Sepia

In the pre-internet era, in the days of non-digital photography, most families owned and treasured their albums of pictures. Often arranged chronologically by year, each series of collections defined lives. Unlike today’s ubiquitous smart phone compilations hung out to dry on line, these assemblages were defined by the tinge, brightness (garishness, for example, personifying the 1970s’ polaroid) and clarity.

Over time, albums built up a folklore of their own, the sepia tinge of the older ones a metaphor for ‘good times’. Whether they really were or not, becomes impossible to objectively define as this is a trick played by time itself to which no one becomes inured

The same is as true of eras as individuals: the ‘swinging’ 60 s (I’m too young to have an opinion); the ‘grim’ 1970s (I feel privileged to remember them); the solipsistic 1980s; the weary, fin de siècle 1990s. None of these are really true or really untrue – there is no way of objectively testing what is ultimately a personal recollection and no way of quantifying the way in which the collective memory has been influenced by the way the stories were construed by the media of the respective eras.

We don’t know how events of 2020 will unfold. It’s unlikely we will know in a month or even 12 months. We don’t know whether the landscape will be permanently altered by the story that is engulfing the planet, changing behavioural patterns (or forcing them to change)… but I do know that I no longer need to use the term that is, now so all-consuming it would feel almost tautological to wheel it out.

So what hue will this render our albums from this year when in a generation’s time we dust them off to retell the stories to our grandchildren: sepia, monochrome or an alternative we’ve yet to encounter, describe, experience or articulate?

Capable, competent, both or neither

It’s gone midnight, there’s still a row of children in emergency department needing attention and the ward phone rings what feels like every 5 minutes. Surely a thorough physical examination on each is sufficient to make decisions on overnight management?

Unfortunately, not so unless you formally tested (rather than presumed) the capacity and competence of the highly articulate, erudite 15-year-old you ended up seeing at 3am.

The differences, though a source of confusion, are important as Wheeler’s thought provoking editorial explains.

The term Gillick competence entered medical vocabulary 35 years ago introducing the concept of the capability or not of making independent decisions if aged under 16 years. In 2005, the complementary Mental Capacity Act, entered the arena. Based on a default presumption of capacity for 16- to 17-year-old young people to consent to treatment independently of their parents, the term took on a statutory meaning, the ‘possession of capacity’. In short, (‘Gillick’) competent children under 16 and capacitous young people (16 and 17 years old) can provide consent, as an alternative to relying on the consent of their parents. It is, of course, not quite this simple. The child under 16 is, by default, presumed incompetent and must prove her competence by demonstrating sufficient understanding of matters: not doing so potentially denies her autonomy. The corollary, is that young people (aged over 16 years), with presumed capacity, can only have this rebutted by the establishment of incapacity a two stage process: diagnostic, is there an impairment in thinking, and, if so, is this for the reason for the inability to make the decision. A recent high profile case has amply demonstrated the importance of this differentiation. See page 419.

Vitamin K

For a form of prophylaxis with such a strong track record, the chequered history vitamin K in its various prophylactic incarnations has had to endure is surprising. Obstacles to smooth adoption despite compelling evidence of effect in the prevention of vitamin K deficiency bleeding (VKDB), are too complex to re-narrate in detail here, but controversies in the late 1970s and early 1990s hindered universal embrace. Shearer’s editorial contextualises Zurynski’s Austrialian Paediatric Surveillance Unit study in which worrying trends of increased parental refusal, abstainers accounting for 63% of VKDB cases in the 2006 to 2017 era compared with 32% from 1993 to 2005 and a rise of 85% among those choosing home deliveries. Consecutive British surveys identified similar trends and a large Canadian study also found strong associations deliveries at home and with vaccine refusal. We know from the Dutch that intramuscular prophylaxis (just a single early dose) solves all the logistical problems and human error related issues home administration of oral doses weeks later involves and avoids potential malabsorption issues in oral dosing related to cholestasis. It is, simply, better. If this message isn’t reaching parents or being heeded, we need to rethink why. See page 417 and 433.

Home ventilation

The number of children in the UK on long term home ventilation has increased near exponentially, from less than 100 children in 1990 to around 1500 in 2015. There are many potential benefits, but also risks. Harrop analyses patient safety incident data relating to long-term ventilation using incident reports from England and Wales’ National Reporting and Learning System over 5 years and identified several recurring themes. Of more than 200 events, 40% were judged harmful. Common problems related to faults with and unavailability of equipment and staff competency. See page 446.

It’s easy to forget there is so much we can influence: isn’t it time to wrest back control?