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It’s not as if the clues weren’t there. Once the cache of documents (many calligraphically etched) were disinterred from the mahogany box under cobweb-veiled trapdoor beside the ever-penumbral fork in the forest trail, events moved quickly. The chronology, ultimately unchallenging, left no doubt that earlier intervention (C’s animus and D’s parsimony were both surely modifiable) and the matter (in the police vernacular) ‘resolved’? ‘Prevention’ became the new mantra, billboards to this effect even appearing at Red Sox games. The rest, as they say is up to you.
Global child health: early child development
You won’t have failed to notice the emphasis (a deliberate one) on ECD recently. This month, Zahra Hoodbhoy at the Aga Khan University, Karachi, demonstrate the excess risk associated in all domains of fetal growth restriction using antenatal doppler data (exposure) and the validated Malawi tool (outcome). Neatly following this trajectory, Karen Emond and colleagues assess which interventions work. To date research has suggested Healthcare Provider (HCP) administered ECD programmes can improve individual level motor and cognitive outcomes. This meta-analysis puts the evidence under more scrutiny, though, the earlier findings are robust to the extra interrogation. Maternal mental health though did not benefit. This is unfortunate, perhaps not surprising given the additional social constructs on which this depends. Indulge me in my broken-stylus repetition in maintaining that addressing maternal depression and female literacy are the keys to enhance what are positive, but so far only modestly positive interventions. See pages 258 and 247
Paediatric emergency medicine: autism in the ED
Parents of children with autism are far more likely than their non-autistic counterparts to present urgently for management of ‘behaviours of concern’: externally or internally directed verbal or physical violence beyond what is manageable at home even in the most experienced parents. The behaviours, as Jasmin Pillai and colleagues’ qualitative work from Melbourne illustrates are sometimes even beyond the ED. After purposive sampling, interviews and inductive thematic analysis, several flags became apparent. The first was an inability to access community care, the second an exhaustion of home strategies not helped by parental burn out. Finally, no family ‘wanted’ to resort to the emergency department (a rational fear of being judged non-competent or non-resilient) but had been left with no choice. Without even needing to read between the lines, there are issues here for regular respite and child and adolescent mental health cover out of hours in the ED. These issues are not unique to Australia: they will resonate for us all: the same scenario could be playing out in front of you, the reader in a few hours’ time, 3AM on your own on call… See page 264
Drugs and therapeutics. vascular access: something in the way?
We’ve talked before about implementation: what happens after the phase 1, 2 PK and PD studies, the RCT, publication, dissemination and, one hopes guidance. Even beyond this, the road is not necessarily pothole free. Joseph Bulmer and colleagues illustrate this beautifully with two papers, one in vivo (epinephrine in neonates) and one in vitro testing the effect of and delays to detecting line occlusion in pump administered IV treatment. The sensitivity of circulatory parameters to changes in line diameter from occlusion is perhaps intuitive (but, even the intuitive needs to be demonstrated at least once) but the delay in alarm triggering to a lower volume/higher drug concentration needs to be appreciated – particularly given the change in guidance to this approach- and the potential consequences of delays in detection. See page 313
Covid: long or short?
In the early days of the pandemic, no more at least than a year or so in, when we were still ‘learning’ about the disease, several uncontrolled studies pointed to a high prevalence of chronic fatigue like symptoms after the initial infection. Criteria for the newly dubbed ‘long covid’ were agreed consensus panel (Stephenson et al doi.org/10.1136/archdischild-2021-323624) as a starting point for more detailed exploration of both epidemiology and causal association. The same group, Terence Stephenson, Snehal Pinto Pereira and colleagues at UCL, London took this further and their data from an exposed and unexposed cohort are presented in this issue. An impressive 6,000+children from each group were enrolled and followed for 6 months, adjustment being made for infection and vaccination during the follow-up period. Six-months post-testing, the most common symptoms in test-positives were tiredness and shortness of breath: other symptoms affected less than 10% of test-positives. The most common symptoms in test-negatives were also tiredness, headaches and shortness of breath in that order; others were reported in less than 10%. Mental health and quality of life were comparable between groups. The cohort is as good as we will get in terms of estimating an effect, but of course (cognisance of infection, media exposure) is susceptible to both selection and recall bias which no amount of propensity score matching can resolve. These biases are likely away from the null so any differences found potentially overestimates and I think, for now, we can cautiously file under ‘reasonably good news’. See page 289
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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.
- Paediatric emergency medicine
- Global child health
- Original research
- Global child health