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Taking a second look
Warmia, Poland 1530s
An extraordinary polymath called Nicolaus Copernicus is completing his work on heliocentricity, challenging (with support from both academic and theological colleagues) the ‘earth at the centre of the universe’ assumption
Soho, London 1850s
A versatile obstetrician, anaesthetist, John Snow becomes intrigued by and embroiled in the localised cholera epidemic and clustering around a particular pump in Broad Street. Governmental officials are sceptical, (‘this is all to do with ‘‘bad air’’’), but, despite the lack of positive microbiology, are ultimately persuaded by the consistency of cases and proximity to a cess pit. Snow has the last say, convincing the authorities of the source. The pump handle is removed. The outbreak ends. Water, sanitation and hygiene as a concept and, simultaneously, modern epidemiology enter stage left and right
Neglected non-tropical diseases: ‘the barking sound is just a floppy larynx – she’ll outgrow it by the time she blows out the candles on her first birthday cake’
Maybe time to rethink the time-honoured line of reassurance proffered (literally) thousands of times a day in paediatric emergency departments and outpatients worldwide. This time-honoured line of reassurance might, however, not be the whole story. There’s already been some debate of the (theoretical at least) link between the ineffective cough due to partial airway closure inhibiting an effective cough, potentially compounded by squamous metaplasia and, in turn leading to retained secretions, then chronic lower airway inflammation and ultimately bronchiectasis. Bronchiectasis in the absence of cystic fibrosis, is enigmatic – yes we all have mental checklists of causes (the usual suspects being turberculosis, measles, pertussis, ciliary dyskinesia) but, in reality the ‘hit rate’ for nailing the cause is paltry. The discussion to date has been fuelled mainly by case series, but Rahul Thomas and colleagues in Brisbane take the evidence to another level. In their case control study 45 children with HRCT evidence of cavitation and bronchoscopic assessment of tracheomalacia compared with 90 children under investigation for other respiratory disease (for example, foreign body inhalation) the adjusted OR the presence of any tracheomalacia was significantly associated with bronchiectasis 13.2, 95% CI 3.2 to 55), while that for ERS-defined tracheomalacia (>50% collapsibility of the trachea) further increased this risk. We can’t estimate the population attributable risk from these data, but given the prevalence of laryngomalacia, it’s a fair assumption that it’s high even if their group was higher risk symptologically. The bottom line as Siobhan Carr and Stefan Unger’s elegant editorial makes clear is that a chronic cough in a child with tracheomalacia is bronchiectasis till proven otherwise. There’s still a window here, but, once a threshold is crossed, reversibility can’t be assumed. See pages 566 and 523
Bladder training: folklore and reality
Until now, no enuresis assessment would be complete without bladder training advice. This makes sense: we all proffer similar tips. The reality, though, is that, under scrutiny, it might not be robust to EQUATOR ‘interrogation’. Tryggve Nevéus and colleagues in Uppsala, Sweden approach this question head on in a three pronged RCT comparing bladder advice, allocation of an enuresis alarm and a non-intervention control group. All were screened for constipation and treated as appropriate. The enuresis alarm stood out as effective, the bladder advice group however, faring no better than the controls. See page 571
Rewriting the headlines
We have an innate duty to absorb and react to new findings. Early in the pandemic, the news consisted of (among others) the increased risk of child abuse as a result of isolation and distancing. A series of single centre case series from large centres able to take extra referrals (but potentially misrepresent the whole picture) during the disruptions inherent to the first few months fuelled this argument. However, the retrospectoscope, as is often the case is the tool of choice in Stevras Stivaros, England wide (all major centres outside London) comparison of prepandemic skeletal survey investigation load. The numbers were large and findings compelling and, even though the pandemic data was early (and that domestic stresses could have appeared later) hints (and complacency clearly has to be avoided) that the initial picture could have been skewed. See page 576
Global child health
Neonatal respiratory care in low and middle income countries
I remember nasal CPAP being used in the university hospital in Port Moresby, Papua New Guinea (home at the time in the early 1990s), so in some ways, it’s rather intriguing that it is still being debated. Kristen Sessions’ and colleagues’ systematic review and meta-analysis of adverse events with CPAP in neonates in LMICs, showed no significant benefit. There’s a rider in that there were very few studies suitable for synthesis, but the three that were pooled, flagged perhaps the most important lesson; that success was dependent on context. Characteristics including the location (a high dependency or intensive care area), adequate numbers of staff trained in CPAP use, close monitoring and mechanisms for escalation, daily direct physician supervision and equipment both age appropriate and user-friendly. This is beautifully illustrated by Rebecca Richards-Kortum and colleagues’ pre-post implementation (oxygen alone to oxygen with CPAP in the 1.0–1–3 kg birth weight group) study from government hospitals in Malawi. The pre-introduction period of training (is this the main dealbreaker?) was lengthy but justified given the improvements – survival increasing from 17.9% (before) to 30.1% (after) introduction. See page 545 and 554
London, April 2020
The COVID-19 pandemic is building up steam, but children are reassuringly non-vulnerable… at least until a new entity is reported after a spate of negative appendicectomies for abdominal pain, colitis, carditis and systemic inflammatory unwellness. There is overlap: IL6 and ferritin are high; there is positive COVID-19 serology; there are prothrombotic changes. The first case series are fast out of the blocks. After a rapid gestation and delivery, a new syndrome arrives earning itself two names, MISC and PIMS-TS, both now so familiar it would not cause any eyebrow-raising on a ward round.
Patient consent for publication
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.