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Bile stained vomiting in the neonatal period
Bile stained vomiting is a ‘red flag' symptom and may indicate intestinal obstruction. The challenge is to select which patients may have a time critical surgical condition, for example volvulus (where a delay in treatment is likely to compromise gut viability), and urgent referral for assessment in a paediatric surgical unit is indicated. Mohinuddin and colleagues report the outcome of 163 neonates with bile stained vomiting referred to their unit over a 4 year period. A surgical diagnosis was more common in infants with abdominal distension (although not a tense abdomen), abdominal tenderness and an abnormal plain abdominal X-ray—sensitivity 74%, 62% and 97%. A normal plain abdominal X-ray reduced the risk from 50% to 16% overall, although didn't exclude a surgical cause of the vomiting. The presence of a soft abdomen was not predictive. Clinical signs/plain radiology were not predictors of whether the surgical condition was time critical or not. The dataset is interesting and of course only reflects cases referred to the unit. It does however suggest that if bile stained vomiting is present (and confirmed) urgent referral to a paediatric surgical centre is indicated. In an accompanying editorial Simon Blackburn discusses the findings and supports the author's recommendation regarding urgent referral. See pages 14 and 1
Ehlers Danlos syndrome
The term Ehlers Danlos syndrome encompasses a group of inherited connective tissue disorders—separate and distinct entities. The manifestations—mild to severe—can be seen in skin, joints, blood vessels and internal organs. In an authoritative review, Glenda Sobey discusses the different subtypes and their genetic basis where known. She emphasises the importance of the history and clinical signs in selecting the most appropriate investigations and the specific features and management for each of the subtypes—classical, hypermobile, vascular, kyphoscoliotic, arthochalasic, dermatosparactic. Ehlers Danlos syndrome needs to be considered when, in the absence of another explanation, one or more of the following occur—late walking with joint hypermobility, abnormal bruising and bleeding, unexplained vessel rupture or dissection, tissue fragility, atrophic scarring or skin hyperextensibility, symptomatic joint hypermobility, hollow organ rupture. Consideration of and correct diagnosis within the Ehlers Danlos syndrome spectrum allows targeted management, family screening and prenatal diagnosis. See page 57
Management of peanut allergy
Peanut allergy is common and can cause severe life-threatening reactions. It is usually life-long. Anagnostou and colleagues present a review regarding the assessment and management. The authors emphasise the importance of a correct diagnosis with carefully conducted challenge in cases where there is disagreement between the clinical picture and results of IgE RAST and skin prick testing. There is no evidence that maternal avoidance or delayed introduction into the diet reduce prevalence. Management is by strict avoidance, education and provision of emergency medication. Food avoidance can be challenging particularly from ambiguous food labelling and cross contamination. Best care in the school setting is crucial. See page 68
Does the EEG help in the assessment of ‘staring' in children with autistic spectrum disorder?
Children with autistic spectrum disorder (ASD) have complex medical needs which can be difficult to assess and manage. There is an increase in the prevalence of epilepsy, and a higher incidence of EEG abnormalities than in the normal population. Staring (and reduced responsiveness) can be due to epilepsy but has a wide differential with the risk of episodic altered responsiveness, communication or behaviour being erroneously attributed to absence or focal dyscognitive seizures. How useful then is the EEG? Hughes and colleagues report on the outcome of EEG's in children with ASD (92 age <16 years) referred for the further investigation of staring. No child had absence or focal dyscognitive seizures confirmed on EEG, although abnormal features were seen in 12 (7 with changes typical of benign focal epilepsy of childhood) none of which were felt to be relevant to the presenting symptoms. The authors conclude that the low yield of significant abnormalities mean that EEG's should be undertaken judiciously and interpreted cautiously in children with autistic spectrum disorder who present with staring. See page 30
Is paracetamol safe?
Paracetamol is the most widely used medicine in children in hospital and in the community used for its analgesic and antipyretic properties. It is therefore important to explore and understand any potential toxic effects. Exposure to paracetamol in pregnancy has been associated with childhood asthma. Cheelo and colleagues report a meta-analysis—the odds ratio for developing asthma (after adjusting for respiratory infections) was 1.06 suggesting the effect is likely to be minimal. The potential hepatotoxicity of paracetamol is well known. Rajanayagam and colleagues report a retrospective analysis of the aetiology of acute live failure in children over 10 years. 14/54 were attributed to paracetamol, the majority due to medication errors—7 received doses in excess of 12 mg/kg/day. Many of the other children received a double dose, too frequent administration, co administration of other medicines containing paracetamol or regular paracetamol for up to 21 days. The findings are discussed further in an accompanying editorial. See pages 77 and 73
Improving the care of children and young people in the UK
Much has been achieved for the care of children in the UK over the last 20 years. Al Aynsley-Green reflects on both the achievements and challenges—children are generally healthy and fewer die, children's cancers can now be cured, advances in immunisation have reduced significantly the burden of infectious disease, children have a more prominent voice in their care to name just some. There is however what he calls an ‘inconvenient paradox’ in that despite these advances there are still significant challenges. In 2007 the UK ranked bottom in the UNICEF league on the well being of children in the richest countries of the world, teenage pregnancy rates are high, we have some of the highest obesity rates in Europe, numeracy and literacy rates need to improve and there are continuing challenges protecting children from exploitation. His perspective reflects his experiences as Professor of Child Health, National Children's Director and Children's Commissioner for England with discussion of the policy changes that have occurred, initiatives for children and the need to move forward.