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.
]]>This study hypothesized a continual decline in current smoking prevalence between four calendar years (1995, 1998, 2002/03, and 2007) and also no significant increase in second-hand smoke (SHS) exposure at home post the workplace smoking ban of March 2004 (2007 survey vs. 2002/03 survey) among the Irish school children.
We used a modified ISAAC (International Study of Asthma and Allergies in Childhood) protocol. Children aged 13-14 years were studied: 2,670 (in 1995), 2,273 (in 1998), 2,892 (in 2002-2003), and 2,805 (in 2007). ISAAC is a cross-sectional self-administered questionnaire survey. Randomly selected representative post-primary schools (the sampling frame) were recruited. Smoking history was self-reported. Beta-coefficients (slopes) of smoking rates across the four survey waves were computed. Odds ratios for smoking rates were also computed using the baseline year (1995), as the reference period. All analyses were performed using SAS software (9.1v).
We saw significant reductions in active smoking rates between 1995 and 2007 (from 19.9 to 10.6%, respectively) resulting in 3.3% survey-to-survey reductions, with a significantly greater survey-to-survey decline among girls vis-à-vis boys (3.8% vs. 2.7%, respectively). 45% of children are exposed to SHS at home in 2007. There was a statistically non-significant 2% overall decline in SHS exposure levels at home in 2007 relative to 2002/03 survey years, but more pronounced in girls.
The continual reduction in active smoking prevalence in children is a welcome sign. No significant increase in SHS exposure at home post the nationwide workplace smoking ban in March 2004 also indirectly suggests that the workplace smoking ban did not increase smoking inside homes.
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.
To investigate the prevalence of 14 viruses in infants with bronchiolitis and to study demographic and clinical differences in those with respiratory syncytial virus (RSV), human bocavirus (hBoV), and rhinovirus (RV) infection.
182 infants less than 12 months old hospitalized for bronchiolitis were enrolled. Infants underwent nasal washing for the detection of RSV, influenza virus A and B, human coronavirus OC43, 229E, NL-63, HUK1, adenovirus, RV, parainfluenza 1-3, human metapneumovirus and hBoV. Demographic, clinical and laboratory data were obtained from parents with a questionnaire and from patient’s medical files.
Age, breast-feeding history, family smoking habits, family history of asthma and atopy, blood eosinophil count, chest radiological findings, clinical severity score and number of days of hospitalization.
A virus was detected in 57.2% of the 182 infants. The most frequently detected viruses were RSV (41.2%), hBoV (12.2%) and RV (8.8%). Infants with dual infections (RSV and hBoV) had a higher clinical severity score and more days of hospitalization than infants with RSV, RV and hBoV bronchiolitis (mean+SD, 4.7 + 2.4 vs 4.3+2.4 vs 3.0+2.0 vs 2.9+1.7, p<0.05; and 6 + 3.2 vs 5.3+2.4 vs 4.0+1.6 vs 3.9+1.1 days; p<0.05) . Infants with RV infection had higher blood eosinophil counts than infants with bronchiolitis from RSVand hBoV (307+436 vs 138+168 vs 89+19 (n/mm3); p<0.05).
Although the major pathogen responsible for bronchiolitis remains RSV, the infection can be caused also by RV and hBoV. Demographic characteristics and clinical severity of the disease may depend on the number of viruses or on the specific virus detected.
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.
]]>Background: Small for gestational age (SGA) infants have an increased risk of later cardiovascular disease. At birth, high sensitivity-C reactive protein (hs-CRP), a prognostic marker of cardiovascular disease, is significantly higher in SGA than in appropriate for gestational age (AGA) infants.
Aim: To measure aortic and carotid intima media thickness (aIMT - cIMT) and blood pressure (BP) in children (aged 3-5 years) who were born SGA and AGA, and to assess the correlation between hs-CRP concentrations obtained at birth and these hemodynamic variables.
Methods: Umbilical cord hs-CRP concentrations were obtained in 38 neonates. In the same subjects aged 3-5 years, aIMT and cIMT were measured by high-resolution ultrasound scan, in the dorsal arterial wall. Anthropometical variables and BPs were obtained for each child.
Results: Maximum (median 0.700 mm, range 0.500-1.080 vs 0.650 mm, 0.400-0.860; p = 0.32) aIMTs were similar between children who were born SGA (n 17) and AGA (n 21), respectively. Concentrations of hs-CRP were not correlated with IMTs. In children who were born SGA, systolic BP was significantly correlated with umbilical cord hs-CRP concentrations (r = 0.60; p = 0.009).
Conclusions: Children who were born SGA have a higher, although not significant, aortic thickening than those who were born AGA. Umbilical cord hs-CRP concentrations don’t seem to be involved in this process.
Instead, hs-CRP concentrations were significantly related to systolic BP values in children who were born SGA suggesting that hs-CRP at birth could be associated to the sympathetic system hyperactivity and to the stress-response during childhood.
]]>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.
]]>Fine needle aspiration biopsy (FNAB) offers a simple outpatient technique for specimen collection in paediatric tuberculosis (TB) suspects with peripheral lymphadenopathy. Culture facilities are usually centralized; to perform FNAB with mycobacterial culture on an outpatient basis requires use of a sterile transport medium to facilitate bedside inoculation, maintain organism viability and reduce contamination risk en route to the laboratory.
We compared the mycobacterial yield and time to positive culture following bedside inoculation into standard MGIT tubes versus initial inoculation into an inexpensive "in house" liquid growth medium used for transport to the laboratory followed by immediate and delayed MGIT inoculation (laboratory inoculation).
Over the period of one year 150 FNAB’s were performed; 57 (38%) cultured M. tuberculosis complex. There was one case each of NTM and M bovis BCG, with the remaining 55 being M tuberculosis. Results were concordant in 142 (94.7%) bedside and laboratory inoculation pairs. There was no significant difference in time to positive culture between the bedside and laboratory inoculation tubes (16.2 days S.D. 0.87 versus 17.1 days S.D. 0.85). There were 31 pairs with matched immediate and delayed laboratory inoculation culture results, of which 29 were concordant (93.6 %). The 2 discordant pairs showed no growth in the delayed culture; both had required repeated decontamination due to bacterial contamination introduced in the laboratory.
The use of inexpensive "in house" liquid growth medium transport bottles, combined with practical tuition in FNAB, will improve cost effective diagnosis of TB at primary health care level.
]]>Determining the prevalence of primary ciliary dyskinesia (PCD) in different populations has proved difficult with estimates varying between 1 in 4,000 to 1 in 40,000. The aim of this study was to determine the incidence of PCD in a well defined highly consanguineous Asian population in the UK.
Over a fifteen year period all patients suspected of PCD in the Asian population of Bradford, UK, were tested by measurement of ciliary beat pattern, frequency and electron microscopy.
The prevalence of primary ciliary dyskinesia in the population studied was 1 in 2265. 52% of the patient’s parents were first cousins. All patients had a history of chronic cough and nasal symptoms from the first year of life. 73% had a history of neonatal respiratory distress.
Clinical suspicion of PCD should be high in populations where it is possible that high levels of consanguinity may result in an increase in those with PCD. In these communities the combination of chronic cough and nasal symptoms should prompt early diagnostic testing.
]]>Objectives: The aim of this preliminary study was to evaluate the efficacy of a 40° supine body-position on infant regurgitation, reflux-associated symptoms and acid reflux.
Intervention: Thirty of fifty-two consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding were evaluated in the "Multicare AR-Bed®" (Peos, Belgium). The Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) and an oesophageal pH monitoring were performed at inclusion and after one week.
Results: Eight out of 30 (27%) infants did not tolerate the 40° positioning, and had to be taken out of the study within the first 2 days. However, in 22/30 (73%) infants the I-GERQ-R and acid reflux decreased significantly with the "Multicare AR-Bed®". The mean duration of use of the "Multicare AR-Bed®" was 3.2 months.
Conclusion: The results of this pilot-study suggest that a specially made bed that nurses the infant at 40 degree supine body position reduces regurgitation, acid reflux and reflux-associated symptoms. However, the intervention was open, the sample size small and the withdrawal rate was substantial. Larger trials are needed.
]]>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.
]]>Setting: Previously, childhood acute lymphoblastic leukaemia (ALL) treatment results in Indonesia differed significantly between poor and prosperous patients. There was striking disparity in the way treatment was provided to poor, as opposed to prosperous, patients. Poor patients received less individualized attention from oncologists. Access to parental education and donated chemotherapy was lacking.
Intervention: Starting from January 2004, a structured parental education program for all parents, poor and prosperous, was introduced to improve access to parental education and donated chemotherapy. The program contained video-presentation in hospital, information-booklet, DVD, audiocassette, informed-consent, statement-of-understanding for donated chemotherapy, and complaints-procedure.
Objective: Our study compared childhood ALL treatment outcome before and after introduction of parental education program.
Design: We reviewed medical records of 283 children with ALL diagnosed during two periods: before (1997-2002; n=164) and after (2004-2006; n=119) introduction of education program. Data on treatment results and parental socioeconomic status were collected.
Results: After introduction of education program, treatment refusal decreased (14%-2%) and event-free survival increased (13%-29%) significantly in poor patients. Treatment abandonment increased (0%-13%) significantly in prosperous patients. In overall population toxic-death (23%-36%) increased significantly and no significant difference in event-free survival was found.
Conclusions: After program introduction, poor families received structured information and donated chemotherapy for the first time. Their treatment refusal decreased and event-free survival increased significantly. To improve survival significantly in overall population, toxic-death and treatment abandonment must diminish. Improving knowledge, skills and communication of doctors is required to manage treatment-toxicity and prevent abandonment. Treatment intensity should be matched with possibilities of supportive-care.
]]>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.
]]>Child protection professionals working in diverse societies are regularly faced with value conflicts. Recognising these, and resolving them in the best interests of children, is a task that requires child protection specialists to make complex judgements and decisions.
In this paper we apply the philosophical concepts of absolutism and relativism to child abuse, and explore how this approach has practical relevance to solving ethical dilemmas in child protection. We conclude that children’s interests are best served by erring towards an absolutist approach to the diagnosis and recognition of maltreatment and towards a relativistic approach in determining how services respond to a harmful incident or situation.
Absolutism and relativism are not alternatives, but part of a continuous process of recognising and negotiating ever-changing community, national, and global norms. At the service level the dichotomy transpires into the need to be culturally competent in handling the conflicting needs, rights and values of children, families, communities, and professionals, whilst retaining the skill of child advocacy.
]]>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.
]]>It is unacceptable that many drugs prescribed to children have not been proven safe and effective for them. Yet some of the necessary drug studies do not provide the participating children direct benefit. From an ethical point of view, involving children in such studies is complex: in view of the absence of direct advantages, the possible disadvantages must be strictly limited. A European ethical framework that provides guidance regarding these limits and that can and will be consistently applied by all European countries is essential for facilitating a harmonised approach to paediatric clinical trials across Europe.
Currently, limits for paediatric research without direct benefit are defined in two European documents. According to the Council of Europe’s European Convention on Human Rights and Biomedicine such research may only be approved if it entails ‘minimal risk and minimal burden’. In contrast, in a more recent document aimed to provide guidance on the application of the Clinical Trials Directive with regard to trials with minors, the EU recommends to allow ‘a minor increase over minimal risk’ in case of benefit for the group of children with the same disease.
On the basis of an example, this paper shows that the inconsistency between these two documents may either prohibit important research or expose participants to unjustified risks of harm. We recommend that both documents use the same terminology and that the EU Recommendations emphasise that exposing children to higher levels of risk and burden that cannot be compensated by direct benefits, must always be regarded as a last resort.
]]>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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