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Increase in emergency admissions
Gill and colleagues report a sustained year on year increase in emergency paediatric admissions over the last 10 years; 63 per 1000 in 1999, 81 per 1000 in 2010. This is by analysis of Hospital Episode Statistics (under 14 years of age) and population estimates for England. Most of the increase (2 fold) is in admissions for less than 24 h offsetting a small decline in admissions for greater than 24 h. Considering specific conditions admissions rates for upper respiratory tract infection rose by 22%, lower respiratory tract infection by 40%, urinary tract Infections by 43% and gastroenteritis by 31% whereas admission rates for chronic conditions fell by 5.6%. The increase in admissions is likely, at least in part, to reflect changes in health care delivery with the 4 h wait target in emergency departments and increased dependence on paediatric assessment units for the assessment and management of children presenting with acute illness. Other factors such as referral thresholds/parental expectations and rapid access to investigation and diagnosis may also play a role. This important change and its potential causation is discussed at length by the authors and in an accompanying editorial by Colin Powell who poses the critical question as to whether we need to change the way we deliver unscheduled care. See pages 328 and 319
Increasing prevalence of childhood visual impairment
WHO estimates that 19 million children are visually impaired worldwide with 1.4 million being blind, 90% living in developing countries. Mistry and colleagues explore temporal trends in incidence in England over the last 30 years. Blind (legal definition) refers to being so blind that the individual cannot do any work for which eyesight is essential, partial sight (no legal definition) refers to substantially and permanently handicapped by defective vision caused by congenital defect, illness or injury. Registration is voluntary. The incidence of new registrations of blindness (all ages) has decreased 2.6 per 10 000 (1982) to 1.7 per 10 000 (2011). The incidence of new paediatric registrations of blindness (a small proportion of the total) has increased from 0.17 to 0.41 per 10 000 during the same period, with an increase in the incidence of new registrations of paediatric partial sight from 0.2 to 0.59 per10 000. This reflects a significant increase in the incidence and thereby prevalence of visual impairment in childhood and while some of it may reflect an increase in awareness and therefore diagnosis it is important that there are adequate health, educational and social resources to cope with this increased need. See page 378
Risk benefit of male circumcision
In 2012 the American Academy of Paediatrics radically changed their previous circumcision policy asserting that the preventative benefits of circumcision in newborn infants (reduced urine infections, transmission of sexually transmitted infections, penile cancer) outweighs the risk of the procedure when performed by trained professionals under sterile conditions with appropriate pain management. This has provoked controversy, discussion and debate and was not supported by other national paediatric and surgical specialist organisations and is discussed by Wheeler and Malone in a leading article. In the UK 30 000 circumcisions are performed annually, mostly in the community and apart from specific indications (therapeutic) not funded by the NHS. This can result in increased risk, although there are suggested standards of care that all boys should receive wherever the procedure is performed. The care standard has implications for clinicians involved and with continued (international) debate regarding the indications, funding and appropriate place for the procedure to be performed the risk benefit discussion gets more and more complex. See page 321
Adolescents with physical disability—seeing the individual in context
Adolescence is a time of profound developmental change—physically, cognitively and socially. Physical disability can produce significant barriers and challenges. In an excellent review Catherine Tuffey discusses this, exploring fundamental issues such as the practicalities and timing of puberty and the transition to the adult role when independent living and employment are less likely to be achieved, emphasising that expectations need to be realistic and appropriate. Different contexts are explored including peer group and family, work, identity, leisure, autonomy and intimacy and sexuality with practical guidance on how clinicians and other health care professionals can support the process. The article is essential reading for those of us who care for young people with physical disability. There is a helpful list of suggestions for how health professionals can help the young person negotiate through adolescence which includes sensitive exploration of aspirations and expectations, encouraging socialisation, encouraging young people to explore their strengths, skills and autonomy and recognition of the need for young people to have sufficient time alone when they choose, as well as time with friends without adults present. See page 373
In F&N this month
There are a number of articles looking at factors that influence outcome after extreme preterm birth. Abdel-Latif and colleagues report worse neurodevelopmental outcomes in infants conceived after assisted conception. In a separate paper the same group report (across 10 neonatal units) that extreme preterm infants who survive the first few days have a reasonable chance of survival to discharge. In a third report, Boland and colleagues explore the National Institute of Child Health and Human Development calculator as a tool to predict morbidity and mortality at 2 years in 114 infants born less than 26 weeks and suggest that it is accurate for mortality (47.1%, 49.5%) but perhaps over estimates death or survival with major disability (72% vs 60.5%). The tool incorporates gestation, gender, birth weight, plurality and any maternal factors such as corticosteroid usage. These data are useful and add further to the outcome data on extreme preterm infants and the factors that influence it.