Hospital inpatient care is frequently mentioned by parents as unsatisfactory for children with diabetes. Ward staff are now less familiar with diabetes, as admissions are less common and diabetes management is more intensive.
To compare current practice with Department of Health Children's Diabetes Working Group care standards.
This audit surveyed the organisation of inpatient care for children with diabetes in three regional networks in southern England, and was funded by the Healthcare Quality Improvement Partnership.
All 27 services completed the questionnaire. Protocols for diabetic ketoacidosis, surgery, new diagnosis and hypoglycaemia were generally available on wards (70% had all four protocols) but less available in emergency departments (EDs) (52%). Trained children's nurses worked on every shift in children's wards (100%) but not necessarily in EDs (33%). Diabetes link nurses were identified on 74% of wards and 61% of high-dependency units (HDUs), and diabetes specialist nurses have inpatient liaison in their job description (89%) and working role (93%). Standards achieved less often were access to dietetic advice on wards (37%), education sessions for ED and ward staff, and informing diabetes team (only 26% within 2 h of admission during the day, and only 11% would contact the diabetes consultant overnight for a child admitted to a paediatric intensive care unit/HDU). Half of centres reported insulin errors.
This first audit of children's diabetes inpatient care organisation demonstrates that some standards can be achieved, but others, such as having children's nurses on every shift in EDs, lack of dietetic advice to ward staff, and liaison with the diabetes team quickly out of hours, are more challenging. Further planned audit outcomes are to produce patient and parent literature for children admitted to hospital and to refine the standards further.
Primary infection with the varicella zoster virus, is characterised by a rash, often accompanied by fever and malaise, which starts as macules, then progresses rapidly through papular and vesicular stages, before crusting over. Skin manifestations are the most common, but it can also affect the mucosa of the conjunctivae, oropharynx and introitus of the genitourinary tract.
Varicella affecting bladder mucosa, is rarely reported. A single case report describes a child with varicella affecting skin...]]>
A priori, paediatricians were given written case definitions of serious ADRs, which they then notified to the New Zealand Paediatric Surveillance Unit (NZPSU) using standard methodologies described elsewhere.
During the 3-year period...]]>
Before the availability of VZIG and antiviral agents, the death rate from varicella was around 7% for children being treated for cancer, with 32% having visceral dissemination; children with lymphopenia were at highest risk.
To describe the change in incidence of paediatric inflammatory bowel disease (IBD) observed at the National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, and to determine whether the presenting disease phenotype and disease outcomes have changed during the past decade.
The annual incidence of IBD in Irish children aged <16 years was calculated for the years 2000–2010. Two subsets of patients, group A (diagnosed between 1 January 2000 and 31 December 2001), and group B (diagnosed between 1 January and 31 December 2008) were phenotyped according to the Paris Classification. Phenotype at diagnosis and 2-year follow-up were then compared.
406 new cases of IBD were identified. The incidence was 2.5/100 000/year in 2001, 7.3 in 2008 and 5.6 in 2010, representing a significant increase in the number of new cases of Crohn's disease (CD) and ulcerative colitis (UC). There were 238 cases of CD; 129 of UC; and 39 of IBD unclassified. Comparing groups A and B, no differences were found in disease location at diagnosis or, for CD, in its behaviour.
There has been a substantial and sustained increase in the incidence of childhood UC and CD in Ireland over a relatively short period of time. However, disease phenotype at diagnosis has not changed. At 2 years follow-up, CD appears to progress less frequently than in some neighbouring countries. These variations remain unexplained. Prospective longitudinal studies will help to elucidate further the epidemiology of childhood IBD.
To evaluate the evidence for double checking the administration of medicines.
A systematic search of six electronic databases—Embase, Medline, British Nursing Index and Archive, CINAHL, National electronic library for Medicines (NeLM) and PsycINFO—for all articles describing double checking of medication and dose calculation, for either dispensing or administration in both adults and children up to and including October 2010.
Sixteen articles met the inclusion criteria. There were only three quantitative studies. Only one of these was a randomised controlled clinical trial in a clinical setting. This study showed a statistically significant reduction in the medication error rate from 2.98 (95% CI 2.45 to 3.51) to 2.12 (95% CI 1.69 to 2.55) per 1000 medications administered with double checking. One study reported a reduction in dispensing errors, by a hospital pharmacy, from 9.8 to 6 per year following the introduction of double checking. The majority of the studies were qualitative and involved interviews, focus groups and questionnaires.
There is insufficient evidence to either support or refute the practice of double checking the administration of medicines. Clinical trials are needed to establish whether double checking medicines are effective in reducing medication errors.
To evaluate whether dual energy x-ray absorptiometry (DXA) and quantitative ultrasound (QUS) classify the same children as ‘abnormal’ (SD (z) score (SDS) ≤–2).
Speed of sound (SOS) was measured at the radius and tibia using QUS and lumbar spine bone mineral density (BMD) using DXA in 621 subjects aged 5–20 years; healthy 412, cystic fibrosis 117 and obese 92.
BMD SDS positively (p<0.001) and tibia SOS SDS negatively correlated with size (p<0.05). Disagreement between DXA and QUS for ‘abnormal’ scans occurred in 6–31%. Those with abnormal BMD and normal SOS SDS had lower mean BMI SDS than those with normal BMD and abnormal SOS SDS. SOS measurements were unobtainable in some children, especially in the obese group.
DXA and QUS identify different individuals as ‘abnormal’. Agreement between BMD and tibia SOS is lower in obese subjects. Without a gold-standard, it is difficult to determine which technique is more ‘correct’.
The interview must allow the girl to be alone with the paediatrician. The time is arranged by mobile phone, often at the end of the school day, and in a different building from the maternity/gynaecology unit. An hour will be needed. Her confidentiality must be respected unless one receives information which puts her in danger. Hospital records should have been consulted. Telephone calls are the best way of communication with the referring general practitioner or social services, with the agreement that the call...]]>
Of those referred, using the suspected cancer system, the numbers diagnosed...]]>
To determine whether an altered hypothalamic-pituitary-thyroid axis is inherent to Down's syndrome or if a high level of thyroid-stimulating hormone (TSH) is a feature in a subset of patients with Down's syndrome.
Comparative analysis.
Major health maintenance organisation (3.8 million insured).
A data warehouse search identified all subjects with Down's syndrome who attended Clalit Health Services in 2006 and were tested for TSH and free thyroxine (T4) level on the day of diagnosis (intention-to-treat population). The study group consisted of patients who were not diagnosed with thyroid disease or did not receive thyroid-modulating medication (n=428). Their findings were compared with a control group of healthy age- and sex-matched subjects who were randomly selected from the general population.
Distribution of free T4, TSH and total T3 levels.
The distribution plot for TSH showed a significant shift of the curve to higher values in the study group compared with the controls (p≤0.0001). This finding held true on further analysis of the whole intention-to-treat population (p<0.006). The free T4 distribution curve also shifted significantly to higher levels in patients with Down's syndrome (p≤0.0001).
Down's syndrome is associated with higher TSH levels. The results suggest that hyperthyrotropinaemia is an innate attribute of chromosome 21 trisomy. Therefore, T4 treatment should not be contemplated in Down's Syndrome unless the TSH is >95th centile in the presence of normal-range free T4 levels.
Basic epidemiological information on childhood cancer in Western Kenya is lacking. This deficit obstructs efforts to improve the care and survival rates of children in this part of the world.
Our study provides an overview of childhood cancer patients presenting for treatment in Western Kenya.
A retrospective analysis of childhood cancer patients presenting for treatment in Western Kenya was carried out using information from three separate databases at the Moi Teaching and Referral Hospital in Eldoret. All patients aged 0–19 years first presenting between January 2006 and January 2010 with a newly diagnosed malignancy were included.
A total of 436 children with cancer were registered during the period. There were 256 (59%) boys and 180 (41%) girls with a male/female ratio of 1.4:1. The group aged 6–10 years contained most children (29%). Median age at admission was 8 years. Non-Hodgkin's lymphoma was the most common type of cancer (34%), followed by acute lymphoblastic leukaemia (15%), Hodgkin's lymphoma (8%), nephroblastoma (8%), rhabdomyosarcoma (7%), retinoblastoma (5%) and Kaposi's sarcoma (5%). Only four (1%) children with brain tumours were documented. Ewing's sarcoma was not diagnosed.
Our study provides an overview of childhood cancer patients presenting for treatment in Western Kenya. The distribution of malignancies is similar to findings from other equatorial African countries but differs markedly from studies in high-income countries. The new comprehensive cancer registration system will be continued and extended to serve as the basis for an evidence-based oncology program. Eventually this may lead to improved clinical outcomes.
While chickenpox in healthy children is normally mild and self-limiting, in immunocompromised children it can cause severe morbidity and even mortality. For this reason, optimising PEP to prevent clinical disease in these patients is essential. Our paediatric haemato-oncology unit was one of 12 included in the observational study of Bate et al. However, while the number of centres studied in PEPtalk meant a necessary reliance on survey data, in...]]>
To demonstrate the sensitivity of musculoskeletal (MSK) history taking.
Prospective study: consecutive children attending outpatient clinics.
Paediatric rheumatology clinic (n=45; girls n=28; median age 12 years, range 3–18), acute general paediatric assessment unit (n=50; girls n=21; median age 8 years, range 3–16).
Pro forma recording abnormal joint involvement from history taking and then following MSK examination completed by clinicians.
Sensitivity of MSK history taking compared with clinical examination.
Paediatric rheumatology clinic: 135 abnormal joints identified in 34 children; 53/135 (39%) by history alone, 82/135 (61%) detected on examination resulting in MSK history sensitivity 53%, specificity 98%. Acute paediatric unit: 29 abnormal joints identified in 17 children; 18/29 identified on history (sensitivity 62%).
MSK history taking failed to identify a large number of abnormal joints which were detected on physical examination, emphasising the need for all joints to be examined as part of a screening examination as a minimum.
Morgagni hernias are the least common of all diaphragmatic defects
The relative frequencies of the causes of hypernatraemia in children after the neonatal period are unknown. Salt poisoning and osmoregulatory dysfunction are extremely rare and potentially fatal. In this retrospective 10-year study, the incidence, causes and differential biochemistry of hypernatraemia in children is examined.
Children with hypernatraemia (sodium ≥150 mmol/litre) aged >2 weeks to 17 years were identified from laboratory data of two paediatric departments serving the Lothian region of Scotland. A review of patient notes established time of onset and cause. Denominator data were available from the Scottish Health Service.
On admission to hospital, 1 in 2288 children (1:1535 admitted as an emergency) had hypernatraemia. This is 1 in 30 563 Lothian children <17 years. Overall 0.04% hospital stays had an episode of hypernatraemia. In 45 children admitted with 64 separate episodes (11 from a case of salt poisoning), the commonest cause was dehydration secondary to either gastroenteritis or systemic infection; 31% had an underlying chronic neurological disorder. A total of 177 further cases developed hypernatraemia after admission. The commonest causes were dehydration secondary to severe systemic infection and postoperative cardiac surgery. Urine sodium:creatinine ratio and fractional excretion of sodium were both much higher in the salt poisoning case than in a child with osmoregulatory dysfunction or children with simple dehydration.
Hypernatraemia after 2 weeks of age is uncommon, and on admission is usually associated with dehydration. Salt poisoning and osmoregulatory dysfunction are rare but should be considered in cases of repeated hypernatraemia without obvious cause. Routine measurement of urea, creatinine and electrolytes on paired urine and plasma on admission will differentiate these rare causes.
The newborn child was administered prophylactically polyclonal intravenous immunoglobulins. On the 4th day of life, a maculopapular rash (
Antibiotic drugs are frequently used for viral infections in children. It is probable that health beliefs and parental concern have great influence on the use of drugs in children. This study, performed in The Netherlands, investigates whether the use of antibiotics in children is associated with the use of medicines by parents.
In this observational cohort study, the authors selected 6731 children from the prescription database IADB.nl who did not receive antibiotics until their fifth birthday and 1479 children who received at least one antibiotic prescription every year. The authors then selected parents for each group of children (5790 mothers and 4250 fathers for the children who did not receive antibiotics and 1234 mothers and 1032 fathers for the children who regularly received antibiotics). The authors compared the use of antibiotics and other medicines between the two groups of parents.
Parents of children who received antibiotics recurrently were found to use more antibiotics themselves compared with parents of children who did not receive antibiotics. Moreover, this group also showed a higher percentage of chronic medication use: (11.3 vs 6.2% (mothers) and 13.1% vs 9.5% (fathers)). Mothers more often use antacids, non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, anxiolytics, hypnotics, antidepressants, drugs for treatment of asthma and antihistamines. Fathers use more antacids, cardiovascular drugs, NSAIDs and asthma drugs.
The parents of children who receive antibiotic drugs regularly use more medicines compared with the parents of children who use no antibiotic drugs. Parents' medicine use may influence that of children and is a factor physicians and pharmacists should take into account.
Her venous blood appeared grossly lipaemic (
The girl was treated according to the standard UK protocol for DKA (BSPED—http://www.bsped.org.uk); however, accurate monitoring of electrolytes was not possible in the first 48 h of treatment due to the hyperlipidaemia, so fluid management was based on clinical evaluation, blood gases and strict adherence to the protocol. After 48 h, blood gases had normalised and subcutaneous insulin was commenced. Venous blood remained grossly lipaemic until day 3. The girl was discharged home on day 5. Triglyceride levels were monitored and...]]>
FOP is a rare genetic disease with two clinical features: progressive heterotopic endochondral ossification and malformations of the great toes. Early fibroproliferative lesions of FOP are histologically indistinguishable from aggressive juvenile fibromatosis
Surgery, ionising radiation and anaesthesia in the presence of an undetected pregnancy could be harmful. British guidelines state that female patients of 'childbearing age' should have their pregnancy status established before surgery. Approaching this topic with an adolescent girl can be challenging.
The authors conducted an observational study and a survey in their institution and a national survey of Association of Paediatric Anaesthetists (APA) linkmen.
Local: Southampton. National: UK.
Both surveys demonstrate widespread concerns about inconsistent and informal practices. Only 45% of respondents in the authors' institution stated they ask adolescent girls if they could be pregnant. 40% of APA linkmen were unaware of national guidelines.
This work illustrates the need for consistent national guidance. We propose that all girls who have reached menarche should be routinely offered a urine pregnancy test before any procedure under general anaesthesia.
To investigate whether backpack weight is associated with back pain and back pathology in school children.
Cross-sectional study.
Schools in Northern Galicia, Spain.
All children aged 12–17.
Backpack weight along with body mass index, age and gender.
Back pain and back pathology.
1403 school children were analysed. Of these, 61.4% had backpacks exceeding 10% of their body weight. Those carrying the heaviest backpacks had a 50% higher risk of back pain (OR 1.50 CI 95% 1.06 to 2.12) and a 42% higher risk of back pathology, although this last result was not statistically significant (OR 1.42 CI 95% 0.86 to 2.32). Girls presented a higher risk of back pain compared with boys.
Carrying backpacks increases the risk of back pain and possibly the risk of back pathology. The prevalence of school children carrying heavy backpacks is extremely high. Preventive and educational activities should be implemented in this age group.
Two-year-old twin girls presented with several small yellow/white lumps on both heels. Some of these lumps discharged white material resulting in resolution. They did not have any discomfort on walking. They were born at 26 weeks of gestation and had numerous heel pricks during their stay in the special care baby unit.
On examination, the girls had small white non-tender papules on both their heels as shown in
Cutaneous calcified papules and nodules are a type of dystrophic calcinosis cutis. They are a recognised complication of heel prick tests performed in the neonatal period particularly in low birth weight babies.
Government plans to increase choice and competition in the National Health Service (NHS) will be implemented from April 2012 and will affect services for all age groups. The Royal College of Paediatrics and Child Health and the NHS Confederation recently expressed concerns that this approach might impede integration and coordination of care for younger patients. They recommend that ‘the Any Qualified Provider policy should only be used for child healthcare services where there are clear benefits to patients’.
In support of the reforms, the government has presented evidence that patients are in favour of a greater choice
David Cameron quotes research by Cooper et al arguing that more competitive healthcare markets can lead to better clinical outcomes. This study
Aerosol therapy in infants may be greatly compromised by face mask rejection due to squirming and crying. Lung aerosol deposition in crying infants may thereby be greatly reduced. Since ‘suckling’ on a pacifier calms infants, they should more readily accept a face mask that incorporates a pacifier. However, since infants must breathe nasally while suckling, lung aerosol deposition may be reduced due to impaction in the nose.
The aim of the present pilot study was to compare lung aerosol deposition while suckling on a pacifier incorporated into a mask with that obtained while inhaling from a conventional mask.
Twelve infants <12 months old and who regularly used pacifiers participated as their own controls. Lung aerosol deposition was measured scintigraphically (technetium-99mDTPA-labelled normal saline aerosol, MMAD (Mass Median Aerodynamic Diameter) 3 um and GSD (Geometric Standard Deviation) of 2) via jet nebuliser using a conventional mask versus ‘suckling’ on their pacifier incorporated into a unique mask.
Mean lung deposition (±SD) while suckling using a mask with attached pacifier (1.6±0.5% in the right lung) was similar to that with a conventional mask (1.7±0.9%, p=0.81).
Lung aerosol deposition during nasal breathing while suckling on a pacifier-equipped mask is similar to that in infants breathing quietly using a conventional mask, and results comparable with previous data in infants and in nasal breathing models of an infant's upper respiratory tract. Using a pacifier during aerosol treatment in infants may be as efficient as conventional treatment without a pacifier.
Until a few years ago, a
To assess the impact of pharmacist intervention in reducing prescribing errors in paediatrics, and to analyse the clinical significance and reasons behind the errors detected.
Cross-sectional epidemiological study analysing the activities of the paediatric pharmacist in a maternity and children's hospital with 180 paediatric beds, between January 2007 and December 2009. The following variables were analysed: impact of the pharmacist's recommendation on patient care, reason for the intervention, clinical significance, type of negative outcome associated with the medication, acceptance rate, medication involved, intervention detection date and observations.
A total of 1475 interventions in medical orders for 14 713 paediatric patients were recorded (40 (2.9%) extremely significant interventions and 155 (11.1%) very significant interventions). There were 1357 prescribing errors, 833 of which were dosing errors. 2.2% of the errors detected were potentially fatal (30 cases) and 14.3% (194 cases) were clinically serious. The main reason for interventions was detection of a dosage between 1.5 and 10 times higher than that recommended. The overall rate of acceptance of the pharmacist's suggestions was 94.3%. The pharmacist carried out an average of 0.019 interventions per patient day throughout the study period.
Interventions by a clinical pharmacist had a major impact on reducing prescribing errors in the study period, thus improving the quality and safety of care provided.
Studies from low-income countries have suggested that diphtheria-tetanus-pertussis (DTP) vaccine provided after Bacille Calmette-Guerin (BCG) vaccination may have a negative effect on female survival. The authors examined the effect of DTP in a cohort of low birthweight (LBW) infants.
2320 LBW newborns were visited at 2, 6 and 12 months of age to assess nutritional and vaccination status. The authors examined survival until the 6-month visit for children who were DTP vaccinated and DTP unvaccinated at the 2-month visit.
Two-thirds of the children had received DTP at 2 months and 50 deaths occurred between the 2-month and 6-month visits. DTP vaccinated children had a better anthropometric status for all indices than DTP unvaccinated children. Small mid-upper arm circumference (MUAC) was the strongest predictor of mortality. The death rate ratio (DRR) for DTP vaccinated versus DTP unvaccinated children differed significantly for girls (DRR 2.45; 95% CI 0.93 to 6.45) and boys (DRR 0.53; 95% CI 0.23 to 1.20) (p=0.018, homogeneity test). Adjusting for MUAC, the overall effect for DTP vaccinated children was 2.62 (95% CI 1.34 to 5.09); DRR was 5.68 (95% CI 1.83 to 17.7) for girls and 1.29 (95% CI 0.56 to 2.97) for boys (p=0.023, homogeneity test). While anthropometric indices were a strong predictor of mortality among boys, there was little or no association for girls.
Surprisingly, even though the children with the best nutritional status were vaccinated early, early DTP vaccination was associated with increased mortality for girls.
Phenobarbital (PB), commonly used as the preferred treatment for neonatal seizure, is a drug that requires careful dose adjustments based on therapeutic drug monitoring. It has been reported that PB metabolism was affected by cytochrome P450 (CYP)2C19 polymorphisms in adults requiring dose adjustment.
This study aimed to evaluate the effects of CYP2C19 genetic polymorphisms on PB pharmacokinetics (PK) in neonates and infants with seizures.
CYP2C19 (wild type: CYP2C19*1/*1, heterozygous extensive metabolisers: CYP2C19*1/*2, *1/*3 and poor metabolisers: CYP2C19*2/*2, *2/*3) genetic polymorphisms in 52 neonates and infants with seizures were analysed. PK parameters were compared based on genotypes. The NONMEM program was used for population PK modelling.
No significant difference in PB clearance (CL), volume of distribution (Vd) and concentrations were shown among the CYP2C19 genotype groups. The results of PK modelling were as follows: Vd=3590 x(body weight (BWT)/4)0.766 x(AGE/2)0.283 and CL=32.6x(BWT/4)1.21.
PB PK parameters of neonates and infants with seizures were not significantly different among the groups with different CYP2C19 genotypes. The addition of CYP2C19 genotyping to PK models did not improve the dosing strategies in neonates and infants.
A 9-year-old girl presented with 2 days of right knee pain and a purpuric rash on her legs and buttocks. She was diagnosed with HSP. On the eighth day of her illness, haemorrhagic bullae began to form on her feet and ankles and her arthritis worsened (
HSP is the most common acute systemic vasculitis of childhood affecting the skin, kidneys, joints and gastrointestinal tract. Skin lesions usually consist of erythematous papules, petechiae and purpura mainly affecting the lower limbs.
Musculoskeletal (MSK) symptoms are a frequent cause of emergency department attendance for children, and while most often indicative of benign or self-limiting disease, such symptoms can occasionally be the first presentation of serious illness such as leukaemia or juvenile idiopathic arthritis. MSK examination, however, is often not included as part of the routine paediatric examination. The authors aimed to evaluate how often and how thoroughly MSK examination was performed during admissions to the paediatric ward and to compare it with the examination of other symptoms in relation to the presenting complaint and eventual diagnosis.
Medical records for 100 consecutive patients were reviewed. A poster campaign to increase awareness was then commenced along with oral and written presentations to staff regarding MSK examination. A further 100 consecutive patients were then reviewed. Only 9% of children in the initial group had routine MSK examination, rising to 32% in the second group. Where performed, MSK examination was often incomplete. Frequent errors included only examining the reported site of injury and only examining a single limb or single joint when limpness/stiffness was the presenting complaint. Non-limb joints were very rarely examined.
MSK examination is not performed routinely during paediatric admissions in contrast to the examination of other symptoms regardless of the presenting complaint. This may need to be addressed by local audit and increased undergraduate teaching.
To compare the difference in plasma sodium at 16–18 h following major surgery in children who were prescribed either Hartmann's and 5% dextrose or 0.45% saline and 5% dextrose.
A prospective, randomised, open label study.
The paediatric intensive care unit (650 admissions per annum) in a tertiary children's hospital in Brisbane, Australia.
The study group comprised 82 children undergoing spinal instrumentation, craniotomy for brain tumour resection, or cranial vault remodelling.
Patients received either Hartmann's and 5% dextrose at full maintenance rate or 0.45% saline and 5% dextrose at two-thirds maintenance rate.
Primary outcome measure: plasma sodium at 16–18 h postoperatively; secondary outcome measure: number of fluid boluses administered.
Mean postoperative plasma sodium levels of children receiving 0.45% saline and 5% dextrose were 1.4 mmol/l (95% CI 0.4 to 2.5) lower than those receiving Hartmann's and 5% dextrose (p=0.008). In the 0.45% saline group, seven patients (18%) became hyponatraemic (Na <135 mmol/l) at 16–18 h postoperatively; in the Hartmann's group no patient became hyponatraemic (p=0.01). No child in either fluid group became hypernatraemic.
The postoperative fall in plasma sodium was smaller in children who received Hartmann's and 5% dextrose compared to those who received 0.45% saline and 5% dextrose. It is suggested that Hartmann's and 5% dextrose should be administered at full maintenance rate postoperatively to children who have undergone major surgery in preference to hypotonic fluids.
Children under 16 in the UK and Ireland with suspected anaphylaxis as an AEFI were reported through the British Paediatric Surveillance Unit (BPSU) between September 2008 and October 2009. Paediatricians completed questionnaires on presentation, diagnosis, management and outcome.
A total of 7 out of 15 reports met criteria for anaphylaxis following immunisation. Four of the seven children reacted more than 30 min after administration of the vaccine. Six children required treatment with intramuscular adrenaline and intravenous fluids, but all made a full recovery. Denominators were not available for all vaccines so an overall incidence was not calculated, however the estimated incidence was 12.0 per 100 000 dose for single component measles vaccine and 1.4 cases per million doses for the bivalent human papilloma virus vaccine (Cervarix, GSK).
Anaphylaxis remains a rare adverse event following immunisation. No cases were related to vaccines given as part of the ‘routine’ infant and preschool immunisation programme, despite over 5.5 million vaccines being delivered in this time period. Some children had delayed onset of symptoms and this should be considered when vaccinating those at higher risk of anaphylaxis.
The state of New South Wales in...]]>
Although the topic of identifying febrile children at risk of serious infections has been addressed by numerous research groups, identified predictors remain diverse and implementation of results in routine practice has been limited. The aim of this paper is to discuss the problems and challenges in advancing diagnostic research in febrile children.
The characteristics and results of 35 studies identified from a systematic review on predictors for febrile children were evaluated.
Current diagnostic research is mainly performed in subpopulations, defined by age and temperature limits and in paediatric emergency settings, ignoring the role of primary care. It is characterised by a dichotomous approach of outcomes and a wide variability of potential predictors. Validation of results to other settings and impact studies of prediction rules on patient outcomes are scarce. In designing diagnostic studies on children suspected of serious infections focus is needed on all clinically relevant populations within the spectrum of primary care and emergency department settings. Consensus is also needed on the definition of fever, the concept of serious infection and the set of predictors to focus on. The heterogeneity of patients in different settings and countries stress the need for continuous updating of prediction rules in routine practice. Broad validation in different clinical settings and countries and impact analysis in routine care is essential.
Scientists in the field of diagnosis of serious infection in children must agree on core design features to be incorporated in all studies in the area of diagnostic research in febrile children. This will improve evidence from future studies, and their generalisability and implementation in routine practice.
A contrast-enhanced CT scan revealed a large complex cystic mass of size 185 x 148 x 300 mm occupying almost the entire left side of the abdomen and extending to the right side. The spleen, left kidney and pancreas could not be separately visualised. The stomach and gut loops were compressed to the right. The mass was predominantly fluid (
On laparotomy, the left kidney was grossly hydronephrotic with papery thin renal parenchyma containing >5 litres of haemorrhagic fluid, and there was obvious narrowing at the pelviureteric junction. Left-sided nephroureterectomy was performed. The child recovered uneventfully after surgery and is doing well on...]]>
Serum CRP, plasma PCT and blood WBC were...]]>
A premature (35 weeks' gestation) girl developed respiratory distress immediately after birth along with frothing from the mouth. A nasogastric tube could not be passed. Breath sounds were absent on the right side of the chest and the cardiac apex beat was located on the right side. Chest x-ray revealed opacification of the right hemithorax, absence of the right lung shadow, apparent dextrocardia and a hyperaerated left lung crossing the midline (
The combination of pulmonary hypoplasia-aplasia (PHA)...]]>
To investigate what data are available on the National Health Service (NHS) experience of children and young people (0–24 years), and how their experience compares with that of older patients.
Review of 38 national surveys undertaken or planned between 2001 and 2011, identified by the Department of Health (2010). Detailed analysis performed on the most recent completed surveys covering primary, inpatient and emergency care, and children's services.
Patients under 16 were included in 1/38 national surveys, comprising <0.6% of over 10 million respondents. The majority of young people aged 16–24 reported a positive experience of NHS care. However, satisfaction was lower than in older adults. 80.7% of 16–24 year olds reported good emergency department care, compared with 89.2% of older adults (Emergency Department Survey 2008, N=49 646, OR=0.51, 95% CI 0.47 to 0.55, p<0.001). In the Inpatient Survey 2009, 86.5% of 16–24 year olds reported good care, compared with 92.7% of older adults, (N=69 348, OR=0.51, 95% CI 0.45 to 0.57, p< 0.001). Satisfaction with primary care was reported by 83% of 18–24 year olds, compared with 90% of older adults (GP Patient Survey 2009–10 (N=2 169 718, OR=0.52, 95% CI 0.51 to 0.53, p<0.001). Young people also reported a poorer experience than older adults for their perceived involvement in care, having confidence and trust in their doctor and being treated with respect and dignity.
Despite the current focus on services for young people and the importance of patients' views in improving services, the voice of under 16s is not included in most national surveys. Despite high levels of overall satisfaction, young adults report a poorer experience of care than older adults.
To compare the QuantiFERON-TB GOLD In Tube test (QTF) and the tuberculin skin test (TST) in children.
A prospective study was carried out in nine hospitals in Madrid, Spain. TST and QTF were performed in immigrants, tuberculosis (TB) contacts and patients with TB disease (TBD).
459 children were included. Disagreement between the tests was more frequently observed among latent tuberculosis infection (LTBI) cases (54%; 38/70) than in non-infected or TBD cases (0.8%; 3/369) (p<0.01). There were more BCG-vaccinated children among LTBI cases with negative QTF (76%) than among LTBI cases with positive QTF (40%) (p<0.001). Agreement between tests in BCG-vaccinated children was lower than in non-vaccinated cases (p<0.05). Tests in TB exposed patients showed better agreement than in non-exposed children (p<0.05).
Agreement of both tests was excellent in TBD cases, non-vaccinated children and non-infected patients. A significant number of QTF negative results were observed among LTBI cases, especially in BCG-vaccinated children. Agreement was better in exposed children.
In this study, we assessed the adherence to ISPE/ISoP guidelines for ADR case reports of paediatric patients published from January 2008 to December 2010 and entered in Pfizer's safety database. We also developed a case report quality score by assigning a value of 1 or 0 based on the presence or absence of the ISPE/ISoP items, respectively. A cut-off score was established at the 75th percentile for adjudicating reports that were acceptably complete. All reports were independently assessed by two physicians; in case of disagreement, the...]]>
Little is known about the impact of British asthma management guideline revisions. Concerns about the use of high dose inhaled corticosteroids (ICS) in children have resulted in the promotion of add-on therapy.
To assess prescribing patterns of asthma medication in children in the primary care setting.
Retrospective observational study of asthma prescribing in children aged 0-18 years using primary care database from 2001 to 2006.
The proportion of children prescribed oral corticosteroids increased significantly (from 6% in 2001-2002 to 16% in 2005-2006, p<0.001), while the proportion of children prescribed an ICS dose of >400 mcg decreased from 16.2% to 11.7% (P<0.001). The proportion of children prescribed an add-on therapy and an ICS dose >400 µg, increased from 38.8 % in 2001-2002 to 61.2% in 2005-2006 (p<0.001).
Although adherence with asthma management guidelines is not optimal, this study has identified improved adherence in primary care.
Based on our experience, PHDUs may improve the care of children with an underlying diagnosis of epilepsy who present with seizures. Some of these children require a period of ventilation for airway management, support of breathing or seizure termination. Early extubation in the DGH may prevent transfer to a regional paediatric intensive care unit (PICU) by intensive care retrieval services, provided an appropriate environment for postextubation care such as PHDU is available. Here, we report findings of an audit which suggest that...]]>
To describe the use of heel blood sampling and non-pharmacological analgesia in a large representative sample of neonatal intensive care units (NICUs) in eight European countries, and compare their self-reported practices with evidence-based recommendations.
Information on use of heel blood sampling and associated procedures (oral sweet solutions, non-nutritive sucking, swaddling or positioning, topical anaesthetics and heel warming) were collected through a structured mail questionnaire. 284 NICUs (78% response rate) participated, but only 175 with ≥50 very low birth weight admissions per year were included in this analysis.
Use of heel blood sampling appeared widespread. Most units in the Netherlands, UK, Denmark, Sweden and France predominantly adopted mechanical devices, while manual lance was still in use in the other countries. The two Scandinavian countries and France were the most likely, and Belgium and Spain the least likely to employ recommended combinations of evidence-based pain management measures.
Heel puncture is a common procedure in preterm neonates, but pain appears inadequately treated in many units and countries. Better compliance with published guidelines is needed for clinical and ethical reasons.
This review focuses on normal variations of menses and common pathological causes of menstrual problems, including amenorrhoea, dysmenorrhoea and menorrhagia. Further consideration is given to the variations of presentation of polycystic ovary syndrome. It provides a guide to evaluate the various symptoms, investigations and management options.
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