The UK is in the midst of a pertussis outbreak with the highest morbidity and mortality being in young unimmunised infants. Over the last 10–15 years high vaccine coverage, the accelerated infant schedule and the inclusion of pertussis in the preschool booster have contributed to a major overall decline in incidence. However pertussis remains the most common cause of hospitalisation and death from a disease potentially preventable through the current UK immunisation programme, and continues to display 3–4 yearly peaks in activity affecting infants, adolescents and adults. Gayatri Amirthalingam reviews the evidence base for and potential strategies to control pertussis in infants. The challenge is to improve individual immunity and thereby reduce infection and transmission. The potential strategies include the introduction of an adolescent pertussis booster to compensate for waning immunity as has been introduced in USA, Australia and France, immunisation of close...]]>
There has been a fourfold increase in young patients on Home Parenteral Nutrition (PN) since 1993 with a mean of 13.7 children per million.
The circumstances that led to the development of this guidance came about from the GMC's handling of a fitness to practice hearing relating to Professor Southall in 2010. As Mr Niall Dickson, Chief Executive of the GMC, wrote in May 2010 ...there is no doubt that this case has caused considerable concern within the paediatric community. This is vital and difficult work and nothing should deter professionals from undertaking it, to protect vulnerable children across the UK. Accordingly, we will convene an expert group to review the guidance for paediatricians involved in child protection to ensure we can provide clarity and reassurance about...]]>
To explore the knowledge and reported thermal injury prevention practices among parents of children aged 0–4 years in disadvantaged areas.
Parents of pre-school children in Children's Centres in four study areas in England (Nottingham, Newcastle, Norwich and Bristol) were interviewed using a structured schedule. Interviews covered smoke alarms, bedtime routines, fire escape plans, other thermal prevention practices and parental knowledge of first aid.
Of the 200 respondents, most reported ownership of at least one smoke alarm (n=191, 96%), of which 95% were working. Half reported a fire prevention bedtime routine (n=105, 53%) or fire escape plan (n=81, 42%). Most parents had matches or lighters in the home (n=159, 80%), some stored where children under 5 years of age could reach them (n=30, 19%). There was a high prevalence of irons (n=188, 94%) and hair straighteners (n=140, 70%). A third of both devices were used daily. Just 17 (12%) parents reported leaving hair straighteners, when hot but not in use, in a heatproof bag. Knowledge of correct initial first aid for a small burn was good (n=165, 83%), but parents reported other potentially harmful actions, for example, applying ointment (n=44, 22%).
Most families report at least one working smoke alarm, but many do not have fire escape plans or fire prevention bedtime routines. A number of reported practices could compromise child safety, such as storage of matches or lighters and leaving hair straighteners to cool unprotected. Reappraisal of health promotion messages, in light of new household consumables, is necessary.
To present the UK experience in genetic diagnoses of surfactant protein dysfunction disorders and develop a referral algorithm for neonates and children with persistent respiratory problems.
Between 2006 and 2011, 427 cases were referred for surfactant mutation analyses to the North East Thames Regional Molecular Genetics Laboratory at Great Ormond Street Hospital, London. The results were reviewed and referring physicians of mutation positive cases contacted to complete a questionnaire providing clinical, radiological, histological and outcome information.
25 new cases were found to have genetic mutations for surfactant dysfunction disorders (7.5%), with six resulting in surfactant protein B dysfunction, seven surfactant protein C dysfunction and 12 ATP-binding cassette subfamily A member 3 (ABCA3) dysfunction. The referrals were from 15 different paediatric centres. In addition, three affected surfactant protein B (SFTPB) cases were prenatal diagnoses, following the birth of previously affected children. The majority of the confirmed cases (23 of 25) were born after 37 weeks gestation. All children with SFTPB dysfunction and the majority of ABCA3 patients presented with respiratory distress at birth. All SFTPB cases died from intractable respiratory failure. The outcome for ABCA3 mutations was variable with seven survivors. The clinical and radiological presentation of surfactant protein C (SFTPC) patients suggested mainly interstitial lung process with the majority surviving on medication.
Surfactant mutation analysis is now well established in the UK and allows better genetic diagnosis and counselling. The rarity of the condition makes it difficult to develop a validated algorithm for genetic evaluation with a need for international networking. Referrals need to be rationalised for the service to be time and cost effective.
To our knowledge this is the fist report of a child with...]]>
Subependymal pseudocysts (SEPC) are cerebral periventricular cysts located on the floor of the lateral ventricle and result from regression of the germinal matrix. They are increasingly diagnosed on neonatal cranial ultrasound. While associated pathologies are reported, information about long-term prognosis is missing, and we aimed to investigate long-term follow-up of these patients.
Newborns diagnosed with SEPC were enrolled for follow-up. Neurodevelopment outcome was assessed at 6, 18 and 46 months of age.
74 newborns were recruited: we found a high rate of antenatal events (63%), premature infants (66% <37 weeks, 31% <32 weeks) and twins (30%). MRI was performed in 31 patients, and cystic periventricular leukomalacia (c-PVL) was primarily falsely diagnosed in 9 of them. Underlying disease was diagnosed in 17 patients, 8 with congenital cytomegalovirus (CMV) infection, 5 with genetic and 4 with metabolic disease. Neurological examination (NE) at birth was normal for patients with SEPCs and no underlying disease, except one. Mean Developmental Quotient and IQ of these patients was 98.2 (±9.6SD; range 77–121), 94.6 (±14.2SD; 71–120) and 99.6 (±12.3SD; 76–120) at 6, 18 and 46 months of age, respectively, with no differences between the subtypes of SEPC. A subset analysis showed no outcome differences between preterm infants with or without SEPC, or between preterm of <32 GA and ≥32 GA.
Neurodevelopment of newborns with SEPC was normal when no underlying disease was present. This study suggests that if NE is normal at birth and congenital CMV infection can be excluded, then no further investigations are needed. Moreover, it is crucial to differentiate SEPC from c-PVL which carries a poor prognosis.
There is evidence of inappropriate medication use, causing unnecessary costs for health systems, particularly those with limited resources. Overprescription is commonly reported and can lead to antibiotic resistance. Prescribing patterns differ between countries; little is known about paediatric prescribing practices in Africa.
To investigate prescribing practices in children in The Gambia, West Africa.
A retrospective survey of prescribing practices in children under 5 years of age based on WHO protocol DAP/93.1 was conducted. Twenty government-run health centres across all six regions in The Gambia were assessed. The first 10 encounters each month in 2010 were recorded. For each encounter, patient demographics, diagnoses and medications were recorded as per protocol.
Two thousand and four hundred patient encounters were included. The mean number of medications per encounter was 2.2 (median 2.0, IQR 2.0–3.0). Across different geographical regions within The Gambia antibiotics were prescribed in 63.4% (IQR 62.8–65.8%) and micronutrients in 21.7% (IQR 15.3–27.1%) of patient encounters. There was evidence of high antibiotic prescription in children with cough and coryzal symptoms (54.5%; IQR 35.8–59.0%) and simple diarrhoea without dehydration (44.8%; IQR 36.7–61.3%). 74.8% (IQR 71.8–76.1%) of medications were prescribed generically.
The study showed an overprescription of antibiotics and substantial usage of micronutrients despite a lack of international evidence-based guidelines. Cost-effective interventions to improve prescribing practices are called for and more studies with a focus on rational prescribing in paediatrics in low-income settings are urgently required to fill the gap in current knowledge.
To assess the impact of measured versus reported environmental tobacco smoke (ETS) exposure on asthma severity and exacerbations in an urban paediatric population.
We analysed cross-sectional data from the Chicago Initiative to Raise Asthma Health Equity study that followed a cohort of 561 children aged 8–14 with physician-diagnosed asthma between 2003 and 2005. Participant sociodemographic data and asthma symptoms were gathered by parental survey; exposures to ETS were determined by salivary cotinine levels and parent report. Multivariable negative binomial and ordered logistic regressions were used to assess associations between ETS and asthma outcomes.
Among 466 children included in our analysis, 58% had moderate or severe persistent asthma; 32% had >2 exacerbations requiring a hospitalisation or an emergency room visit or same day care in the previous year. Half of caregivers reported that at least one household member smoked. In multivariable analyses, salivary cotinine was significantly associated with frequently reported exacerbations in the previous year (adjusted incidence rate ratio=1.39, 95% CI 1.09 to 1.79), but not significantly associated with asthma severity. Reported household smoking was not significantly associated with either asthma severity or frequency of exacerbations.
Salivary cotinine was more predictive of asthma exacerbation frequency but caregiver- reported household smoking was not. Use of a nicotine biomarker may be important in both the clinical and research settings to accurately identify an important risk factor for asthma exacerbations.
Attempts to improve blood glucose control in type 1 diabetes have led to the use of technology such as insulin pumps and glucose sensors, or both (sensor augmented pump) but they have not eliminated the risk of nocturnal hypoglycaemia. It has been estimated that three quarters of hypoglycaemic seizures in children occur during the night. Fully automated artificial pancreas systems use computer controlled algorithms to link glucose sensors with insulin pumps to control insulin delivery. Such devices have improved blood glucose control in hospital trials and have reduced the risk of nocturnal hypoglycaemia. New researchers in Israel, Slovenia and Germany (Moshe Phillips and colleagues. New England Journal of Medicine 2013;368:824–33) have used the artificial pancreas system at a youth diabetes camp in each of these countries.
The study included a total of 56 patients aged 10–18 years who had had type 1 diabetes for at least a year,...]]>
Effective strategies to combat childhood obesity are challenging, especially among South Asian girls. We conducted a pilot cluster trial of a school-based physical activity programme among preadolescent girls to determine the feasibility (recruitment, retention and implementation) of the programme and influence on blood pressure (BP) and body mass index (BMI).
This two-arm parallel cluster intervention trial was conducted in four similar all-girls public sector schools in Karachi over a 20-week period. All girls aged 9–11 years were included. Intervention was a physical activity programme of 30 min duration four times a week. Primary outcome was to assess the feasibility of the physical activity programme defined as recruitment and retention >70% and treatment fidelity of >80% of physical activity programme. Secondary outcomes were changes in systolic BP (SBP), diastolic BP (DBP) and BMI from baseline to follow-up.
A total of 360 participants were invited to participate, 280 girls met eligibility criteria, and were recruited; 131 (77%) in the intervention group and 146 (87%) in control group. At follow-up, the overall retention of participants was 222 (79.2%); 105 (80.1%) in the intervention group and 117 (78.5%) in the control group. The difference in mean change from baseline to follow-up in SBP, DBP and BMI score was 1.9 mm Hg, 0.7 mm Hg and 0.55 kg/m2 between intervention and control arms, respectively.
A school-based physical activity programme in a public sector girls school of urban Pakistan is feasible. There was a favourable trend in BP and BMI at follow-up. (Clinical trial ID NCT 00533819).
Terra Firma-Forme Dermatosis is still sometimes referred to as Duncan's Dirty Dermatosis following the initial publication by Duncan et al.
The condition is more common in children than adults and is most commonly found on neck, face and ankles.
The UK National Institute for Health and Clinical Excellence (NICE) introduced guidelines for the diagnosis, treatment and management of urinary tract infection (UTI) in children and adolescents in August 2007.
The primary aim was to determine whether publication of NICE guidelines was associated with a change in the use of diagnostic imaging investigations in patients with a documented first UTI in a tertiary children's hospital. Secondary aims were to describe the epidemiology, microbiology, prescription of prophylactic antibiotics and follow-up for these children, and the incidence of structural renal tract abnormalities, vesicoureteric reflux and renal uptake defects identified.
Retrospective review of the case notes of patients presenting to Princess Margaret Hospital, Perth, Western Australia with a first UTI over a 4-year period (August 2005–2009). Details of demographics, radiological investigations, microbiology and follow-up were obtained. Data for subjects presenting before and after 31 August 2007 were compared.
Data from 659 subjects, median age 6 (range 0–186) months were analysed. Compared with the pre-NICE period, there was no change in the proportion of patients undergoing renal USS in the 2 years following publication of the guidelines. There was a decrease in the proportion undergoing MCUG (p<0.0001) and receiving antibiotic prophylaxis (p<0.0001) and an increase in the proportion undergoing DMSA (p<0.001).
Practice changed following publication of the NICE guidelines. While the reduction in MCUG requests and prescription of antibiotic prophylaxis is in line with NICE guidelines, the increase in DMSA requests is contrary to the recommendations.
The mode of delivery has recently gained attention as another potential perinatal risk factor for childhood obesity but results are conflicting.
To examine whether caesarean section is independently associated with childhood obesity after adjusting for a broad range of confounding factors.
The current study used a population-based survey in Grade 5 students linked to a provincial perinatal registry in the Canadian province of Nova Scotia. Associations between caesarean section and childhood overweight and obesity at age 10/11 years were examined using multiple logistic regression.
Of the 4298 students who participated in the 2003 Children's Lifestyle and School Performance Study (response rate 51.1%), 3426 (80%) could be linked with information in the Atlee Perinatal Database, and 2988 mother-child pairs (70%) had complete information on the exposure and outcome. Compared to vaginal delivery, caesarean section was associated with offspring obesity (OR) 1.49, 95% CI 1.10 to 2.00) in the univariate analysis. After adding maternal prepregnancy weight to the multiple regression model, the OR for obesity dropped from 1.48 to 1.20 (95% CI 0.87 to 1.65). When caesarean section with and without labour were considered separately, we found no statistically significant associations relative to the vaginal delivery group (OR 1.24, 95% CI 0.84 to 1.82 and OR 1.03, 95% CI 0.58 to 1.84).
Our results do not support a causal association between caesarean section and childhood obesity. Maternal prepregnancy weight was an important confounder in the association between caesarean delivery and childhood obesity and needs to be considered in future studies.
To examine morbidity among children with sickle-cell disease (SCD) during and after travel to a tropical area.
Observational study.
Tertiary care children; Robert Debré Hospital, Paris, France.
Children with SCD younger than 18 years old and managed in the SCD referral centre at the Robert Debré Hospital who travelled to a tropical or subtropical area between 1 June 2009 and 31 December 2009.
To assess morbidity, we used the number of clinical events requiring medical consultation during the trip as the primary outcome and the number of hospitalisations required after returning as the secondary outcome.
Thirty-nine children were included. The median age was 7.8 years (4.3–11.7 years). All of the children and their parents attended a pretravel visit focusing on the prevention of travel-related diseases. Twelve children (30%) consulted a physician while they were abroad. Thirteen children (33%) were hospitalised, and 23 children (59%) consulted a physician while they were abroad or within 3 months after returning to France. Considering the 3 months before and after travel, the number of children hospitalised after travel (n=12, 30.7%) was significantly higher than the number hospitalised before (n=4, 10.2%; p=0.01). One child was hospitalised for multifocal osteoarthritis as a complication of Salmonella enterica septicaemia of gastrointestinal origin.
Travels to tropical areas are associated with high morbidity in children with SCD. Salmonella infection is a particularly significant threat, and empirical antibiotic therapy should be prescribed routinely for traveller's diarrhoea in this population.
The spleen is usually fixed in a retroperitoneal position within the abdominal cavity by the...]]>
To describe the course of obstructive sleep apnoea syndrome (OSAS) in children with syndromic craniosynostosis.
Prospective cohort study.
Dutch Craniofacial Centre from January 2007 to January 2012.
A total of 97 children with syndromic craniosynostosis underwent level III sleep study. Patients generally undergo cranial vault remodelling during their first year of life, but OSAS treatment only on indication.
Obstructive apnoea-hypopnoea index, the central apnoea index and haemoglobin oxygenation-desaturation index derived from consecutive sleep studies.
The overall prevalence of OSAS in syndromic craniosynostosis was 68% as defined by level III sleep study. Twenty-three patients were treated for OSAS. Longitudinal profiles were computed for 80 untreated patients using 241 sleep studies. A mixed effects model showed higher values for the patients with midface hypoplasia as compared to those without midface hypoplasia (Omnibus likelihood ratio test=7.9). In paired measurements, the obstructive apnoea-hypopnoea index (Z=–3.4) significantly decreased over time, especially in the first years of life (Z=–3.3), but not in patients with midface hypoplasia (Z=–1.5). No patient developed severe OSAS during follow-up if it was not yet diagnosed during the first sleep study.
OSAS is highly prevalent in syndromic craniosynostosis. There is some natural improvement, mainly during the first 3 years of life and least in children with Apert or Crouzon/Pfeiffer syndrome. In the absence of other co-morbid risk factors, it is highly unlikely that if severe OSAS is not present early in life it will develop during childhood. Ongoing clinical surveillance is of great importance and continuous monitoring for the development of other co-morbid risk factors for OSAS should be warranted.
A 13-year-old boy presented to A&E with an erythematous rash on his lower legs, arms and torso after swimming in a local river the previous day. On initial examination, he appeared well and afebrile with several irregularly shaped erythematous lesions that were tender and warm to touch (
The following day the lesions progressed into a distressing painful blistering rash. The diagnosis remained unclear until the boy's father visited and proclaimed the lesions Giant Hogweed burns. Diagnosis was confirmed by internet searches and collaboration with dermatology.
Treatment of Hogweed-induced phytophotodermatitis follows that for chemical burns. Large bullous lesions were de-roofed and potassium permanganate impregnated dressings used for their bactericidal and astringent properties. The addition of paraffin gauze dressings showed an immediate improvement in pain and prevented further damage from ultraviolet...]]>
To assess the sensitivity of an adult-derived red cell distribution width (RDW) reference limit in the detection of iron deficiency in young children.
Haematological analysis performed on a cohort of 13-month-old healthy term infants of North European ancestry.
21/98 infants were iron-deficient (>2.5% hypochromic red cells). Of the remaining 77, 35 with RDW >13.9% also had evidence of incipient iron deficiency on the basis of significantly lower haemoglobin (11.5 vs 11.8 g/dl, p=0.046), mean cell volume (75.6 vs 77.8 fl, p=0.002) and mean cell haemoglobin (25.4 vs 26.2 pg, p=0.002) values and higher zinc protoporphyrin (55 vs 44 μmol/molhaem, p<0.001) values than those of the 42 with RDW ≤13.9%.
An adult-derived RDW reference limit has utility in screening for iron deficiency at the age of 13 months. The incidence of non-anaemic iron deficiency in this group was 52.8%.
A 9-year-old child with relapsed acute lymphoblastic leukaemia postbone marrow transplant was admitted to the children's intensive care unit (ICU) for non-neutropenic fever with worsening respiratory distress that required mechanical ventilation. Despite broad-spectrum antimicrobials, serial chest radiographs showed worsening bilateral infiltrates and increasing mechanical ventilatory requirements. As the registrar in the unit, you wondered if intratracheal surfactant would be beneficial in treating this child with acute respiratory failure.
In critically ill children with acute respiratory failure (patient), does treatment with surfactant (intervention) improve gaseous exchange and shorten duration of mechanical ventilation and length of ICU stay (outcomes)?
Secondary source—Cochrane Database of Systematic Review, BestBETs
Primary source—PubMed, CINAHL, Web of Science
Search terms were (‘children’) AND (‘surfactant’) AND (‘acute respiratory distress syndrome’ OR ‘adult respiratory distress syndrome’ OR ‘acute lung injury’ OR ‘acute respiratory failure’).
Thas nowt so blind as ‘em that won't see The RAMbo acronym that Archimedes first chattered on about five years ago As with so many elements of evidence based medicine, the idea of checking if blinding of subjective outcomes really does make a difference has been subject to intense, methodologically robust, systematic review. A paper from the Cochrane centre
A 15-year-old girl comes to your outpatient clinic with a 6-month history of fatigue, headaches, nausea and muscle pain. Clinical examination and investigations are normal and you make a diagnosis of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). She is going to sit her General Certificate of Secondary Education (GCSE) examinations in 6 months, but is currently unable to attend school full time. She and her mother ask you which behavioural treatment (they don't want medication) is the most likely to get her back to school.
Do teenagers with CFS/ME (P) benefit from behavioural treatments (I) compared with usual care (C) in improving school attendance and fatigue (O).
A comprehensive list of synonyms was compiled for the subjects (adolescents) and the condition (CFS). These were then combined and applied to the following databases so that all possible combinations of synonyms...]]>
A 15-year-old boy presented with a 2-month history of a painless lesion on the right earlobe and multiple neck lumps. He had emigrated from Pakistan 4 years earlier and had received the Bacillus Calmette–Guérin (BCG) vaccine at birth. He denied systemic or respiratory symptoms. On examination, a 14 mm soft painless pigmented lesion on the pinna was noted (
Lupus vulgaris represents the most common form of cutaneous tuberculosis in Pakistani children and primarily affects the head...]]>
Twenty premature infants with ROP, born between 1 May 2010 and 31 July 2012 at 24–28 weeks’ gestation and birth weight <1500 g, were randomised either to oral propranolol (propranolol+sucrose 5%; n=10) or placebo (sucrose 5%; n=10) (
A 22-month-old boy was admitted to the children's ward through Accident and Emergency (A&E) with accidental hanging from a window blind cord. On the day of the incident at around 18:30, the child was with his elder sister in a bedroom and his mother was in the kitchen. When his mother came back after about 4 min of absence from the bedroom, the child was found hanging onto a pull chain of the blind cord of the window. He was not breathing and was blue. His mother immediately picked him up and laid him on the ground; after about 20 s, he started breathing and his colour improved. When the paramedics arrived shortly after that, the child's breathing pattern had normalised. There were obvious strangulation marks on the front and side of his neck with multiple petechiae on the face. As the boy remained well overnight, he was...]]>
In forming an international collaborative to find clinical variables that predict the outcome of children and young people presenting with febrile neutropenia, we undertook an investigation into the ethical and regulatory considerations involved in sharing such information for our projects. This paper reports the outcome of our work to help inform the practice...]]>
The recent paper by Gill et al
In our emergency department we have examined data on presentations and admissions rates in age groups from 2008 to 2012 (
Up to 20% of people with tuberous sclerosis complex develop subependymal giant cell astrocytomas that are usually situated near the foramen of Monroe and commonly obstruct CSF flow, causing hydrocephalus. Operation on these tumours may be hazardous and about a third of patients has an ipsilateral recurrence or contralateral occurrence. Activation of the mammalian target of rapamycin complex 1 (mTORC1) is fundamental to tumour growth in tuberous sclerosis complex, and everolimus inhibits mTOR. A preliminary study showed that treatment with everolimus caused shrinking of subependymal giant cell astrocytomas. Now a trial in Europe, North America, and Australia (Lancet 2013;381:125–32; see also Comment, ibid:95–6) has given support to the use of everolimus for these patients. The trial included a total of 117 patients aged 0–65 years (20 <3 years old, 101 <18 years old) with tuberous sclerosis complex and at least one new or growing subependymal giant cell astrocytoma, or associated new...]]>