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The first taboo
Events in Ukraine are so distressing, baffling and rapidly-evolving that we are still assimilating. There are many strands to potential support and, as these take shape the children there and their families will never be far from our thoughts
Liverpool Lime Street station, platform 5: February 1920
Immersed in the plumes of steam emitted by the lacquered locomotive pausing temporarily for disembarkation, the couple gaze mournfully at each other, oblivious to the hordes of jostling travellers. After an exhilarating few months, it has become painfully obvious that this chapter in their lives has come to a natural end, their immaculate clothes (her starched pinafore, his chamois waistcoat) only serving to accentuate rather than attenuate the poignancy and now clear gulf that has pushed them to this junction. She boards the train (a single ticket of course): he turns abruptly and disappears in the haze, his shrouded bowler the last part of him she will ever see. In time, both will look back on this episode with fondness, grateful for the good times, but, without regret, having acknowledged the need for change, the importance of letting go.
Genetically tailored treatment: what do children themselves think?
It’s hard to put a finger on the start of the pharmacogenomics era but easy to recall that oncologists and rheumatologists and gastroenterologists (take TPMT and azathioprine and six mercaptopurine), clinical pharmacologists and hepatologists (CYP enzymes) to name but a few hit the ground running. Asthma, a heterogenous problem by any definition, arrived at the party surprisingly late given its prevalence – or maybe because of its prevalence. The scientific literature here (polymorphisms, for example, predicting treatment efficacy and adverse effects) is catching up, but, somewhere in the febrile enthusiasm, the single most important factor appears to have been overlooked: what do children and their parents feel, in principle, about contributing treatment-related genetic material to inform their own treatment? In the Drug therapy section, Dan Hawcutt and colleagues report. See page 394
Paediatric emergency medicine: our tools are still blunt
The PERUKI-based multicentre UK and Ireland study (555 children, median age 53 days) by Tom Waterfield and colleagues, reports the validation and comparison of the currently used clinical practice guidelines in fever in young infants, two by the National Institute for Clinical Excellence and the third from the British Society for Antimicrobial Chemotherapy. The vast majority underwent blood testing and received intravenous antibiotics. Approximately 1% had bacterial meningitis, 1% bacteraemia (1%) and 12% urinary tract infections. The test sensitivities were all in the good to excellent range but specificities (the identification of true negatives), bluntly, poor. The combined predictive values were substantially lower than the US PECARN and Step by Step counterparts, one explanation being the use of procalcitonin (PCT) levels in the latter algorithms. Procalcitonin testing is not widely available in the UK but surely this doesn’t warrant leaving the elephant in the room that is (the absence of) a test to roam unfettered. This feels like this is a crossroad moment. Do we want to carry on treating the majority of febrile 2- and 3-month-olds with IV antibiotics and accelerating the world’s largest pandemic, antimicrobial resistance, when we know that from the already expansive literature, the real risk group is the under 1 month group? Or is it time to accept that PCT-free assessment simply isn’t adequate in the 2020s Or both? There is a recent precedent: the neonatal Kaiser Permanente based sepsis screen has convincingly demonstrated the safety and effectiveness and savings in postnatal inpatient stays of a more expectant approach. See page 329
Global health: essential medicines
A prerequisite for successful pharmacological treatment is that a medicine enters the body in the intended active form at the right dose, is absorbed and is appropriately bioavailable. Stating the obvious? The advantages (logistical, economic and pharmacological) of pill rather than liquid/solution-based preparations have been known for some time as has the ability of school age children to swallow standard tablet forms. With this in mind, in 2008, WHO proposed that medicines for children should ideally be made as flexible solid oral dosage (FSOD) forms such as dispersible tablets. These were subsequently included in the Essential Medicines List for Children (EMLc). Ebiowei Orubu and colleagues’ assessment of appropriateness (ease of swallowing and dose delivery) and temporal changes of the EMLc listed formulations is both welcome and important. See page 317
‘I won’t see you next week’
Few areas are as laden with mythology as the infant weight chart, particularly the frequency of measurement. The new UK-WHO growth charts specifically come with the instruction that in healthy babies, monthly measures up to 6 months and 2 monthly beyond this age are adequate to avoid ‘noise’ (false warnings resulting from measurement error and random variation) which alter management unnecessarily. Given the pervasive strength of attachment to the regular weighing philosophy tradition, data endorsing the eminently sensible, new recommendations are needed: and are precisely what Charlotte Wright, Tim Cole and colleagues provide. Using databases from three large longitudinal studies and a separate estimate of the ‘noise SD’, the probability of false alarms (which we know lead to concern, then well-meaning if unnecessary, advice and investigation) increasing in parallel to the frequency of measurements. See page 341
The last taboo?
This month’s Voices by Vincent is achingly poignant: partly a chronicle of our role as paediatricians, partly a societal commentary around the inconsistencies and muddy relationship with one of society’s still – effectively – persona non grata areas, fetal alcohol syndrome. FAS is, in essence, the final common pathway of a number of social and individual vulnerabilities, an outcome in which there are no winners. But, if were able to talk about it more openly, who knows? See page 407
Patient consent for publication
This study does not involve human participants.
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.
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