What the brochure says

The WHO top ten list of threats to global health feature many directly relevant to children: climate change, pollution; vaccine hesitancy; dengue; COVID-19; influenza; antimicrobial resistance – all ‘deserving members’ of this unenviable top table, though the non-inclusion of female literacy baffles me. But, there’s another strand to this. Please indulge any over generalisation but one common thread here, surely, is of accountability. Potential superintendents at a national level are rarely held responsible for global issues and the metaphorical, nonchalant shrug of the shoulders approach, therefore, is effectively legitimised based on saving expenditure for example, rather than being flagged as the deflection of responsibility and dereliction of duty it really represents. This could not be exemplified better than Rob Wheeler does in this month’s legal piece, ‘beds for children’ in which one poor girl’s nightmare journey through repeated refusal of inpatient psychiatric care despite a succession of failed foster placements is described. Why? Simply, because there was no single person or body accountable. See page 114

‘I’m sure he’d benefit from a few sessions of cognitive behavioural therapy…’

It’s been a long tough outpatient session, you’re running late (the result of several calls from the ward) and you’re hungry. The travails of the morning worsen during the last appointment, a peri-pubescent boy with clearly functional abdominal pain, his parents seemingly oblivious to your iteration of ‘we don’t always find a physical cause for these sorts of symptoms’. To coax them into understanding your standpoint, you allude to the place of cognitive behavioural therapy. The problem is, when they ask probing (and completely reasonable questions) about what this might involve, you struggle to answer them.

Available as NHS treatment since the 1990s, the approach, as described in Paul Stallard’s review, involves exploring the associations between thoughts, feelings and behaviours to introduce objectivity and a way out of negative and deeply entrenched cycles. See page 109

Food protein intolerance enterocolitis syndrome

‘FPIES’, despite gaining traction and infamy some years ago is still something of an enigma. A severe, non IgE mediated response within hours of ingestion of a protein (usually milk, soya, rice, fish, egg and fruit) characterised by gastrointestinal symptoms and hypovolaemia unresponsive to epinephrine. Gary Stiefel’s summary of BPSU findings and Paul Turner’s editorial suggest the incidence in the UK is low with the rider that, because of the lack of diagnostic markers, it may be an underestimate – the delay in median time to diagnosis endorses the suspicion of slippage. This matters because the prognosis is good (most resolve by the age of 5), unnecessary epinephrine autoinjector prescription (and use) can be avoided and that treatment in terms of anti-emetics and fluids is different to its IgE mediated bedfellows. See pages 123 and 105

Mucositis and lasers: end of the cocktail era?

Oncologists have long been at the forefront of paediatric research. The international collaborations for rare tumours, the expectation that newly presenting children will be recruited into the relevant ongoing trial testing equipoise of different treatment regimes, the evolution of new radiological and radiotherapeutical techniques, the pioneering of stem cell transplantation, the use of monocloncal antibodies as adjuncts. However, there remain a few (surprisingly) hard, tantalisingly prosaic, nuts to crack. We’ve previously reported on safe, admission-shortening short course alternatives to the time-honoured, morale-sapping, 5 day-long admissions for IV antibiotics in neutropenic though well, culture negative children.1 Arguably even more troublesome is the near ubiquitous mucositis which has spawned any number of ‘local’ remedies, cocktails of opiates, topical analgesics and disinfectants, each centre loyally sticking with their potion of tradition. Some perhaps help, but none (to my knowledge) do so consistently. Melody Redman’s systematic review of the use of low level laser prophylaxis to the oral mucosa suggests doors might be opening: pain free periods after chemotherapy, enjoyment of food, independence of parenteral nutrition and nasogastric tubes. See page 128

Respiratory enigma

It’s now well established that whole exome sequencing (WES) has a place in assessment in dysmorphology and developmental delay work up even as a near ‘point of care’ test. Dan Dai and colleagues at Fudan University, Shangai assessed close to 1,000 children with respiratory phenotypes without diagnosis by conventional analyses and re-evaluated them using WES. Of these, 14.4% received a monogenetic diagnosis. Was this more than merely academic? Emphatically so: there were changes in approach in more than 50% including: redirection of care and medication, a switch to palliation; change in diet and stem cell transplantation. In addition, of course, parents would have been given some certainty about what the future might hold. See page 141

The maths

By chance, this issue includes two unrelated pieces on BCG. In an image, Sarah Band describes the course of a 3-year-old subsequently found to have interleukin six deficiency with systemic BCG (skin and bone) resulting from vaccination. Sam Oddie discusses the downsides to the proposed delay to routine BCG vaccination in high risk babies while waiting for the result of the newly introduced screening programme for severe combined immunodeficiency (SCID), the principles being on the one hand that vaccination will leave a small number of babies exposed to disseminated BCG and on the other that the remainder (many times more) will be unprotected during an early life window of vulnerability particularly if surrounded by household contacts. It all comes ‘down to the maths’… and, as always, accountability for doing the sums. See pages 202 and 203

That’s all for now

Nick