigated. The recovery position into which an unconscious child can be placed to protect the airway (and keep it clear and open) is a well known first aid manoeuvre. Martinez et al report a prospective cohort seen following an episode of loss of consciousness. Seizures were the most frequent cause (n=278, 147 febrile) followed by vasovagal syncope (n=124). Caregivers put the child in the recovery position in just 145 cases (26%). In another 53% of cases, some other manoeuvre was used—most notable was the potentially dangerous use of shaking in 91 cases (16.5%). 56% of cases were admitted. The recovery position was independently associated with a reduced rate of admission to hospital.

The authors call for a push to inform and educate about the importance of the recovery position. We as paediatricians have a key role to play in this particularly as for many of the children in this study there had been a previous episode requiring hospital assessment.

In an accompanying editorial Robert Tasker discusses ‘Positioning the breathing but unresponsive patient: what is the evidence?’ There is little published evidence. He discusses the lack of published evidence and calls for this important evidence to be included in new recommendations for the management of the unconscious patient. See pages 521 and 508

Voice problems in children following very preterm birth

Dysphonia is a potential outcome of preterm birth. Dysphonia refers to a disruption in voice quality, that is, the sound produced as exhaled air sets the vocal folds into vibratory motion for speech production. Dysphonia therefore reflects underlying abnormalities in the structure and/or function of the larynx.

Reynolds et al report the outcome of 178 children screened between age 5 and 12 (23–32 weeks gestation). Participants were randomly selected from a sample stratified by gestational age and number of intubations. Assessment was by a speech therapist. Diagnosis of dysphonia was based on the presence and severity of disturbance to voice—mild, moderate (noticeable disruption in quality), severe (severe disturbance in quality with or without periods of aphonia). The prevalence of dysphonia was 61%, (mild 30%, moderate 23%, severe 8%). Risk factors included female sex, early gestation and duration of intubation. The data presented and discussion of the topic is interesting. The authors advise routine screening as part of the developmental follow up for these children. See page 556

Sleep quality in children and their resident parents when in hospital 

Poor sleep in hospital is likely to inhibit recovery and exacerbate stress. Stickland et al explore this issue by interviews of co-sleeping parents one week after discharge from hospital. The interviews explored parents and child sleep quality, factors contributing to this, impact on daytime functioning and factors that could (should) potentially change. Parents reported that they experienced reduced sleep quality. Noise and light as well as ward schedules were identified as key factors. Parents reported that lack of sleep caused difficulties with their own emotional regulation and that of their child, affecting daytime parent–child relationships. They reported a negative impact of sleep deprivation on decision-making about their child's medical care. Many potential modifiable factors were identified. It is worth working through the paper and reflecting on the vulnerability and stress of parents with children in hospital and this being a potentially modifiable factor that may reduce that stress and aid recovery of the child. See page 546

Fussy eating and parental anxiety and depression

Fussy eating—consistently rejecting particular food items—is common, particularly in young children. Maternal post natal anxiety and depression are common associations although it is unclear whether these are risk factors for or as a consequence of the child's fussy eating behaviour. de Barse et al examine this association (4746 four year olds embedded in a birth cohort). Food fussiness was assessed by a children's eating behaviour questionnaire; score >3 was classified as a fussy eater. Mother's anxiety during pregnancy and the preschool period were associated with higher food fussiness scores—per point on anxiety scale children had on average 1.02 higher score on the food fussiness scale. Similar data was found for antenatal and postnatal depression. Paternal anxiety was associated in the postnatal but not antenatal period. These findings should be interpreted with caution but do imply antenatal and post natal anxiety and depression in mothers and post natal anxiety in fathers are risk factors for fussy eating in children. See page 533

What is normal blood glucose

This issue includes a comprehensive review of the physiology and evidence— why it is difficult to define normal, glucose physiology in the term infant, the transition to ‘normal levels’ after birth and how to maintain normal glucose integrating the physiological changes relating to fasting and feeding states. It is an excellent read and aids considerably with understanding of the complexities of controlling blood glucose in clinical practice. See page 569

Recognition, assessment and management of hypoglcaemia

Hypoglycaemia is common and prompt treatment is required to prevent brain injury. Gosh and colleagues review the recognition assessment and management outside the neonatal period. The commonest causes are diabetes mellitus and idiopathic ketotic hypoglycaemia (IKH). Diagnosis is dependent on investigation at the time of hypoglycaemia in the first instance although more complex testing may be required if, for example an endocrine or more complex metabolic disorder is suspected. Metabolic causes such as IKH are prevented by limiting the durations of fasting. Endocrine causes may require cortisol replacement. The authors take us through all these issues including a comprehensive list of different potential causes, the investigations required during hypoglycaemia, the indications for and detail of further investigation and the specifics of treatment for the different potential diagnosis. It is an essential read for the busy clinician and an excellent information source. See page 575