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Evidence base for interventions to reduce acute admissions
There is a broad consensus that if children are unwell, and it is safe to do so, acute management is best in the home setting. There has been a considerable drive to achieve this as most appropriate and cost effective strategy to manage acute illness in childhood. This has involved an increase in the consultant ‘delivery’ at the coal face with the intent to streamline decision making and improve patient flow. Many hospitals now have acute paediatric assessment units working in close collaboration with or as part of the accident and emergency department. Coon et al in their systematic review of interventions to reduce acute paediatric admissions highlight the lack of an evidence base for this change. This should challenge us to at least investigate service changes made and confirm that what we all feel is right is right and therefore confirm that the service changes are correct and appropriate. See page 304.
Bronchiolitis: ready for discharge
Challenging discharge guidance for bronchiolitis Cunningham et al have looked at the potential effect of two guideline discharge oxygen saturations (≥90% and ≥94%) in recovering bronchiolitis once feeding issues have resolved. Most Infants admitted with bronchiolitis (UK data) stay for around 3 days. Many factors are involved in the timing of discharge but if the lower guideline discharge oxygen saturation were adopted infants could potentially be discharged on average 22 h earlier. Clearly there would be a significant cost saving although the safety and practicality of this change needs further exploration as is planned by the authors. See page 361.
Outcome of cardiovascular abnormalities in Down's syndrome
Cardiac abnormalities are common in Down's syndrome. Irving et al report the spectrum, management and survival in a large cohort over a 22 year period. This dataset is important for clinicians involved in counselling families and then the long term management of infants, children and young people with Down's syndrome and reflects a significant improvement in the outcome for infants with Down's syndrome and cardiac disease. Forty-two per cent of the 821 live births had cardiovascular anomalies. The commonest abnormality was an atrioventricular septal defect (37%), followed by ventricular septal defect (31%) and atrial septal defect (15%). Twenty-three per cent had more than one anomaly. Most cardiac defects were amenable to surgery, with surgery rates increasing from 62% (1985–1995) to 72% (1996–2006); with corresponding surgical death rates falling during the same period from 30% to 5%. Single ventricle palliation for complex disorders and cardiac transplantation for cardiomyopathy have been carried out with a good outcome. One year survival for infants with cardiac anomalies has improved from 82% to 94%. See page 326.
Nasopharyngeal airway in Pierre Robin sequence
Upper airway obstruction is common in Pierre Robin sequence (micrognathia, glossoptosis, cleft palate). Abel et al report their experience of 104 referrals over 10 years. Twenty-seven patients were managed conservatively, 63 by nasopharyngeal airway and 14 by tracheostomy. Nasopharyngeal airways were used on average for 8 months. The authors highlight the low usage of tracheostomy promoting the conservative management (with or without airway) as being successful in more than 86% of cases. See page 331.
Paediatric palliative care
Paediatric palliative care is a specialty in its infancy. Hain et al trace the origins of palliative care in children looking at its current strengths and the challenges in establishing consistent standards of clinical expertise, education and research. Specialty recognition has enabled the development of a curriculum and competencies ranging from those expected of all clinicians to those required by the specialist clinician.
Life threatening or life limiting conditions are increasingly prevalent in childhood. It is estimated that there are 20 000 children in England with life threatening or life limiting conditions who are likely to need palliative care input. It is a priority to establish local needs and care pathways through networks and support the further development of this important specialty. See page 381.
Education and Practice: adolescent focus
We all recognise that the needs of our adolescent patients are not always well met. Adolescence is a time of massive change for the individual and significantly more challenging if you have a chronic illness. Education and practice have made this their focus this month with articles on the development and running of an adolescent unit and how best to achieve it and make it work, the management of Anorexia Nervosa, research involving young people and the important issue transition to adult services. These four articles give focused and practical advice on these important aspects of adolescent healthcare.
On a personal note
It is a real honour to take on the role of Editor in Chief of this prestigious journal. I feel humbled by the task. I have been actively involved as Associate Editor for Gastroenterology and Nutrition since 2006. I have found that role stimulating and enjoyable. I have been impressed by the strong team approach to the journal development and the time, energy and enthusiasm put into creating excellence.
The journal is an essential part of the professional development of paediatricians nationally and internationally with a reputation for publishing high-quality research, up to date reviews and education packages responsive to the reader's needs.
I see the challenge and my vision as Editor in Chief to provide leadership to the strong and committed team further developing the academic credibility, educational profile and international reputation of the journal.
The success of the journal is through its readership and I hope very much I can count on your support.