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Even compared with ‘the sizzler in 36’, this summer would go down in the East Coast annals. It wasn’t just the relentless heat, the unbroken shimmer over the skyscraper backdrop, the drinking water considered too unreliable to be imported as ice from outside. Neither was it solely the stream of children that week. Some were, after all, quite chipper, others really sick, overstretching both personnel and pharmacy stocks. There were lights at the end of his proverbial tunnel, though: the fall vacation in Vermont with his childhood sweetheart in the Ford, the Olympic games from Finland on television – our peerless athletes certain to show Emil Zatopek and his European cronies how to run a 5000 m race – and the expected, sought after reference from his head of service to an upstate counterpart.
At first, she didn’t seem ill. His first impression was that her sore throat was nothing that some sponging wouldn’t solve. Though the heart rate was brisk at 120 beats per minute, her fever at 99.1 F pain, environmental conditions and dehydration seemed reasonable explanations. So, home she went, armed with advice, linctus and acetaminophen. It wasn’t until the following week, that he learnt of her re-presentation. Her throat had become sorer, her vigour sapped and breathing more laboured. On this occasion, she was admitted. Not just admitted, but allocated one of the few remaining iron lungs, the supply dented by the recent run of paralysis cases. Some days later, in fact the day he returned, the laboratory technician called. “Hot off the press from my petri dish – as suspected – Corynebacterium diphtheriae on the agar, good that you thought beyond the presenting symptoms.”
Liver transplantation: the world in microcosm
Zhen Yu Wong and colleagues in Kuala Lumpur, Malaysia, examine ‘gender differences’ global practice in paediatric liver transplantation in terms of donor-recipient status by sex and Gender Development Index. In the low- and middle-income countries studies there was consistent male recipient preponderance and in Middle Income Countries female donor predominance. Other than gender disparity (time, I think, to use the expression), there are a few alternative contributors (HLA types, liver failure phenotype distributions, matriarchal volunteerism). These though, can’t alone account for the findings which the authors tantalisingly conclude are not easily explained and their forest plot is the single most important piece of information you will see this month. Anywhere. See page 878
Failing to thrive but coping just fine
Assessing mental non-wellbeing in high-risk children is well recognised, but, harder to incorporate into day to day practice than the brochure implies. The standard tools are time consuming to administer and, therefore, used more as research tools. Rapid screening could identify those warranting a closer look. Mary White and colleagues in Melbourne assess a single question screening test in a group of children with chronic disease receiving day ward care. The question, simply: ‘thinking about your child’s mental health over the past 4 weeks, are they thriving/coping/struggling/always overwhelmed?’ was validated against the gold parameters the Strengths and Difficulties questionnaire (SDQ). There were few false positives: an excellent specificity (0.98) and positive predictive value (0.87). The sensitivity (the headline in a screening test) low when coping and thriving were combined. However, when ‘thriving’ alone was used, it improved dramatically to a respectable 0.7. There’s an important semantic lesson here: non-coping is a more extreme point, a much more precarious life quality situation and as a screen therefore blunter. Not thriving (and the UNICEF made this point long ago) and, as a result picking up those not enjoying life to their potential is much subtler and, therefore, inherently more sensitive. See page 906
The contemporaneous rise in overweight-obesity and eating disorders marches on. Aryati Ahmed and colleagues in Oxford, UK examine trends from 1997 to 2016 through a series of cross-sectional studies in the Health Survey for England surveys in which routinely collected data on anthropometry and reported attempts at weight loss n children aged 8–17 years are interrogated. The headlines include a rise in weight loss attempts from 21.4% in 1997–98 to 26.5% in 2015–16. Though absolute prevalence was higher in girls, the increases were more pronounced in boys and associated with age, Asian origin and low household income. The increase was seen in all BMI categories and was particularly marked in the overweight and obesity groups. The fastest rate of rise was seen in 2011–12, wasn’t that around the time that social media really got into its stride?
Global child health: unnecessary admissions for pneumonia
In 2014, the WHO updated the guidance on pneumonia management in children in low- and middle-income countries (LMICs) from the previous (2005) iteration. Rising antimicrobial resistance (AMR) played a part, as did evidence in viral preponderance now (PERCH and GABRIEL studies) an estimated 70% of all cases. The new simplified algorithm recategorised pneumonia into just two phenotypes: non-severe (with or without chest wall indrawing) suitable for outpatient oral antibiotics and severe (indrawing and danger signs) needing parenteral treatment. The study by Ruth Lim and colleagues in Lao (which in the uninsured majority is pay for admission) assessed whether children presenting with pneumonia phenotypes managed according to 2014 WHO guidance. In the nearly 600 children studied, 86% of children with non-severe illness were admitted. Pressures on assessing doctors and an understandably lower threshold for younger children aside, hospitalisation when not needed remains an obstacle as the march of AMR accelerates. See page 872
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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.
Provenance and peer review Commissioned; internally peer reviewed.