The Chinese educational system is highly competitive from the start of primary school with great emphasis on academic performance and intolerance of failure. This study aimed to explore the pressures on primary school children, and to determine the relationship between these pressures and psychosomatic symptoms: abdominal pain and headache.
Cross-sectional survey using self-completion questionnaires.
9- to 12-year-olds in primary schools in urban and rural areas of Zhejiang Province, eastern China.
Proportion of children with defined school-related stressors and frequency of psychosomatic illness.
Completed questionnaires were obtained from 2191 children. All stressors were common in boys and girls and in urban and rural schools. Eighty-one per cent worry ‘a lot’ about exams, 63% are afraid of the punishment of teachers, 44% had been physically bullied at least sometimes, with boys more often victims of bullying, and 73% of children are physically punished by parents. Over one-third of children reported psychosomatic symptoms at least once per week, 37% headache and 36% abdominal pain. All individual stressors were highly significantly associated with psychosomatic symptoms. Children identified as highly stressed (in the highest quartile of the stress score) were four times as likely to have psychosomatic symptoms.
The competitive and punitive educational environment leads to high levels of stress and psychosomatic symptoms in Chinese primary schoolchildren. Measures to reduce unnecessary stress on children in schools should be introduced urgently.
To investigate the relation between breastfeeding, use of docosahexaenoic acid (DHA)-fortified formula and neuropsychological function in children.
Prospective cohort study.
Southampton, UK.
241 children aged 4 years followed up from birth.
IQ measured by the Wechsler Pre-School and Primary Scale of Intelligence (3rd edn), visual attention, visuomotor precision, sentence repetition and verbal fluency measured by the NEPSY, and visual form-constancy measured by the Test of Visual-Perceptual Skills (Non-Motor).
In unadjusted analyses, children for whom breast milk or DHA-fortified formula was the main method of feeding throughout the first 6 months of life had higher mean full-scale and verbal IQ scores at age 4 years than those fed mainly unfortified formula. After adjustment for potential confounding factors, particularly maternal IQ and educational attainment, the differences in IQ between children in the breast milk and unfortified formula groups were severely attenuated, but children who were fed DHA-fortified formula had full-scale and verbal IQ scores that were respectively 5.62 (0.98 to 10.2) and 7.02 (1.56 to 12.4) points higher than children fed unfortified formula. However, estimated total intake of DHA in milk up to age 6 months was not associated with subsequent IQ or with score on any other test.
Differences in children’s intelligence according to type of milk fed in infancy may be due more to confounding by maternal or family characteristics than to the amount of long-chain polyunsaturated fatty acids they receive in milk.
To determine the incidence and nature of prescribing and medication administration errors in paediatric inpatients.
Prospective review of drug charts to identify prescribing errors and prospective observation of nurses preparing and administering drugs to identify medication administration errors. In addition, incident reports were collected for each ward studied.
Paediatric patients admitted to hospitals and nurses administering medications to these patients.
11 wards (prescribing errors) and 10 wards (medication administration errors) across five hospitals (one specialist children’s teaching hospital, one nonteaching hospital and three teaching hospitals) in the London area (UK).
Number, types and incidence of prescribing and medication administration errors, using practitioner-based definitions.
391 prescribing errors were identified, giving an overall prescribing error rate of 13.2% of medication orders (95% CI 12.0 to 14.5). There was great variation in prescribing error rates between wards. Incomplete prescriptions were the most common type of prescribing error, and dosing errors the third most common. 429 medication administration errors were identified; giving an overall incidence of 19.1% (95% CI 17.5% to 20.7%) erroneous administrations. Errors in drug preparation were the most common, followed by incorrect rates of intravenous administration.
Prescribing and medication administration errors are not uncommon in paediatrics, partly as a result of the extra challenges in prescribing and administering medication to this patient group. The causes and extent of these errors need to be explored locally and improvement strategies pursued.
Design: We reviewed all sweat tests performed in our institution to assess the relationship between sweat volume and conductivity, and between sweat volume and sweat chloride. We also compared results between pairs of sweat tests taken simultaneously from a single patient, one with sweat volume below and the other above the currently accepted minimum volume (15µl).
Results: A weak inverse relationship between sweat volume and sweat conductivity was found (n=1500, R2=0.105, p<0.001). There was no correlation between sweat volume and sweat chloride (n=463, R2= 0.002, p>0.05). In discordant pairs, one below and one exceeding the accepted minimum volume, the mean test result in the low volume sample was slightly higher than its counterpart. In 76 such pairs, mean conductivity was 41.1±14.6 mmol/L in the lower volume sample, compared to 36.8±16.0 mmol/L in the higher volume sample (p<0.001). Similarly, in 33 of the pairs, mean sweat chloride was 28.4±15.7 mmol/L in the lower volume sample compared to 25.1±15.2 mmol/L in the higher volume sample (p=0.004).
Conclusion: A normal sweat conductivity and/or chloride value from a sweat volume less that 15µl in a patient whose clinical symptoms are not very suggestive of CF, renders this diagnosis unlikely. In contrast, elevated sweat chloride or conductivity measured from a sample whose volume is below 15µl may represent an artifact related to the low volume.
]]>Design: Prospective cohort study
Setting: Hospital out-patient weight management clinic in UK.
Patients: Eighty eight adolescents (40 male, 86% Caucasian) of median age 12.4 years (range 9.1-17.4) and mean (standard deviation) BMI SDS 3.23 (0.49).
Main outcome measures: Baseline and 12-months. Weight and height used to derive BMI as kg/m2. BMI was adjusted for age and gender providing BMI SDS using British 1990 Growth Reference Data. Body composition was measured by bioimpedance. A standard oral glucose tolerance test (OGTT) examined glucose metabolism. Fasting lipid profiles, High Sensitivity 'C' Reactive Protein (HsCRP) and blood pressure were taken.
Results: Reducing BMI SDS by ≥0.5 achieved significant improvements in important measures of body composition: mean waist circumference SDS reducing by 0.74 units and body fat SDS by 0.60 units, whilst also leading to significant reductions in key metabolic risk factors (triglycerides [-30%], LDL-Cholesterol [-15%], HsCRP [-45%]). A lesser reduction of ≥0.25 improved insulin sensitivity, total cholesterol/HDL ratio and blood pressure. The greater the BMI SDS reduction, the better the improvement seen in insulin sensitivity. The most insulin sensitive individuals at baseline were most likely to achieve BMI SDS changes ≥0.5 regardless of baseline BMI SDS.
Conclusions: Improvement in body composition and cardio-metabolic risk can be seen with BMI SDS reductions of ≥0.25 in obese adolescents whilst greater benefits accrue from losing at least 0.5 BMI SDS. The most insulin sensitive individuals seem best able to effect these changes.
]]>Methods: The medical records of all patients up to 18 years of age during a 3-year period presenting at Assaf Harofeh Medical Center due to toxic exposure, were retrospectively reviewed. Patients suffering from dipyrone overdose were compared to all the other patients.
Results: Two hundred and thirty five cases were included in the final analysis. Of these, 26 (11%) patients were exposed to dipyrone (median age 15 years). Three of the 26 patients (12%) had transient nonoliguric renal insufficiency. One other patient who did not receive dipyrone also developed transient renal insufficiency.
Conclusions: Dipyrone overdose is frequent and may cause acute nonoliguric renal insufficiency. Renal function should be monitored in such patients.
]]>Objective: To compare the growth of Belgian and Norwegian children with the WHO standards.
Participants: 6985 children 0 - 5 years of age from Belgium and Norway.
Design: Proportion of children below –2 SD and above +2 SD of the WHO standards was calculated for length/height, weight, body mass index and head circumference. Average SD-scores of exclusively breastfed children of non-smoking mothers were compared with national reference data and with the WHO standards.
Results: Generally, the number of Belgian and Norwegian children below –2 SD lines of the WHO standards was lower, and above +2 SD higher than expected. The largest differences were for head circumference (0.97% Belgian and 0.18% Norwegian children below –2 SD, 6.55% Belgian and 6.40% Norwegian children above +2 SD), and the smallest for length/height (1.25% Belgian and 1.43% Norwegian children below –2 SD, 3.47% Belgian and 2.81% Norwegian children above +2 SD). The growth pattern of breastfed children of non-smoking mothers was in both countries more alike the local national growth references than the WHO standards.
Conclusions: There are significant deviations in the proportion of children outside normal limits (± 2SD) of the WHO standards. This was true for all children, including those who were exclusively breastfed. Hence, adoption of the WHO growth charts could have consequences for clinical decision making. These findings advocate the use of national references in Belgium and Norway, also for breastfed children.
]]>Design: Systematic review
Setting: Child and adult services and interface between healthcare providers.
Patients: Young people aged 13 to 24 years with palliative care conditions in the process of transition.
Main outcome measures: Young people and their families’ experiences of transition, the process of transition between services and its impact on continuity of care, and models of good practice.
Results: 92 studies included. Papers on transition services were of variable quality when applied to palliative care contexts. Most focused on common life threatening and life limiting conditions. No standardised transition programme identified and most guidelines used to develop transition services were not evidence based. Most studies on transition programmes were predominantly condition-specific (e.g. cystic fibrosis, cancer) services. Cystic fibrosis services offered high quality transition with the most robust empirical evaluation. There were differing condition-dependent viewpoints on when transition should occur but agreement on major principles guiding transition planning and probable barriers. There was evidence of poor continuity between child and adult providers with most originating from within child settings.
Conclusions: Palliative care was not, in itself, a useful concept for locating transition-related evidence. It is not possible to evaluate the merits of the various transition models for palliative care contexts, or their effects on continuity of care, as there are no long-term outcome data to measure their effectiveness. Use of validated outcome measures would facilitate research and service development.
]]>Design: Prospective quality improvement cohort study.
Setting: Tertiary care free-standing children’s hospital in the Intermountain west, USA.
Participants: 23 children with MCC identified from 219 admissions between 12/16/04 and 1/7/05.
Intervention: Medication reconciliation at hospital admission using information from 5 sources.
Main outcomes: Accuracy of information sources determined by sensitivity and specificity compared to verified outpatient medication lists. Errors were determined by comparing admitting orders to reconciled inpatient medication lists, and categorized by frequency, type, and clinical risk.
Results: Children with MCC averaged 5.3 chronic medications. The reconciliation process took an average of 90 minutes. Availability/sensitivity/specificity respectively were: Parents 52%/0.75/0.96, Pharmacy 61%/0.64/0.74, primary provider 43%/0.25/0.86, last admission electronic health record 87%/0.74/0.33, and admitting history 65%/0.31/0.94. 39 errors were identified in 182 admission medications (21%) including 17 omissions, affecting 13 patients (57%). The estimated clinical risk, if an adverse drug event had occurred, was serious or life-threatening in 5 instances.
Conclusions: In children with MCC admitted at our institution during the study period, no medication information source was optimally available, sensitive, and specific. Admitting order medication errors affected more than half of patients, the most common being omissions. Efforts to improve medication reconciliation at hospital admission in this population must account for availability and accuracy of information sources, and medication omissions at the time of hospital admission.
]]>Design: Since May 1997 we have performed active surveillance to search for vCJD among the many diseases that cause neurological deterioration in children, using the monthly surveillance card sent to all UK consultant paediatricians by the British Paediatric Surveillance Unit. We obtain clinical details from reporting paediatricians by questionnaire or site visit and an Expert Group then independently classifies the cases.
Results: After 12 years 2636 patients less than 16 years old with suspected PIND had been reported of whom 1114 had a confirmed diagnosis to explain their deterioration: in these children there were 147 different diseases. These were the six commonest diagnostic groups: leukoencephalopathies (183 cases), neuronal ceroid lipofuscinoses (141 cases), mitochondrial diseases (122 cases), mucopolysaccharidoses (102 cases), gangliosidoses (100 cases) and peroxisomal disorders (69 cases). Relatively large numbers of PIND children were reported from parts of the UK where there are high rates of consanquinity. Only 6 children with vCJD (4 definite, 2 probable) had been identified.
Conclusions: Although our study does not ascertain all UK cases it provides a novel insight into the epidemiology of the neurodegenerative diseases that cause PIND in children. It is reassuring that in general these children are carefully investigated and that active surveillance has found only 6 children with vCJD. However there is concern that more childhood vCJD cases may appear, possibly with a different genotype from those identified so far.
]]>Methods: A process evaluation using a population-based study of all unexpected deaths from birth to 2 years in the South West of England between January 2003 and December 2006. Local police and health professionals followed a standardised approach to the investigation of each death, supported by the research team set up to facilitate this joint approach as well as collect data for a wider research project.
Results: We were notified of 155/157 SUDI, with a median time to notification of 2 hours. Initial multi-agency discussions took place in 93.5% of cases. A joint home visit by police officers with health professionals was carried out in 117 cases, 75% within 24 hours of the death. Time to notification and interview reduced during the 4 years of the study. Autopsies were conducted on all cases, the median time to autopsy being 3 days. At the conclusion of the investigation, a local multi-agency case discussion was held in 88% of cases. The median time for the whole process (including family support) was 5 months.
Conclusions: This study has demonstrated that with appropriate protocols and support, the joint agency approach to the investigation of unexpected infant deaths can be successfully implemented.
]]>Design: Cross-sectional observational study.
Setting: University of York.
Participants: Fifty severely-profoundly deaf and 56 normally-hearing children recruited via a charity, the UK National Health Service, and schools.
Interventions: Thirty of the deaf children had received bilateral cochlear implants; 20 had unilateral cochlear implants.
Main outcome measures: Performance measures of children’s listening skills; parental-proxy valuations of the deaf children’s health utility obtained with the Health Utilities Index Mark 3 and of their QOL obtained with a visual analogue scale.
Results: On average, bilaterally-implanted children performed significantly better than unilaterally-implanted children on tests of sound localisation and speech perception in noise. After conservative imputation of missing data and while controlling for confounds, bilateral implantation was associated with increases of 18.5% in accuracy of sound localisation (95% CI 5.9 to 31.1) and of 3.7dB in speech perception in noise (95% CI 0.9 to 6.5). Bilaterally-implanted children did not perform as well as normally-hearing children, on average. Bilaterally- and unilaterally-implanted children did not differ significantly in parental ratings of health utility (difference in medians 0.05, p>.05) or QOL (difference in medians 0.01, p>.05).
Conclusions: Compared to unilateral cochlear implantation, bilateral implantation is associated with better listening skills in severely-profoundly deaf children.
]]>Design: Prospective survey.
Setting: Hospital for Sick Children, Toronto Canada.
Patients: Parents of inpatients and outpatients.
Interventions: Anonymous questionnaire for demographic characteristics, and clinical vignette to identify thresholds for disclosure of medical error.
Main outcome measures: Thresholds for parent and patient disclosure, and associated factors.
Results: 99% of 431 parents (181 inpatients, 250 outpatients), wanted to be informed if there was potential or actual harm versus 77% if not (p<0.0001). Most (71%) wanted their child informed if there was potential or actual harm versus 41% if not (p<0.0001).
Parents’ age, education, religion, experience with error and child’s age did not affect preference for disclosure to themselves. Asia-born parents (p=0.014; OR 2.4, 95% CI 1.2, 4.9), parents of inpatients (p=0.03, OR 1.65, 95%CI 1.04, 2.62), and those administered the survey with increasing severity of harm had a lower disclosure threshold (p<0.0001, OR 2.46; 95% CI 1.58,3.83).
Asian-born parents (p <0.0001, OR 5.3, 95% CI 2.7, 10.6), older child (<6 yrs vs >10 yrs p < 0.0001, OR 2.74, 95% CI 1.73, 4.33), previous experience with error (p =0.05; OR 1.5, 95% CI 1, 2.2), and survey administration with increasing harm (p=0.04, OR 1.46; 95% CI 1.01, 2.10) predicted a lower threshold for informing the child.
Conclusions: Most parents want to be informed of medical error whether harm was caused or not, and want their child informed only if potential or actual harm. Parental country of birth, previous experience with error, and age of the child are potential factors that may influence the parents’ desire for disclosure to their child.
]]>Objective: To compare characteristics of children entering the randomised trial with those recruited to a parallel, non-randomised study, to establish trends in referral and patient preferences for treatment.
Design: Baseline data from a randomised controlled trial with parallel non-randomised preference study, comparing surgical intervention with medical treatment in children aged 4 to 15 years with recurrent sore throat referred to five secondary care otolaryngology departments located in the north of England or west central Scotland.
Results: Centres assessed 1546 children; 21% were not eligible for tonsillectomy. Among older children (8–15 years), girls were significantly more likely to be referred to secondary care. Of 1015 eligible children, 268 (28.2%) agreed to be randomised while 461 (45.4%) agreed to the parallel, non-randomised preference study, with a strong preference for tonsillectomy. Participants reporting that progress at school had been impeded or with more experience of persistent sore throat were more likely to seek tonsillectomy. Referred boys were more likely than girls to opt for medical treatment. Socioeconomic data showed no effect.
Conclusion: Preference for tonsillectomy reflects educational impact and recent experience, rather than age or socioeconomic status.
]]>Methods: Longitudinal stored blood samples (n=1105) were available from 417 young people from the Oxford Regional Prospective Study (an inception cohort of 527 children followed for a median of 10.3(interquartile range 7.1-12.3)years), for measurement of SDMA and creatinine. Additional annually collected data on anthropometric parameters, HbA1c, insulin dose and 3 early morning albumin-creatinine ratios were available. In-GFR was measured in a representative sub-group of 183 subjects.
Main outcome measures: SDMA and eGFR.
Results: SDMA and eGFR were significantly and similarly associated with In-GFR (r=-0.38 and r=0.36 , p<0.001). Overall SDMA levels were lower in microalbuminuric (n=116) than normoalbuminuric subjects (n=301) (0.385±0.063 vs 0.412±0.059µmol/l, p<0.001), probably reflecting hyperfiltration. The pattern of change in SDMA levels with age differed between microalbuminuric and normoalbuminuric subjects. Whereas SDMA levels declined in both groups until the age of 16 years, thereafter they tended to rise only in microalbuminuric subjects, probably reflecting a decline in renal function.
Conclusions: In this longitudinal study of young people with T1D, measurement of SDMA, in contrast to eGFR, proved to be a reliable marker in identifying changes in filtration rates associated with the development of MA.
]]>Aim: Ongoing monitoring of junior doctors’ prescribing competency to assess the effect of these national and local initiatives.
Methods: Junior doctors receive training and subsequent assessment on prescribing competency at induction. A 1-hour bleep-free session concerning paediatric prescribing precedes completion of 4 prescribing tasks. BNFc and calculators are provided. Those scoring 0 or 1 are retrained before prescribing is permitted. Our previously published data of doctors between 2001 and 2004 was compared to assessment in 2007.
Results: Thirty junior doctors were assessed in 2007 (32 in 2001-4). All 4 questions were answered correctly by 22/30, compared to 10/32 (31%) in 2001-4. The mean score in 2007 was 93.3% compared to 57.8% previously (see Table 1). Comparison of means with previous results demonstrated statistically significant improvement with a mean difference of 36% (95% CI: 24,47). In 2007, eight (27%) doctors got just one question wrong and no doctor answered all questions incorrectly. In 2001-4 22/32 (67%) made at least one error during previous assessment, and one doctor answered all questions incorrectly.
Conclusion: Ongoing monitoring of junior doctors’ prescribing ability has demonstrated improvements which may be due to local and national training initiatives.
]]>Aim: We aimed to estimate, using limited available pharmacokinetics data, potential infant exposure to nifurtimox through breast milk.
Methods: Original nifurtimox plasma concentrations were obtained from published studies. Pharmacokinetic parameters were estimated using nonlinear mixed effect modeling with NONMEM version VI. One thousand nifurtimox plasma-concentration profiles were simulated and used to calculate the amount of drug that an infant would be exposed to, if breastfed 150 ml/kg/day.
Results: Breast milk concentrations on the basis of peak plasma levels (1,361 ng/ml) and milk-plasma ratio were estimated. We calculated infant nifurtimox exposure of a breastfed infant of a mother treated with this drug to be below 10% of the maternal weight-adjusted dose, even if milk – plasma ratio were overestimated. Simulation led to similar estimates.
Discussion: Risk for significant infant exposure to nifurtimox through breast milk seems small and below the level of exposure of infants with Chagas disease receiving nifurtimox treatment. This potential degree of exposure may not justify discontinuation of breastfeeding.
]]>Design: Prospective comparison of echocardiograms on infants with suspected significant CHD performed as: (1) hands-on evaluation and echocardiogram by paediatrician at district general hospital (DGH) followed by (2) transmitted echocardiogram via ISDN 6 with guidance from paediatric cardiologist and finally (3) hands-on evaluation and echocardiogram by paediatric cardiologist. The economic analysis compares the cost of patient care associated with the telemedicine service compared with a hypothetical control group.
Setting: Neonatal units of three DGH and a UK regional paediatric cardiology unit.
Results: Echocardiograms were transmitted on 124 infants. In five cases scans were inadequate for diagnosis. Of the remaining 119 tele-echocardiograms, a follow up echocardiogram was performed on 109/119 (92%). Major CHD was diagnosed in 39/109 infants (36%) and minor CHD in 45 (41%). The tele-echo diagnosis was accurate in 96% cases ( = 0.89). Unnecessary transfer to the regional unit was avoided in 93/124 patients (75%). Despite relatively high implementation costs, telemedicine care was substantially cheaper than standard care. Each DGH potentially saved money by utilising the telemedicine service: mean saving £728/patient.
Conclusions: CHD is accurately diagnosed by real time transmission of echocardiograms performed by paediatricians under live guidance and interpretation by a paediatric cardiologist. Remote diagnosis and exclusion of CHD affects patient management and may be cost saving.
]]>Development of competence is linked both to a child’s neurodevelopmental and their experience and may be enhanced by information sharing and encouraging participation.
Formal testing of competence is likely to be requested when the child wishes to make a decision that others regard as not being in his/her best interests. Assessors should have skills in talking with children, understand the relevant test to be applied and avoid conflicts of interests. Assessments require understanding of the child in the context of their illness and their family and should facilitate enhancement of competence. They should be developmentally appropriate, explore systemic influences, and consider the child’s emotional state, cognitive development and ability to balance risks and benefits.
Responsibility for the overall assessment of Gillick competence lies with doctors but involvement of a psychologist or other independent third party should be considered when a child’s competence is the subject of serious concern or the decisions involved are complex or where there is conflict between the various parties involved.
All members of the multidisciplinary team have a duty to enhance the competence of children in their care.
]]>Patients: 103 consecutive paediatric admissions to a neurological rehabilitation facility after closed head injury
Methods: Children’s recoveries were defined by repeated scores on the WeeFIM (a validated paediatric measure of functional independence) assembled into recovery trajectories. Non-linear mixed effects modelling was used to define "typical" recoveries and to identify useful simple predictor variables.
Results: WeeFIM recovery curves showed a characteristic sigmoidal form with an initial slow phase followed by a mid-phase of fastest improvement and a late plateau. Final WeeFIM scores ranged from 18 to 125 (median 105, interquartile range 87-117). The time taken to reach 50% final WeeFIM score ranged from 5 to 145 days (median 27, interquartile range 17-46). Both final WeeFIM and time to reach 50% final WeeFIM correlated with Time to Follow Commands (TFC), defined as the post-injury day on which a child was first observed to follow two simple commands in a 24h period
Conclusions: Simple models predicting outcome trajectory can be built incorporating early rate-of-recovery indices (such as TFC) as proxies of injury severity. Such models allow informed discussion with families of likely rates of progress, and the confidence intervals on these estimates. Models of this nature also potentially allow identification of children making better- or worse-than-expected recoveries.
]]>Methods: Randomized, prospective, controlled trials published January 1996-February 2009 with a minimum of 4 weeks of ICS vs. MONT and of ICS vs. MONT+ICS were retrieved through Medline, Embase and Central databases. Primary outcome was asthma exacerbations requiring systemic corticosteroids (AEX); secondary outcomes were pulmonary function, withdrawal/hospitalization due to AEX, change in symptoms score, rescue medication free days, albuterol use, adverse effects and adherence.
Results: Of 124 studies identified, 18 studies (n=3757 patients) met criteria for inclusion (13 compared ICS vs. MONT, 3 ICS vs. MONT+ICS and 2 ICS vs. MONT vs. ICS+MONT). Patients receiving ICS showed a significantly decreased risk for AEX than those with MONT (RR=0.83, 95% CI= 0.72-0.96, p=0.01); post-hoc analysis suggests this effect was independent of quality, sponsorship and study duration. Children treated with ICS had significant higher pulmonary function (final FEV1 % predicted, change from baseline FEV1 %, final morning PEF) and better clinical parameters (albuterol use, symptom score, rescue medication free days, withdrawals due to AEX) vs. MONT. No significant difference in primary or secondary outcomes was found when MONT was add-on to ICS vs. ICS alone; however these analyses were based in only two studies.
Conclusions: Schoolchildren and adolescents with mild-persistent asthma treated with ICS had less AEX and better lung function and asthma control than with MONT. There is insufficient data to determine if the addition of MONT to ICS improves outcome.
]]>Methods: Body mass index data from three sources were used. Children were aged 3-13 years. Obesity was defined as above the 98th centile (British reference dataset). The data were analysed by age group and gender, then tested for significant micro-level hot spots of childhood obesity using a spatial scan statistic and a 2-level multi-level model.
Results: Older children (13y) were 2.5 times (95%CI: 2.1 to 3.1) more likely to be obese than younger children (3y). Childhood obesity was significantly associated with both deprived and affluent areas. ‘Blue collar communities’, ‘Constrained by circumstances’, and ‘Multicultural’ had significantly higher (relative risk: 1.1, 1.2, 1.2; 95%CI: 1.0 to 1.2, 1.1 to 1.2, 1.1 to 1.3, respectively), ‘Typical traits’ and ‘Prospering suburbs’ had significantly lower (RR: 0.9, 0.8; 95%CI: 0.8 to 1.0, 0.7 to 0.9, respectively), obesity levels. In the unadjusted model, obesity ‘hot spots’ were found in deprived (RR 1.5) and affluent (RR 6.1) areas. After adjusting for demographic covariates, hot spots were found only in affluent areas (RR 1.6 to 1.9), and cold spots in affluent (RR 1.3 to 4.4) and deprived (RR up to 1.1) areas.
Conclusion: These results suggest there is either a spread of obesity across socio-economic groups and/or something special about the high/low prevalence areas that affects the likelihood of obesity. The micro-level spatial analyses displayed the variations in obesity across Leeds thoroughly, identifying high-risk populations.
]]>Methods: We examined 514 children from the Mysore Parthenon birth cohort for whom breast-feeding duration (6 categories from <3 to >18 months) and age at introduction of complementary foods (4 categories from <4 to >6 months) were collected at the 1st, 2nd and 3rd year annual follow-up visits. Their cognitive function was assessed at a mean age of 9.7 years using 3 core tests from the Kaufman Assessment Battery for children and additional tests measuring long-term retrieval/storage, attention and concentration, visuo-spatial and verbal abilities.
Results: All the children were initially breast-fed. The mode for duration of breast-feeding was 12-17 months (45.7%) and for age at introduction of complementary foods 4 months (37.1%). There were no associations between longer duration of breast-feeding, or age of introduction of complementary foods, and cognitive function at 9-10 years, either unadjusted or after adjustment for age, sex, gestation, birth size, maternal age, parity, socio-economic status, parents’ attained schooling, and rural/urban residence.
Conclusions: Within this cohort, in which prolonged breast-feeding was the norm (90% breast-fed >6 months and 65% breast-fed for >12 months), there was no evidence suggesting a beneficial effect of longer duration of breast-feeding on later cognitive ability.
]]>Methods: Literature search of 20 electronic databases, websites, references and bibliographies (1950- 2009) using selected keywords. Critical appraisal: by two trained reviewers, (a third review, if discrepant). Inclusion criteria: primary studies of inflicted spinal injury in children <18 years, alive at presentation, with a high surety of diagnosis of abuse and sufficient detail to analyse.
Results: 19 studies of 25 children were included. Twelve children, (median age 5 months) had cervical injury. In seven cases the clinical signs of spinal injury were masked by respiratory symptoms and impaired levels of consciousness, six of these children had co-existent inflicted head trauma. Twelve children with thoraco-lumbar injury (median age 13.5 months), 10/12 had lesions at T11-L2, 9/12 were fracture dislocations. All children had focal signs: 10/12 had lumbar kyphosis or thoraco-lumbar swelling, two had focal neurology. One child had cervical, thoracic and sacral injuries.
Conclusions: Spinal injury is a potentially devastating inflicted injury in infants and young children. The published evidence-base is limited. However this case series leads us to recommend that any clinical or radiological indication of spinal injury warrant a MRI. In children undergoing brain MRI for abusive head trauma, consideration should be given to including a MRI of the spine. All skeletal surveys in children with suspected abuse should include lateral views of the cervical and thoraco-lumbar spine. Further prospective comparative studies would define the discriminating features of inflicted spinal injuries.
]]>In many neonatal services Advanced Neonatal Nurse Practitioners (ANNPs) have been introduced and have been shown to be effective in providing an alternative option for the provision of neonatal care at both "junior" and "middle-grade" medical staffing level. One of the key factors of the success of this role is the underpinning years spent in clinical practice, a foundation which provides a valuable and unique perspective for professional functioning at a senior level. In order for this potential to be fully exploited a more integrated approach to the development of career pathways for ANNPs is needed. However, there are challenges related to recruitment, and the relatively small numbers of ANNPs available means that they are unlikely to provide an immediate solution for many units.
The introduction of physicians’ assistant (PAs) would seem to be worthy of consideration as part of the neonatal workforce but it is likely that their functioning will be best integrated with that of ANNPs.
In the longer term, economic factors will be a powerful determinant of the relative proportion of consultants, trainee doctors, ANNPs and PAs in the workforce.
]]>Methods: We established a paediatric tuberculosis network (PTBNET-UK) and conducted a retrospective analysis of data from children investigated for active TB at six large UK paediatric centres. All centres had used TST and at least one of the commercially available IGRA (T-Spot.TB or Quantiferon-Gold in Tube) in the diagnostic work up for active TB. Data were available from 333 children aged 2months to 16 years. We measured the sensitivity of TST and IGRA in definite (culture confirmed) and probable TB in children, agreement between TST and either IGRA and their combined sensitivity.
Results: Of 333 children, 49 fulfilled the criteria of definite TB and 146 had probable TB. Within the definite cohort, TST had a sensitivity of 82%, Quantiferon-Gold in tube (QFT-IT) had a sensitivity of 78% and T-Spot.TB of 66%. Neither IGRA performed significantly better than a TST with a cut-off of 15 mm. Combining results of TST and IGRA increased the sensitivity to 96% for TST plus T-Spot.TB and 91% for TST plus QFG-IT in the definite TB cohort.
Conclusions: A negative IGRA does not exclude active TB disease, but a combination of TST and IGRA increases the sensitivity for identifying children with active TB.
]]>Design: Retrospective cohort study of children referred to a hospice.
Setting: Martin House Children’s and Young Person’s Hospice in Boston Spa, North Yorkshire, UK
Participants: All children who had been referred for care at Martin House Children’s Hospice since it opened in August 1987, until May 2008.
Main outcome measures: Demographic profiles and survival times overall and by diagnostic group classified by the Association of Children’s Palliative Care (ACT) Diagnostic Categories, calculated using the Kaplan Meier and log rank pair-wise methodology.
Results: Over a 20 year period 1554 children aged from birth to 19 years were referred to Martin House of whom 89.5% (mean age 7.45 years ) were accepted. The deprivation profile, referral source and distribution of diagnoses of these children have changed over time with recently increasing numbers of non-progressive disorders (ACT category 4). The ethnicity profile has changed with an increase in the numbers of South Asian children. Overall mean survival time was 5.6 years (95% confidence interval 5.1-6.1) but this differed by ACT category. Diagnostic category was significantly associated with differing survival patterns.
Conclusions: There are a disproportionate number of children from areas of higher deprivation being referred for palliative care services.
There has been a recent increase in the number of children from South Asian families being referred to palliative care services in Yorkshire.
Survival times for children and young people receiving care from a hospice can vary from hours and days to more than 20 years.
]]>Design: Clinical cohort.
Setting: KwaZulu-Natal, South Africa.
Patients: HIV-infected children aged ≤15 years on ART, June 2004-2008
Main outcome measures: Survival according to baseline characteristics including age, WHO clinical stage, haemoglobin, and CD4% was assessed in Kaplan-Meier analyses; hazard ratios for mortality estimated using Cox proportional hazards regression. Changes in laboratory parameters and weight-for-age z-scores (WAZ) after 6-12 months on treatment.
Results: 477 HIV-infected children initiated ART: at a median age of 74 months (range 4-180); median CD4 count (CD4%) 433 cells/mm3 (17%); and median HIV viral load log 4.2 copies/ml; 105 (22%) were on treatment for tuberculosis; and 317 (76.6%) were WHO Stage 3/4. There were significant increases after ART initiation in CD4% (17% vs. 22%; p<0.001), haemoglobin (9.9 vs. 11.7 g/L; p≤0.001), and albumin (30 vs. 36 g/L; p≤0.001). 32 (6.7%) children died over 732 child-years of follow-up (43.7 deaths per 1000 child-years; 95% CI, 32.7 - 58.2), 17 (53.1%) within 90 days of treatment initiation; median age of death 84 (IQR 10-181) months. Children with baseline haemoglobin ≤8g/L were more likely to die (adjusted HR 4.5; 95% CI 1.6 - 12.3), as were those aged <18 months compared to >60 months (adjusted HR 3.2; 95% CI 1.2 - 9.1).
Conclusions: Good clinical outcomes in HIV-infected children on ART are possible in a rural, decentralized service. Few young children are on ART, highlighting the urgent need to identify HIV-exposed infants.
]]>The gold standard assessment for sleep quality is polysomnography (PSG). However, actigraphy has gained popularity as an ambulatory monitor. We aimed to assess the value of actigraphy in measuring sleep fragmentation in children.
130 children aged 2-18y referred for assessment for sleep disordered breathing (SDB) were recruited. The arousal index (AI) scored from PSG was compared to the actigraphic fragmentation index (FI) and number of wake bouts/h.
The ability of actigraphic measures to correctly classify a child as having an AI>10 events/h rated as fair for the FI, and poor for wake bouts/h (area under the ROC curve, 0.73 and 0.67 respectively).
Actigraphy provides only a fair indication of the level of arousal from sleep in children. While the limitations of actigraphy prevent it from being a diagnostic tool for SDB, it still has a role in evaluating sleep/wake schedules in children.
To determine whether a structured program of parent anticipatory guidance ‘Toddlers Without Tears’, delivered in universal primary care, can prevent preschool child behaviour problems.
Cluster randomised controlled trial.
40 primary care nursing centres (clusters) in metropolitan Melbourne, Australia. 733 English-speaking mothers of 6-7 month old infants consecutively recruited from well-child appointments; 589 (80%) retained at age 3 years.
Parenting program from age 8-15 months, with two group sessions co-led by well-child providers and a parenting expert. The program addressed normal behaviour development, and offered strategies to increase desired and reduce unwanted behaviour. While 93% of intervention parents received at least some of the program, only 49% completed all components.
Usual primary care.
Maternal report of child externalising behaviour (Child Behaviour Checklist), parenting (Parent Behaviour Checklist) and maternal mental health (Depression Anxiety Stress Scales) when children were aged 3 years.
Behaviour scores in the intervention and control groups were similar (mean (sd)) 11.4 (7.1) versus 12.4 (7.6); adjusted mean difference -0.8, 95% CI: -2.2 to 0.6, p = 0.26). On the parenting subscale scores, intervention parents reported fewer unreasonable expectations of child development (37.3 (10.9) versus 39.9 (10.2), adjusted mean difference -3.1, 95% CI: -4.9 to -1.4, p = 0.001). Mean scores for harsh/abusive and nurturing parenting, and maternal mental health, were similar between the two groups.
A brief universal parenting program in primary care is insufficient to prevent development of preschool externalising problems. A new population trial targeting more intensive prevention to distressed parents with toddler behaviour problems is now under way, aiming to prevent both externalising and internalising problems before school entry.
Child protection guidelines highlight the importance of medical assessments for children suspected to have been abused. However, the contribution of the medical examination to the outcome for the child has not been evaluated.
To identify how medical assessments might contribute to a diagnosis of child abuse and to the immediate outcome for the child.
Review of all notes pertaining to medical assessments between January 2002 and March 2006.
There were 4549 child protection referrals during this period, of which 848 (19%) proceeded to a medical examination. 742 (88%) case notes were reviewed. Of the medical examinations, 383 (52%) were for alleged physical abuse, 267 (36%) for sexual abuse, 20 (3%) for neglect. 258 (67%) of physical abuse cases were considered to have diagnostic or supportive findings as compared to 61 (23%) of sexual abuse cases (chi-squared=146.31, P<0.001). In diagnostic or supportive examinations or where there were other potentially abusive concerns identified, 366 (73%) proceeded to further multi-agency investigation and 190 (41%) to case conference. 131 (69%) of these resulted in the registration of the child on the child protection register. Other health concerns were identified in 121 (31%) of physical and 168 (63%) of sexual abuse cases.
In this case series 465 (63%) out of 742 examinations showed signs diagnostic or supportive of alleged abuse or highlighted other abusive concerns. This endorses the view that medical examination is an important component in the assessment of child abuse as it provides information to support or refute an allegation and helps to identify health and welfare needs of vulnerable children.
Unfortunately this is not because the impasse in adult donation is unknown in paediatrics, but perhaps hints at the even greater efforts that significant changes in paediatric organ donor rates will require.
Can we, however, seize the opportunity afforded by the focus on donation that the Task Force will generate to improve the situation in regards to children? This review cannot address all aspects of donation but will highlight areas in which there may be opportunities to optimize provision of organs to severely ill and dying children.
]]>To investigate the heterogeneity of chronic fatigue syndrome (CFS/ME) in children and young people.
Regional specialist CFS/ME service.
Children and young people aged < 19 years old.
Exploratory factor analysis was performed on symptoms present at assessment in 333 children and young people with CFS/ME. Linear and logistic regression analysis of data from self completed assessment forms was used to explore the associations between the retained factors and sex, age, length of illness, depression, anxiety and markers of severity (fatigue, physical function, pain and school attendance).
Three phenotypes were identified using factor analysis: Musculoskeletal (Factor 1) had loadings on muscle and joint pain and hypersensitivity to touch, and was associated with worse fatigue (regression coefficient 0.47, 95% CI 0.25, 0.68, p <0.001), physical function (regression coefficient –0.52, 95% CI –0.83, -0.22, p= 0.001) and pain. . Factor 2 (Migraine) loaded on noise and light hypersensitivity, headaches, nausea, abdominal pain and dizziness and was most strongly associated with physical function and pain. Sore throat phenotype, (Factor 3) had loadings on sore throat and tender lymph nodes and was not associated with fatigue or pain. There was no evidence that phenotypes were associated with age, length of illness or symptoms of depression (regression coefficient for association of depression with Musculoskeletal pain -0.02, 95% CI -0.27, 0.23, p= 0.87). The Migraine phenotype was associated with anxiety (0.40, 95% CI 0.06, 0.74, p=0.02).
CFS/ME is heterogeneous in children with 3 phenotypes at presentation that are differentially associated with severity and are unlikely to be due to age or length of illness.
A total of 406 tests were performed (2.6 tests per week) over a two-year period at a teaching hospital (70 tests per 1000 live births yearly), with 233 tests (1.5 tests per week) performed over a three-year period at a local district hospital (39 tests per 1000 live births yearly). The highest proportion of all the tests was performed as routine investigation of prolonged neonatal jaundice (64% and 55% respectively). Other common indications were maternal thyroid disorders (5.4% vs 4.7) and suspected neonatal thyroid disorders (3% vs 9%). There was no confirmed diagnosis of infantile thyroid disease.
Available evidence and this audit suggest that too many thyroid function tests are unnecessarily performed in young infants.
]]>Studies reporting the developmental outcomes for very preterm children often focus on development at age 2. The aim of this study was to assess the stability of the rates of diagnosis of developmental disability from age 2 to age 8 years in a regional cohort of very preterm and extremely low birth weight children and compare these with term controls.
Very preterm (22 to 27 completed weeks of gestation, VPT) and extremely low birth weight (birthweight 500-999 g, ELBW) children and matched term controls, born in Victoria, Australia, in 1997, were enrolled at birth in a regional prospective longitudinal study. Outcomes were assessed at ages 2 and 8.
Of the 283 VPT/ELBW livebirths, 71% survived to age 8 and 94% were assessed. Of the 199 controls, 100% survived to age 8 and 86.9% were assessed. At age 2, the rates of nil, mild, moderate and severe disabilities in the VPT/ELBW children were 51.9%, 20.9%, 13.4% and 13.9% respectively, and at age 8 were 43.9%, 36.9%, 10.7% and 8.6%, respectively. Cohen's Kappa statistic revealed poor agreement between disability status at age 2 and 8 for VPT/ ELBW children (0.20, P<0.001), but a higher level of agreement (0.37, P<0.001) for the control children. This was primarily driven by differences in classification of cognitive disability between age 2 and 8.
Developmental outcomes at age 2 are only a moderate predictor of long-term outcome and are not a reliable endpoint for follow-up studies of very preterm and ELBW children.
To determine the incidence and demographic features of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in children in the UK and Republic of Ireland, and to characterise MRSA isolated from cases.
Prospective surveillance study.
Children aged <16 years hospitalized with bacteraemia due to MRSA.
Cases were ascertained by active surveillance involving paediatricians reporting to the British Paediatric Surveillance Unit and by routine laboratory surveillance. Patient characteristics were obtained using questionnaires sent to reporting paediatricians. MRSA isolates were characterised using molecular and phenotypic techniques including antimicrobial susceptibility testing.
265 episodes of MRSA bacteraemia were ascertained, involving 252 children. The overall incidence rate was 1.1 per 100,000 child population per year (95%CI 0.9-1.2): 61% of the children were aged <1 year (a rate of 9.7 cases per 100,000 population per year [95% CI 95% CI 8.2 – 11.4]) and 35% were <1 month. Clinical data were obtained from 115 cases. The clinical presentation varied, with fever present in only 16% of neonates compared with 72% of older children. A history of invasive procedure was common, with 32% having had intravascular lines and 13% having undergone surgery. Sixty-two per cent of patients for whom data were available were receiving high-dependency care (46% in SCBU/NICU and 16% in PICU). Of 93 MRSA isolates studied, 73% belonged to epidemic strains widely associated with nosocomial infection in the UK and Ireland.
MRSA bacteraemia in children was relatively uncommon and was predominantly seen in very young children, often those receiving neonatal or paediatric intensive care. Bacteraemia predominantly involved well documented epidemic strains of MRSA associated with nosocomial infection.
Systematic flexible bronchoscopy (FB) is advocated in the initial management of childhood pulmonary tuberculosis.
Our aim was to describe and to compare the systematic FB findings of 53 children (6.5 ± 4.4 years; 52.8% boys) with active pulmonary tuberculosis to their initial clinical and radiological (chest X-Ray, n=53; computerized tomography (CT), n=45) features in a 11-year retrospective study.
FB was normal in 51% of the cases. A severe tracheobronchial involvement (extrinsic compression >50% or obstructive endoluminal mass >25% of the lumen) was found in 10 patients. FB guided therapy in 13 cases (steroids n=12, bronchoscopic extraction of a granuloma n=1) and permitted to isolate Mycobacterium tuberculosis in 3 patients (5.7%). No useful information was obtained by FB in 73.5% of the cases. No correlation was found between FB findings and clinical features or X-Ray findings. Conversely, a strong correlation was found between severe bronchoscopic involvement and tracheobronchial luminal narrowing on CT. CT negative predictive value was 100% (95% confidence interval = 91-100%). Based upon CT results, FB could have been avoided in about 60% of our patients.
FB remains a very relevant tool in the diagnostic and therapeutic management of childhood pulmonary tuberculosis but resulted in treatment modification or microbiological proof in a minority of our patients. We propose that FB in children with pulmonary tuberculosis might be limited to those who show tracheobronchial luminal narrowing on an initial CT scan.
Psychosocial adversity is a risk factor for cardiovascular disease (CVD) in adults. We assessed associations of reactive hyperemia peripheral arterial tonometry (RH-PAT) – a measure of endothelial function predictive of CVD – with self-assessed psychological health among school children.
A total of 248 healthy school children (age 14.0±1.0 136 girls, 112 boys) underwent RH-PAT testing. They completed Beck Youth Inventories of Emotional and Social Impairment scales (BYI), used to screen for depression, anxiety, anger and disruptive behaviour.
No sex differences were observed for the RH-PAT score. Statistically significant differences were observed for the BYI scores; girls had higher scores for depression, anger and anxiety. Among girls there were statistically significant associations between lower RH-PAT scores and higher scores for anger (B coefficient = -0.100, p=0.040), depression (-0.108, p=0.009) and anxiety (-0.138, p=0.039), after adjustment for age. Among boys, disruptive behaviour was associated with higher RH-PAT scores (0.09, p=0.006).
Girls have higher levels of self assessed anger; depression and anxiety compared with boys, and these characteristics are associated with lower RH-PAT scores, indicating attenuated endothelial function. Among boys, disruptive behaviour was associated with better endothelial function. As psychological ill-health is associated with impaired endothelial function and CVD among adults, such processes may also be relevant to children. Psychosocial adversity in childhood might be a risk factor for subsequent CVD.
Glucose polymer based emergency feeds (EF), used during illness to prevent metabolic decompensation and encephalopathy in inherited metabolic disorders, should be produced accurately and safely.
In a randomised, prospective, controlled study, the aim was to investigate if when preparing age-appropriate EF, a pre-measured sachet of glucose polymer, compared with scoops and weighing (using digital scales), decreased carer errors.
Forty-seven carers (3 male, 44 female) of 52 inherited metabolic disorders patients were recruited. Setting and intervention: The carers made EF using all three techniques (weighing, scoops and pre-measured sachets) under supervision in controlled and home conditions. A 100 ml aliquot of each EF was analysed for carbohydrate concentration.
Under controlled preparation conditions, with 1 litre EF’s, the % median glucose polymer concentration closest to target amounts was 1) pre-measured sachets (105%); 2) weighing (107%); and 3) scoops (118%) (p<0.001). Similarly, under home conditions, the closest method was 1) pre-measured sachets (111%), 2) weighing (112%), and 3) scoops (118%) (p<0.05). Under home preparation conditions, with 200 ml EF’s, the pre-measured sachets were more likely to be within 20% of target weight than weighing (p<0.05) but there was no difference with scoops. Common errors observed were inaccurate water measurements (40% controlled and home conditions), incorrect scoop measurements and difficulty using digital scales.
Overall, using pre-measured sachets was more accurate in EF production. Pre-measured sachets are likely to decrease preparation error and, therefore, reduce the risk of feed intolerance, particularly osmotic diarrhoea, and consequential metabolic decompensation and encephalopathy.
Care thereafter should be delivered close to home by a multi-disciplinary team with a clear point of access during times of crisis. The aim of care is to keep the infant as well as possible with the best possible quality of life.
There are many forms of active respiratory management which can help maintain the well-being of infants with severe type 1 SMA. These include approaches to reduce the risk of infection and aspiration as well as appropriate techniques of airway and secretion clearance. The use of NIV may be helpful for some, usually less-severely affected infants, particularly to assist extubation. Long-term invasive ventilation is not recommended.
Active assessment of feeding and nutrition is vital and most babies can be managed well with nasogastric feeds. Gastrostomy may be considered for some infants but the benefits should be carefully weighed against the risks.
It is vital to share information and formulate an anticipatory care plan with the infant’s parents from the point of diagnosis.
]]>Renal tract imaging after urinary tract infection (UTI) has been widely recommended but clinical practice varies substantially among pediatricians.
To describe changes in knowledge and reported ordering practices of pediatricians in response to an evidence based summary about prevalence of abnormalities and test performance of renal tract imaging, in the setting of UTI in children.
354 pediatricians were randomly selected from a register of Australasian physicians and surveyed 14 months before, and concurrent with, a summary of a relevant systematic review. Respondents’ estimates were dichotomised and labelled as correct when within 5% of the evidence-based value. Frequency of correct responses was compared using McNemar’s test for paired proportions.
Response rate for the return of both surveys was 61% (215/354). Provision of the evidence summary significantly improved knowledge of the frequencies of associated renal tract abnormalities (vesicoureteric reflux and kidney damage), with an increase in correct responses of about 30% post summary (p<0.001 for both reflux and damage). Prior to the summary, clinicians underestimated the sensitivity of all imaging tests for the diagnosis of renal damage and reflux by about 30%, with an increase in correct responses of 30-50% for all tests after the summary (p < 0.001 for all). In contrast, reported imaging practices for all tests showed no significant change in practice after receipt of the evidence summary.
Provision of evidence based information on rates of abnormality and test sensitivity improved knowledge but did not result in any significant change in reported practice. Properties of diagnostic tests conventionally thought to modify use, sensitivity and likelihood of detecting abnormalities, did not influence test ordering practices.
Automated microscopy (AM) is increasingly used to screen samples for suspected urinary tract infection (UTI). A 98.8% negative predictive value has been reported in adult studies. The aim of our study was to validate this method in a paediatric population.
Urine samples were collected from children with known or suspected nephrourological disease attending nephrology and urology clinics over a 6 week time period. Samples were tested with dipstick, the UF100 flow cytometer (AM) and culture. A gold standard of a positive culture of 105 colony forming units per ml (cfu/ml) with a pathogenic organism was used and the sensitivity, specificity and likelihood ratios were calculated.
280 urine samples were collected from 263 patients (143 male, median age 10.2 years, range 0.1-19.75 years). 221(79%) were midstream or clean-catch samples. AM identified 42 of 186 samples as requiring culture and 17 of 19 samples which had a pure growth > 105 cfu/ml. Two patients were not identified by AM, one was treated for vulvovaginitis, one commenced prophylactic antibiotics prior to the culture result being obtained. The sensitivity, specificity, positive and negative likelihood ratios were 0.89, 0.85, 5.98 and 0.17 respectively. This compared to 0.95, 0.72, 3.34 and 0.29 respectively with urine dipstick.
AM performed comparably to urine dipstick in the diagnosis of UTI with improved specificity and likelihood ratios with a slight reduction in sensitivity. The data support the use of AM for screening urines for culture in children but different AM methods and algorithms require local evaluation.
Study design and methods: Sample survey. Safety guidelines on PS were split into 4 domains (‘Presedation Assessment’, ‘Monitoring during PS’, ‘Recovery after PS’ and ‘Facilities and Competences for Emergencies and Rescue’). Each domain was operationalized into subdomains and items. Items were presented within a questionnaire list as procedural points of attention on which respondents could give their personal adherence score. Percentages of full adherence were calculated. Non-adherence was defined as gradual deviation from full adherence. After factor and reliability analysis, observed scores were summed up to scales and results were transformed to a 0-10 report mark (RM). A RM of ≥ 9 is considered as a satisfactory level of adherence while an RM < 6 is considered as unacceptably low.
Results: Full adherence was rare. For most (sub)domains only a minority of respondents achieved a satisfactory level of adherence. Large numbers of respondents had scores below 6.
Conclusions: Potentially unsafe PS practices are common under Dutch general pediatricians, despite the availability of guidelines. The design of guidelines should include a goal-directed plan for implementation including training, initiatives for continuous quality assurance and improvement and repeated measurements of adherence to guidelines.
]]>Objective: To assess clinical management of disorders of sex development (DSD) subsequent to recommendations issued in the 2006 Consensus Statement.
Design: Online questionnaire and audit of DSD literature.
Subjects: Paediatric endocrinologists from 60 medical centres representing 23 European countries.
Main outcome measures: Clinic activity, multidisciplinary team composition, provision of psychological support services, incidence of feminising clitoroplasty, and use of diagnostic algorithms and newly proposed nomenclature.
Analyses: Data are reported in terms of percentages with respect to implementation of recommendations outlined in the Consensus Statement. X2 was used to analyse changes in nomenclature reported in the literature.
Results: Sixty centres reported on management of an average of 97.3 (range, 8 - 374) patients per year, totalling approximately 6000. Fifty-seven percent of centres regularly included the services of recommended paediatric subspecialists: paediatric endocrinologist, paediatric surgeon/urologist, plastic surgeon, paediatric psychiatrist/psychologist, gynaecologist, clinical geneticist, histopathologist, and neonatologist. Additionally, 95% of centres reported offering primary psychological support services and 65% of centres reported using a diagnostic algorithm. Fifty-two percent and 44.8% of centres reported having performed fewer or similar numbers, respectively, of clitoroplasties than in previous years. Finally, 100% of respondents reported using the newly proposed terminology. Likewise, an audit of the literature reflected a recent reduction in usage of the non-preferred historical terminology.
Conclusions: There is evidence that the majority of European DSD centres have implemented policies and procedures in accordance with the recommendations issued by the 2006 Consensus Group. These findings represent a change in practice with the collaborative goal of improved patient care.
]]>Aim: To compare rates of emergency readmission following discharge for common paediatric conditions from a range of hospital services.
Design: Retrospective analysis of hospital episode statistics and telephone survey of service provision.
Setting: 12 hospitals serving a metropolitan area in the North West of England.
Outcome measures: Emergency admissions to hospital within 7 days of discharge for breathing difficulty, feverish illness, and/or diarrhoea.
Results: Hospital episode statistics were obtained for all children under 15 years discharged following emergency admission for breathing difficulty; feverish illness; and/or diarrhoea during 2005/6 (n=20,354) or 2006/7 (n=23,018). The readmission rate for all hospitals in 2006/07 was 5.5%. The percentage of same day discharges was associated with readmission (Kendall’s taub correlation=0.61, p=0.007). Readmissions were also associated with the proportion of same day discharge for breathing difficulty (Kendall’s taub=0.83, p<0.001), feverish illness (Kendall’s taub=0.50, p=0.023) but not significantly so with diarrhoea (Kendall’s taub=0.37, p=0.098). The total number of admissions at a hospital in the year was associated with its readmission rate (Kendall’s taub=0.71, p=0.002). Most of the sample lived in the 40% most deprived areas in England but there was no significant association between readmission and living at the 10% most deprived areas.
Conclusions: Readmission rates are associated with higher numbers of annual admissions and higher proportions of children discharged on the day of admission. Variations between hospitals suggest that other factors can also affect readmission rates. Readmission rates calculated from hospital episodes statistics can contribute to assessments of the outcome of emergency services.
]]>Objective: To explore the effect of research ethics, governance and consent requirements, and recent reforms, on UK-wide follow-up of children with congenital heart defects (CHD).
Design: Prospective cohort study.
Setting: UK National Health Service.
Patients: 3,897 children with CHD requiring intervention, or resulting in death, before one year old (1993-95).
Main outcomes: Impact on study protocol, timeliness and findings of a multicentre study of survival and quality of life.
Results: The peer-reviewed study protocol was altered to accommodate ethics committee stipulations that researchers should not approach families directly with a request to participate and that the general practitioner’s (GP) permission be sought before the local clinician could do so. Individual consent was required to confirm vital status of participants and for future tracing of public death registrations. Local study registration took a median 40 weeks (IQR 25-57). 180 (24%) of 739 surviving children (5 centres) could not be contacted because their GP was untraceable (32), had changed (128) or considered contact inappropriate (20). Invitations could not be sent to 31% from the most deprived compared with 17% from the least deprived areas.
Conclusions: Decision-making about childhood interventions should be influenced by evidence about long-term outcomes, however current UK research regulations are an impediment to follow-up in multicentre studies. Stipulations preventing researchers contacting families directly with research invitations appear disproportionate to the risks, impede equitable access to research opportunities and introduce bias. The requirement for an individual’s consent to confirm whether they are alive and monitor survival precludes effective long-term follow-up.
]]>Introduction: Child abuse is a serious problem worldwide and can be difficult to detect. Although children who experience the consequences of abuse will probably be treated at an emergency department, detection rates of child abuse at emergency departments remain low.
Objective: To identify effective interventions applied at emergency departments that significantly increase the detection rate of confirmed cases of child abuse.
Design: This review was carried out according to the Cochrane Handbook. Two reviewers individually searched Pubmed, The Cochrane Library, EMBASE, Web of Science, and CINAHL for papers that met the inclusion criteria.
Results: Fifteen papers describing interventions were selected and reviewed; four of these were finally included and assessed for quality. In these studies the intervention consisted of a checklist of indicators of risk for child abuse. After implementation, the rate of detected cases of suspected child abuse increased by 180% (weighted mean in 3 studies). The number of confirmed cases of child abuse, reported in two out of four studies, showed no significant increase.
Conclusions: Interventions at emergency departments to increase the detection rate of cases of confirmed child abuse are scarce in the literature. Past study numbers and methodology have been inadequate to show conclusive evidence on effectiveness.
]]>Cardiac abnormalities are the commonest form of congenital malformation, with moderate and severe forms affecting about 0.6% of live births1. Although congenital heart disease remains an important cause of death in infancy, not all forms of major congenital heart disease will be evident at birth or in the early neonatal period 2,3. Reports indicate that approximately 25% of babies with severe forms of congenital heart disease are still discharged from hospital undiagnosed and in some cases the cardiac lesion is not recognised during life 2,4,. Early diagnosis of such babies would improve survival, as well as reducing the morbidity associated with circulatory collapse prior to recognition of a problem and administration of appropriate treatment.
]]>Objective: To determine the utility of a novel paediatric consultation assessment tool (PCAT)
Design: Developed to measure clinicians' communication behaviour with children and their parents/guardian, PCAT was designed according to consensus guidelines and refined at a number of stages. Volunteer clinicians provided videotaped real consultations. Assessors were trained to score communication skills using PCAT, a novel rating scale.
Setting: Eight UK paediatric units.
Participants: 19 paediatricians collected video recorded material; a second cohort of 17 clinicians rated the videos.
Main outcome measures: Itemised and aggregated scores were analysed (means and 95% confidence intervals) to determine measurement characteristics and relationship to patient, consultation, clinician and assessor attributes; generalisability coefficient of aggregate score; factor analysis of items; comparison of scores between groups of patients, consultations, clinicians and assessors.
Results: 188 complete consultations were analysed (median per doctor = 10). 3 videos marked by any trained assessor are needed to reliably (r>0.8) assess a doctor's triadic consultation skills using PCAT, 4 to assess communication with just children or parents. Performance maps to two factors – 'clinical skills' and 'communication behaviour'; clinicians score more highly on the former (mean ± 95% CI = 0.52 ± 0.075). There were significant differences in scores for the same skills applied to parent and child, especially between the ages of 2 and 10 years, and for information sharing rather than relationship building skills (2-tailed significance <0.001).
Conclusions: The Paediatric Consultation Assessment Tool appears to be reliable, valid and feasible for the assessment of triadic consultation skills by direct observation.
]]>Background: The UK Newborn Screening Program Centre recommend that a blood-spot TSH cut-off of 10mU/l is used to detect congenital hypothyroidism. The value used varies from 5-10mU/l and so we examined the implications of altering this threshold.
Methods: Our regional blood spot TSH cut-off is 6mU/l. Positive or suspected cases were defined as a TSH >6mU/l throughout the study period (1/4/2005 to 1/3/2007). All term infants (>35 weeks) whose first TSH was 6-20mU/l had a second TSH measured. The biochemical details of infants with a TSH between 6.1-10.0mU/l and then >6mU/l on second sampling were sent to Paediatric Endocrinologists to determine approaches to management.
Results: 148 of 65446 infants (0.23%) had a first blood spot TSH >6.0mU/l. 120 were term infants with 67 of these (0.1% of all infants tested) having a TSH between 6.1-10.0mU/l and 53 a TSH >10.0mU/l. Of the 67 term infants with a TSH between 6.1-10.0mU/l on initial testing, 4 continued to have a TSH >6mU/l. One with a TSH greater than 10 mU/l and 1 infant with a TSH <10mU/l on the second blood spot have been diagnosed with congenital hypothyroidism. The survey of endocrinologists highlighted significant differences in practice.
Conclusions: A reduced threshold of 6mU/l will increase the number of false positive ‘term’ infants by 126% but abnormalities of thyroid function requiring treatment will be detected. We suspect that the additional expense involved in setting a lower threshold is justified.
]]>Objective: To describe current practice during stabilisation of children presenting with critical illness to the district general hospital, preceding retrieval to intensive care.
Design: Observational study using prospectively collected transport data.
Setting: A centralised intensive care retrieval service in England and referring district general hospitals.
Patients: Emergency transports to intensive care during two-month epochs from 4 consecutive years (2005-2008).
Interventions: None.
Main outcome measures: Proportion of key airway, breathing, circulatory and neurological stabilisation procedures, such as endotracheal intubation, mechanical ventilation, vascular access and initiation of inotropic agents, performed by referring hospital staff prior to the arrival of the retrieval team.
Results: 706 emergency retrievals were examined over a 4-year period. The median age of transported children was 10 months (IQR 18 days to 43 months). District general hospital staff performed the majority of endotracheal intubations (93.7%, CI 91.3-95.5%), initiated mechanical ventilation in 76.9% of cases (CI 73.0-80.4%), inserted central venous catheters frequently (67.4%, CI 61.7-72.6%) and initiated inotropic agents in 43.7% (CI 36.6-51.1%). The retrieval team was more likely to perform interventions such as re-intubation for air-leak, repositioning of misplaced tracheal tubes and administration of osmotic agents for raised intracranial pressure. The performance of one or more interventions by the retrieval team was associated with severity of illness, rather than patient age, diagnostic group or team response time (OR 3.62, 95% CI 1.47-8.92).
Conclusions: District general hospital staff appropriately perform the majority of initial stabilisation procedures in critically ill children prior to retrieval. This practice has not changed significantly over the past four years, attesting to the crucial role played by district hospital staff in a centralised model of paediatric intensive care.
]]>Purpose: To describe the formation of a pediatric palliative care program providing care in hospital, at home or in hospice, ensuring continuity of care where the child and family desire.
Study design: Descriptive analysis was performed on referral source, diagnosis and reason for discharge for patients referred to the Palliative Care Team at the Children’s Hospital of Eastern Ontario in Ottawa, Ontario, Canada from 1999 to 2007.
Results: Three hundred forty-one children were referred. Twenty-four percent had a neurological condition, 21% had genetic disorders or congenital anomalies, 20% had cancer, 18% had metabolic or neurodegenerative conditions and 17% had another diagnosis. The major sources of referral included Pediatricians, Neonatologists, Oncologists and Intensivists. Fifty-five percent of the children have died. Fifty-eight percent of these died in hospital, 27% at home and 15% in hospice. Of the remaining 152 children, 7% were discharged from the program after clinical improvement, 4% moved to another geographic location or an adult center, 2% were not eligible, 1% declined services and 4% were lost to follow-up. The remaining 90 children continue to be followed. Of hospitalized patients who died, the annual referral rate increased from 20% to over 50%.
Implications: Referral to our palliative care team has increased over time in all diagnostic categories and from all sources. The majority of children died in hospital, however a significant number of families chose end-of-life care at home or in a hospice.
]]>Eleven newborn babies of normal weights sustained falls onto a hard surface in hospital. The one baby who fell from over a metre sustained clinical and radiological trauma and encephalopathy, with a skull fracture and cerebral contusion. No other baby demonstrated neurological signs despite the presence of parietal skull fractures in four of six who were X-rayed; only two babies had scalp swelling. The findings suggest that parietal fractures can result from very low level falls and scalp swelling is a poor marker for underlying fracture.
]]>Objectives: Adolescent obesity is linked to measurable, asymptomatic metabolic and cardiovascular precursors, but its associations with adolescents’ experienced health and morbidity is less clear. The objective of this paper was to determine (1) Prevalence of comorbidities experienced by overweight/obese adolescents; (2) Associations between timing of overweight/obesity and morbidity.
Methods: Data were drawn from the three waves (1997, 2000, 2005) of the Health of Young Victorians Study (HOYVS), an Australian school-based longitudinal study. The main outcome measures were blood pressure; self- and parent-proxy reported health status (PedsQL, global health); self-reported mental health (SDQ), psychological distress (K-10), physical symptoms, sleep, asthma, and dieting; parent-reported health care needs (CSHCN screener) and visits. Regression methods, adjusted for sociodemographic factors, were used to assess associations with (1) Body mass index (BMI) status (non-overweight, overweight or obese) and (2) Timing of overweight/obesity ( never , childhood only , adolescence only , ‘persistent ).
Results: Of the 923 adolescents (20.2% overweight, 6.1% obese), 63.5% were categorised as ‘never’ overweight/obese, 8.5% as ‘childhood only’, 7.3% as ‘adolescence only’, and 20.8% as ‘persistent’. Current BMI status was strongly associated with poorer physical and global health, hypertension and dieting behaviours. Associations were weaker for emotional morbidity, and there was no clear evidence of association with any other variable. Other than dieting, adolescent morbidity was not associated with resolved childhood overweight/obesity.
Conclusions: Despite poorer overall health, overweight/obese adolescents were not more likely to report specific problems that might prompt health intervention. Morbidity was mainly associated with concurrent, rather than earlier, overweight/obesity.
]]>Objective: To investigate how infants and children with suspected viral encephalitis are currently managed in a UK tertiary children’s hospital.
Methods: Case note review of all infants and children who received intravenous aciclovir for suspected encephalitis over a six month period. Suspected viral encephalitis was defined as a child with fever or history of febrile illness and a reduced level of consciousness, irritability or a change in personality or behaviour or focal neurological signs.
Results: Fifty-one children were identified. Two had proven herpes simplex encephalitis (HSV) and two had clinically diagnosed viral encephalitis with no cause identified. Forty children had cerebrospinal fluid analysis, but basic results were incomplete in 13 cases. Cerebrospinal fluid was sent for the detection of HSV DNA by polymerase chain reaction in 27 cases. The initial dose of aciclovir was incorrect in 38 cases. The median (range) length of intravenous aciclovir treatment was 4 (1- 21) days. Six children were given a full course of aciclovir (10 or more days). For 14 children, there appeared to be no real indication for starting aciclovir. Case note documentation was generally inadequate.
Conclusions: The management of children with suspected viral encephalitis appears haphazard in many cases. Guidelines for the management of children with suspected viral encephalitis are needed.
]]>Sudden unexplained collapse within the first 12 hours of life is a rare but recognised event. Over a 2-year period 5 infants, previously assessed as healthy, were found collapsed in our maternity unit in the care of their primiparous mothers. Two were found prone on their mother's chest, two were in their mother's bed. The outcomes were poor with four neonatal deaths and one death aged 18 months. The rate of sudden unexplained neonatal collapse was 0.4 per 1000 live births. No cause for collapse was identified despite extensive investigations, which included post mortem in all the neonatal deaths. One infant, however, showed widespread antenatal brain damage at post mortem. We postulate that some infants with an underlying vulnerability may maladapt to extrauterine life following an hypoxic stressor possibly caused by positional airway obstruction.
]]>Objective: Nationwide prevalence studies on malnutrition in hospitalized children have not been done. This study aimed to investigate the prevalence of malnutrition of all newly admitted children in the Netherlands during three consecutive days.
Design: Prospective observational study.
Setting: Pediatric wards of 44 hospitals (7 academic and 37 general).
Participants: A total of 424 children aged ≥ 30 days and hospitalized for ≥ one day were included, 63% male, 86% non-Caucasian. Median age was 3.5 years and median hospital stay was 2 days.
Main outcome measures: SD-scores < -2 for weight for height and height for age were considered to indicate acute and chronic malnutrition respectively.
Results: Overall 19% of the children had acute and/or chronic malnutrition at admission (academic 22% and general 17%). The proportion of children with chronic malnutrition was significantly higher in academic hospitals (14% vs. 6%). Logistic regression analysis allowing for age, underlying disease, ethnicity, surgery and type of centre showed a significant relationship between the presence of malnutrition at admission and underlying disease (OR= 2.2). For chronic malnutrition both underlying disease and non-Caucasian ethnicity were significantly related to a higher prevalence (OR 3.7 and OR 2.8 respectively).
Multiple regression analysis showed that children with acute malnutrition stayed on average 45% longer (95% CI: 7-95%) in the hospital than children without such malnutrition.
Conclusions: This unique nationwide study shows that 19% of children admitted to Dutch hospitals are malnourished at admission. This high prevalence underlines the need for routine screening and treatment of malnutrition in hospitalized children.
]]>Objective: To study the effectiveness of a minimal intervention strategy to improve the adherence to paediatric asthma guidelines.
Design and setting: A group of pharmacists was encouraged to discuss essential elements of asthma care with the general practitioners they normally worked with. The adherence to guidelines was evaluated by studying prescriptions for children with asthma. We compared the treatments of children who were registered at pharmacies who participated in the study (intervention group) with a control group of children, registered at other, non-participating pharmacies (reference group) and with results of an earlier study.
Main outcome measures: The numbers of children who had no short-acting betamimetics, no inhaled corticosteroids while on long-acting betamimetics, and who had more than one type of inhaler.
Results: The number of children who had no short-acting betamimetics was significantly lower in the intervention group (176/1447 vs. 534/3527; p < 0.01); fewer children had no ICS although on long-acting betamimetics (6/219 vs. 41/477; p = 0.03). The number of children who had more than one type of inhaler was equal in both groups (5.1%), but this was significantly lower than compared to the earlier study (119/2311 vs. 239/3217; p <0.01).
Conclusions: The assistance of pharmacists in adherence to paediatric asthma guidelines is beneficial. Pharmacists should be involved actively in the care of children with asthma.
]]>Objective: To assess the safety aspects of carers enteral feeding (EF) technique when home tube feeding (HETF) children with inherited metabolic disorders (IMD).
Methods: 40 patients (median age 5.1yrs: range 0.3-13.6yrs) with IMD requiring pump tube feeding were recruited. 12 had GSD; 11 organic acidaemias; 8 fatty acid oxidation disorders; 4 urea cycle disorders and 5 had other conditions. 50% were fed by gastrostomy and 50% nasogastric tube. A questionnaire and practical assessment of feeding process was completed with carers by a dietitian and nurse in the child’s home. Areas investigated included: carer hygiene; feed preparation; tube care; tube changing; use of feeding pumps and equipment; and storage of EF equipment.
Results: The main issues identified were poor hygiene practices (78% unclean work surfaces; 25% no hand washing); inaccurate ingredient measuring (40%); irregular checking of tube position (40%); inadequate tube flushing (50%); poor knowledge of how to clear tube blockages (80%); incorrect priming of pump sets (50%); incorrect position of child for night feeding (63%); untrained secondary carers (43%); and poor knowledge of pump alarms, battery life and charging time. Children commonly slept in parent’s room as a safety precaution (58%).
Conclusions: Long term follow up of children with IMD on HETF suggests that regular updates on knowledge and technique for carers may be necessary to reduce risk.
]]>Objective: To evaluate the benefits and harms of universal newborn hearing screening programmes in the detection of hearing impairment.
Methods: In the absence of randomised trials evaluating whole screening programmes, we divided the objective into three systematic reviews of non-randomised controlled studies of screening versus no screening, therapeutic effect of early versus later treatment, and diagnostic accuracy of screening tests.
We searched eleven bibliographic databases, contacted authors, and checked references of included trials and reviews, and we sent enquiries to hospitals and manufacturers.
Results: Seventeen studies (screening: 2, treatment: 6, and diagnostic: 9) were included.
All studies apart from one treatment study showed major quality deficits. The studies comparing screening versus no screening showed an improvement of speech development of children in the screening group compared to the group without screening. Early treatment of hearing impairment was associated with better language development in comparison to children with later treatment. Eight diagnostic studies comparing otoacoustic emissions with auditory brainstem response show sensitivities (and specificities) between 50% (49.1%) and 100% (97.2%). Only one study evaluated these tests in a two-stage screening procedure and reported a sensitivity of. 91.7% (95% CI, 74.2% to 97.7%) and a specificity of 98.5% (95% CI, 98.3% to 98.7%).
Conclusions: There is a lack of high-quality evidence regarding all elements of newborn hearing screening. Early identification and early treatment of children with hearing impairments may be associated with advantages in the language development. Other patient-relevant parameters, such as social aspects, quality of life, and educational development, have not been adequately investigated.
]]>Objective: To compare the prevalence and intensity of victimization from bullying, and the characteristics of the victims of bullying, comparing adolescents with and without chronic conditions.
Design: School survey.
Setting: Post-mandatory schools.
Participants: A total of 7005 students (48% females) aged 16-20 years, distributed into adolescents with chronic conditions (728, 50% females) and controls (6277, 48% females). Chronic condition was defined as having a chronic disease and/or a physical disability.
Outcome measures: Prevalence of bullying; intensity of bullying; and socio-demographic, bio-psychosocial, familial, school, and violence context characteristics of the victims of bullying.
Results: The prevalence of bullying in our sample was 13.85%. Adolescents with chronic conditions were more likely to be victims of bullying (Adjusted Odds Ratio [AOR] 1.53), and to be victims of two or three forms of bullying (AOR 1.92). Victims of bullying with chronic conditions were more likely than non-victims to be depressed (Relative Risk Ratio [RRR] 1.57), to have more physical symptoms (RRR 1.61), to have a poorer relationship with their parents (RRR 1.33), to have a poorer school climate (RRR 1.60), and to have been victims of sexual abuse (RRR 1.79) or other forms of violence (RRR 1.80). Although these characteristics apply to victims in general, in most cases they are less pronounced among victims without chronic conditions.
Conclusions: Chronic conditions seem to be a risk factor for victimization from bullying. Therefore, as adolescents with chronic conditions are increasingly mainstreamed, schools should be encouraged to undertake preventive measures to avoid victimization of such adolescents.
]]>Background: HBoV, a recently discovered parvovirus, is present in a substantial proportion of respiratory tract diseases of suspected infectious origin. The relative importance of HBoV in viral respiratory tract illnesses is still not well known.
Objective: This study looked for HBoV in pediatric patients and asymptomatic children, to determine the prevalence of HBoV compared with common respiratory viruses and to describe the clinical course associated with HBoV infections in children.
Methods: A prospective study was conducted on the clinical characteristics of children less than 14 years old admitted for respiratory infection between September 2004 and December 2006 at the Pediatrics Department of the Severo Ochoa Hospital in Madrid (Spain). The incidence of HBoV and other fifteen respiratory viruses was tested in nasopharyngeal aspirates of these patients and in asymptomatic children.
Results: At least one respiratory virus was detected in 587 (64.4%) of the 908 studied patients. HBoV was found in 153 (16.8%) samples and was the most common virus after RSV. Infections with HBoV were found year-round, although most occurred in the winter months. 50% of patients with HBoV infection were aged "T 14.3 months. The more common diagnoses were recurrent wheezing (51%) and bronchiolitis (30.5%). Fifty-five percent of patients required oxygen therapy and 70% presented high fever. Other manifestations of HBoV-associated disease outside the respiratory tract could be observed such as petechial skin rash, thrombopenia, and clinical sepsis. In 99 (65%) of the HBoV positive children, coinfections with other respiratory viruses were present. No significant differences were found between single and dual or multiple infections. HBoV was detected in 5% of asymptomatic children.
Conclusions: HBoV was the second most prevalent virus after RSV in children hospitalized for respiratory infection, and was associated with recurrent wheezing and bronchiolitis as well as extrapulmonary manifestations. Co-infections were frequent and clinically similar to single infections.
]]>Clinical medicine is a holistic attempt to provide the best care for patients. What are the relevance of Evidence-based Child Health (EBCH) and of guidelines in informing clinical practice? In this review examples drawn from paediatric endocrinology practice, and an outline of the (sometimes contrasting) methodologies of the National Institute for Health and Clinical Effectiveness (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) are used to inform what needs to be a continuing debate.
There is regular contact and cooperation between guideline-producing bodies both nationally and internationally but there are still many impediments to avoiding duplication.
Policies and practice do not inevitably flow from research evidence and guidelines. There is an urgent need to produce evidence of the impact of guidelines, not only on changing clinical practice where appropriate but on improving child health.
]]>The incidence of anaphylaxis is rising. Confusion can still occur about the diagnosis, treatment, investigation and follow up of children after an anaphylactic reaction. Recently, the Resuscitation Council (UK) published revised consensus guidelines based on the available limited evidence on the recognition and treatment of anaphylaxis reactions ( http://www.resus.org.uk/pages/reaction.pdf ). Significant changes have been made to simplify the emergency management for first responders especially in regards to the recognition of anaphylaxis and the immediate use of intramuscular adrenaline which remains the mainstay of treatment.
]]>Limited clinical evidence plus much biochemical analysis suggests that carbonated drinks, such as cola (whether "flat" or otherwise) should not be recommended for oral rehydration in children with acute viral gastroenteritis. Parents and carers should be discouraged from using "flat" fizzy drinks for this purpose.
]]>Clinical bottom line
1. Aggression and/or hostility can be associated with ADHD (Grade B).
2. Present evidence does not suggest aggression/hostility with atomoxetine compared with methylphenidate or placebo, although it can not be completed ruled out (Grade A).
]]>Atopic eczema is a common condition, affecting as many as 15-20% of school age children, with 1-2% of children with the condition being severely affected. It commonly begins in early childhood, when it can be particularly severe. Whilst most children with atopic eczema are treated in primary care, backed up by dermatologists, paediatricians need a degree of competence in managing the condition and should know when to refer for a specialist dermatological opinion.
]]>Objective: The New Ballard Score (NBS) has been evaluated only until 96 hours of age. We studied the validity and reliability of NBS for gestational age (GA) assessment on days 1, 5 and 7 of postnatal age (PNA). Design and setting: This prospective, analytical study was conducted in a level III neonatal unit.
Patients: Neonates born at a GA of 29-35 wks (based on accurate LMP) were eligible. Encephalopathy, malformations, and unstable vitals were exclusion criteria. LMP-based GA was the gold standard. NBS was assessed within 24 hrs of birth by one rater and two raters assessed NBS on days 5 and day 7. All were blinded to LMP and each other's ratings. Recruitment continued until >100 subjects were enrolled with >25 in each LMP-based GA group: 29-30 wks, 31-32 wks, 33-34 wks and 35 wks.
Main outcome: Correlation of GA assessed on day 7 with gold standard.
Results: 129 neonates were studied. NBS-based GA on days 5 or 7 did not differ from the gold standard GA by more than 2 weeks in any subject. On day 7, NBS over-estimated GA in 26.7% and under-estimated in 19.8% cases; all discrepancies being <2 wks. Compared to gold standard GA, the intra-class correlation (ICC) of the NBS-based GA of the day 1 rater, day 5 rater and day 7 rater were 0.94, 0.94 and 0.92 respectively. ICC for inter-rater reliability on day 5 and day 7 were 0.97 and 0.96 respectively. Compared to the day 1 rater's raw NBS, the ICC of day 5 and day 7 raters' total scores were 0.98 and 0.97; of day 5 and day 7 raters' neurological scores were 0.98 and 0.97; and of day 5 and day 7 raters' physical scores were 0.92 and 0.88. All ICC's mentioned above had p values <0.001.
Conclusions: NBS is a valid and reliable clinical tool for GA assessment until day 7. It slightly over-estimates the GA with increasing postnatal age. Neurological signs are more reliable than physical ones.
]]>There is increasing evidence that preterm birth is a risk factor for the development of adiposity associated disease though the pathophysiological basis in unclear. <BR>We have previously shown that preterm infants have increased internal abdominal (visceral) adiposity by term. In adults increased internal adiposity is associated with elevated intrahepatocellular lipid (IHCL). <BR>We measured IHCL using 1H NMR spectroscopy in 26 infants (8 healthy preterm-at-term and 18 term-born) and compared values with a reference group of 32 adults.<BR> There was no significant difference between adult and term-born IHCL values. In preterm-at-term infants IHCL was significantly elevated when compared with term-born infants and with adults (IHCL CH2/water median (interquartile range): preterm 1.69 (1.04, 3.529), term 0.21 (0, 0.535) and adult 0.55 (0.08, 1.57).
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