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What’s going on…
It’s now almost exactly 50 years since the release of Marvin Gaye’s seminal album, one of the few records worthy of the accolade, the fruit of months of work with The Funk Brothers at the Hitsville USA studio in Detroit. Why do I mention this now? Anniversary aside, simply because the themes of social breakdown, the surge in mental illness in Vietnam veterans and (and here he really was ahead of his time) the environment in ‘Mercy, mercy me’. The title of course, didn’t (clearly deliberately) include a question mark: it’s more of a statement reminding us (like many of these papers) how far we still have to go and, I still love it for its prescience, continued relevance and beauty.
We all have moments either in our recollective lockers (or stored up in the ‘this could happen to me’ cortex) of ‘what if I’d facilitated/done more than focus on the examination because it was Friday afternoon/not allowed myself to ignore my gut feeling on the basis of a normal blood work up?’ These are the children where benign appearing symptoms of abdominal pain, dysuria, headaches are chalked up to functional abdominal pain, constipation, migraine… but are in reality a somatisation of abuse, a diagnosis that no lab test will corroborate. Pain, after all whatever the source always signifies a discomfort and these are the children you hear about through adolescent psychiatry a decade or so after that first consultation in year 1, typically on a Friday afternoon, the end-of-clinic typed notes now vaguely embarrassing. That first consultation becomes (and I defy anyone reading to say they haven’t had one) a ‘closing door and turn the lock’ moment in the same way that certain questions and styles of questions can do, these single moments teaching us more than 100 courses ever could.
Two wonderful pieces, a leading article by the late Ruth Marchant of the Triangle organisation, Jamie Carter and Charlie Fairhurst and an accompanying editorial by Geoff Debelle and Robin Powell, illustrate the delicacies, interactive and legal of the tantalising consultation where a child whose symptoms appear functional and (you sense) might be at the point of wanting to say more. The editor’s choice this month was easy. See page 108 and 105
Many of us will remember the intense debate on neonatal ward rounds certainly as recently as 20 years ago over how far (among other symptoms) a growth restricted neonate should be investigated in the absence of ‘an obvious reason’: voices would become raised a notch (think strident) over whether this was ‘symmetrical’ or ‘ asymmetrical’ (even though definitions were largely subjective) and so it would go on. The acronym of choice in that era was ‘TORCH’ – easy to remember but, as we now know, slightly naive in the reliance on serology and eminence based medicine rather than direct testing. The piece by Justin Penner and colleagues gently eviscerates (if you’ll excuse the oxymoron) some of the mythology in this area and reconstruct the approach, giving us ‘SCORTCH’, both user friendly and pragmatic. Reflecting on this, there’s an additional spoke: shouldn’t we be routinely meeting and preparing more high risk women for the post-natal course in the ante-natal clinic rather than delaying the first encounter to the NICU ward round? See page 117
School opening and COVID-19
With the vaccine launch and new UK viral strain currently (among other pandemic-related issues) competing for headline space, it’s impossible to gauge what the situation might be when this edition thuds onto your door mats. The component parts of the risk-benefit equation in terms of school opening/re-opening and infection/transmission, though, will be largely unaffected. As Russell Viner and colleagues remind us, think: depression, child abuse, school meals, exercise and (largely beyond the UK) teenage marriage, teenage pregnancy, family finances, the long term educational and economic impact on children unable to reach their academic potential and policies, of course, don’t need to be mutually exclusive. The arrival in the last few days of a new COVID-19 variant apparently more transmissible and the closing of borders around Europe might demand some remodelling, but the general principles do not. See page 111
Global child health
Unwell young infants: Part 1
Among other papers, Christina Obiero and colleagues reassessment of the performance of the WHO meningitis algorithm in infants aged under 2 months in a large Kenyan referral centre in the post conjugate vaccine era. These babies, of course would not have been vaccinated, but, due to herd immunity the number of s.pneumoniae and h. infuenzae type B cases relatively only a very small fraction of the early mid 2000s’ study counterparts. Fever, unsurprisingly enhanced sensitivity but reduced specificity – important in the antibacterial resistance era, a time at which arguably more rather than fewer lumbar punctures (a skill we shouldn’t be losing) should be undertaken to confidently rule out meningitis. See page 130
Paediatric emergency medicine
Unwell young infants: Part 2
The original PECARN test validation for serious bacterial infection (SBI) in febrile young infants was derived and validated in US children. It showed high promise and, though likely generisable, Roberto Velasco and colleagues tested this assumption in a secondary analysis of a group of Northern Spanish children. The test missed 4.5% of serious bacterial infections (SBIs) in low risk children where the original study had missed only 2.3% of SBIs. By my estimation this equates to a ‘number needed to miss’ a case of SBI using the PECARN tool of 45 in this population. On the face of it, a 95% sensitivity still seems reasonable, but is it? Interpretations will vary (they almost always do) but ‘reasonable’ depends, surely, on the provision of additional safety netting for the 2% or so that elude the screen. See page 143
What’s gone on
Somehow, though Marvin Gaye appeared to be ruminating over the end of the 1960s, the record could equally easily have been made with 2020 in mind: maybe, somehow, it was. Homework: discuss. See you next time.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.