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  1. Nick Brown, Editor in Chief1,2,3
  1. 1 Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
  2. 2 Department of Paediatrics, Länssjukhuset Gävle-Sandviken, Gävle, Sweden
  3. 3 Department of Child Health, Aga Khan University, Karachi, Pakistan
  1. Correspondence to Dr Nick Brown, Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala 75237, Sweden; nickjwbrown{at}gmail.com

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Cherry Picking

Checkov’s The Cherry Orchard lit up the literary world at the dawn of the 20th century, its portrayal of the inexorable decline of the aristocracy and the lost sense of purpose of the bourgeoisie still resonates and is widely performed today. Though the pathway arguably doesn’t lend itself to standard modelling, (directed acyclic graphs welcome), the trails all end with the identification and consumption of (the perceived) best fruit. Shoegazingly, blushingly, we’ve all, at some point been guilty of the metaphorical equivalent, the weeding out of awkward data in place of the comfortable, comforting, but inheritably flawed mythologies which for some reasons are so hard to let go—let’s file this ‘personal bias—the human condition’. Redemption is more than afforded in this issue, so plenty of opportunity to try again…

Disarmed with knowledge

Occasionally (my hunch is somewhere between Haley’s comet and the Olympic flame lighting ceremony in frequency) an idea so brilliantly obvious is aired that one is forced to stand still, breathe deeply and simply applaud the audacity. This doesn’t mean every jaw drops in unison, naysayers inevitably now airing their opinions on social media, a symptom of the ostrich-like conservatism that permeates our collective nature. For decades, standard practice for pregnancies deemed of perinatal high risk as a result of a range of antenatally detected anomalies have been delivered ‘early’ (by induction or CS) at an appropriate time before the estimated delivery date. This has been based on the ‘much better to know in advance’ philosophy. Much ‘worse’, the traditionalists would argue to not know, but (and I ask rhetorically) is this always the case? Often overlooked, is that this practice, inevitably, involves incurring a small (but, not negligible) degree of prematurity. This is just one angle, early knowledge also theoretically triggering stress-mediated adverse pathways. Siva Namachivayam and colleagues’ study in Melbourne and Victoria Jowett’s (Great Ormond St Hospital, London) editorial examine early outcomes in maternal-child dyads by knowledge or not of antenatal diagnosis of transposition of the great arteries (TGA) in a state wide study in Victoria, Australia. In short, antenatal diagnosis was associated with longer ventilation time, PICU and hospital stay, mediation analysis suggesting the pathway ran through GA. So, while, even in a study so robust, there might be residual confounding and the findings not necessarily applicable to all congenital heart disease, this, at the very least, should give us pause (and cause) for reflection. See pages 16 and 1

Aversion therapy

We all have mental pictures of a ‘typical’ at-risk of harm child: sometimes, this likely reflects our own (experiential) biases; sometimes it is more diffuse. Unlike the now advanced literature on injuries (after they’ve occurred) and features of non- accidental causes, little is known about the advance predictors, about those whose trajectory might be modifiable. Jennifer Smith and colleagues at the Sick Kids, Toronto, Ontario, Canada and UCL, London linked and retrospectively interrogated demographic and hospital episode databases between 2005 and 2017 to identify (adverse) outcomes by several candidate vulnerabilities: maternal age, own vulnerability (inter-partner violence, SES, substance abuse, homelessness and mental health) using logistic regression to estimate predictive value of each. Maternal age (OR 5.5) and mental health diagnoses (OR 2.0) stood out independently, age a predictor up to 28 years and their compelling discussion leaving no doubt as to the way ante, peri and post natal services could contribute to future prevention. See page 23

Immunocompromise and risk: a sequel

We’ve published a great deal in the recent past around the safety of shorter antibiotic courses in low risk groups of children with haematological malignancy. Alexander Martin at Newcastle University, UK and colleagues take the story a step further using data from the multinational Feverkids study including children with a range of immunosuppressive diseases (including cancer, immune modulating treatment and HIV). Their model included a range of clinical signs (‘exposures’) to predict both pneumonia and (other) serious invasive infection. It performed well for pneumonia both in terms of ruling in and out (fewer chest x rays can be no bad thing), but less so for other SBIs. In a hint of the future, the authors raise the possibility of adding cytokines or personalised microbiological RNA testing to enhance the model. See page 58

Global child health

Neonatal malaria: too soon to abandon the microscope

For a disease near unique in its (sic) stubbornness, malaria continues to confound. There has, though, over the last decade or so been more of a spring in the step of research. One major such advance was the validation in older children of rapid diagnostic tests, essentially antibody assisted detection of specific malaria antigens such as HRP2. This reached the point some time ago that RDT testing became part of WHO recommendations. The predictive value in neonates (those with suspected congenital, transfusion-related and early acquired malaria), however, is far from clear. This group is different in terms of haemogoblin (F rather than A) and transferred maternal antibody blunting the RDTs. Yasanga Adeniji and colleagues in Gome teaching hospital, Nigeria estimate the validity in this group against the trophozoites- on -microscopy standard, a test that is far from universally available. The RDT did not perform well either in sensitivity or specificity, an important finding which means that attention will need to turn to other RDTs or, in the short term, back again to the Giemsa stain and lens. See page 11

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Footnotes

  • Contributors -

  • 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.