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Highlights from this issue
  1. R Mark Beattie, Editor in Chief

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Can foster care ever be justified for weight management?

This is an interesting and important question – can foster care help with severe obesity? Children should only be separated from their parents if it is in the best interests of the child. In this issue Williams and colleagues report on the impact of placing a 12 year with long-standing intractable obesity into foster care. It is a complex case with complex issues and it is clear many other strategies were tried first. It took time for the foster carer to impact on his behaviour with an initial period of weight gain. The longer term impact was profound with the child's BMI falling from 45.6 to 35 over 18 months. The authors discuss the detail and other cases from their unit. Childhood obesity is often only one of many concerns during safeguarding procedures. The authors conclude that removal of a child from obesogenic environment should be considered if there is failure of the parents/carers to address the obesity as a major cause for concern and all other avenues have been explored. See page 297

Reflective practice

Reflection is an essential part of medical practice and all good doctors reflect on their practice as part of their ongoing professional development. In the new era of revalidation we have to provide evidence for it as part of the annual appraisal process. The challenge much discussed is just how to do that. Deborah Murdoch Eaton and John Sandars discuss the educational theory underpinning reflection, the importance of refection for enhancing performance and consider how to enhance its value within current paediatric practice. The concepts discussed are useful and practical including consideration of reflection as a ‘reflective, active and deliberate’ thinking process that requires the relationship between present and previous experiences to be linked together. Effective reflection has the potential to change practice by striving to generate insight to facilitate change – the stages of ‘generativity’ being reflection, introspection, critique and personal voice. The authors discuss current approaches to reflection for professional development, meaningful professional development from reflection including dialectic reasoning which is the practice of arriving at a conclusion by the exchange of logical arguments and give an example of a useful reflective log template for single identified and cumulative events. Key features of productive reflection are listed. Certainly effective reflection requires specific skills and this article helps to rationalise the thinking behind the increasing emphasis on it. In an accompanying editorial Henrik Steinbrecher discusses ‘proving I am improving’ giving his perspective as an appraisal lead for a large organisation. See pages 279 and 188

Next-generation sequencing

There is a constant demand to keep up to date – embracing new ideas, treatments and technologies that enhance your practice. Reflecting on how best to keep up to date with advances in genetics is just one of many challenges. There is no doubt that next-generation sequencing is one of those key developments which is set to transform clinical diagnostics in every branch of medicine. Schnekenberg and Nemeth explain the basic concepts, give examples of its role in clinically applied research (where is has already been instrumental in identifying hundred of novel genetic syndromes) and examine the challenges of its introduction into clinical practice. The technology is explained with discussion of different sequencing strategies including targeted, whole exome and whole genome. The clinical potential including discoveries, diagnostics and ethics are explored in detail. Treat the article as an important update. Next generation sequencing offers the potential to profoundly alter diagnostics and investigation of the genomic contribution to human disease although there are many challenges involved in the effective, ethical and cost effective introduction into routine clinical practice. See page 284

Factors associated with early neonatal attendance to the paediatric emergency department

The provision of out of services for acute medical care has received considerable coverage over the last few years with increased attendances to emergency departments. Newborn infants are a particularly vulnerable group with modern postnatal care promoting early discharge of term infants. Flanagan and colleagues report factors associated with early neonatal (term babies less than 2 weeks) attendance to the emergency department at the Royal Belfast Hospital for Sick Children. 208 babies (223 attendances) attended over a 6 month period, 62% out of hours. Common presentations included feeding difficulty, vomiting and faltering growth. 24% were admitted (34% for less than 24 hours). Significant risk factors for attendance were low birth weight, social deprivation and a postnatal stay of greater than 48 hours. This is a large cohort of babies, most are discharged after assessment or within 24 hours. The authors rightly conclude that this data should inform better models of care for this vulnerable patient group. See page 239

Inhaled corticosteroids and children's growth

This is an important issue to patients, parents and clinicians. Andrew Bush summarises the evidence including data from the Children's Asthma Management Program in the USA. In children treated with 400mcg of budesonide long term (4 to 6 years) there was a deficit in final adult height of 1.2cm (compared to placebo), with the impact on height velocity principally in the first two years of treatment. There are issues that arise from this data set. Children may have received a higher dose than needed and received it long term and delivery was via a dry powder device rather than a metered dose inhaler and spacer. These issues are explored with discussion of different asthma treatment strategies, the need to increase treatment during exacerbations, the need for regular treatment reviews and the potential impact of asthma per se on growth. See page 191

In F&N this month

Neonatal hypoglycaemia can lead to devastating consequences and constant, accurate and safe glucose monitoring is crucial. Woo and colleagues discuss monitoring options and describe new methodologies for non-invasive glucose monitoring in newborns. In a second article Hawkins and colleagues examine compliance with the Baby-Friendly Hospital initiative and impact on breastfeeding rates in Maine, USA – it is an interesting read. The initiative does impact on breast feeding rates although compliance with the initiative needs to improve and there remains much to be done to promote and maintain increased breast feeding rates.

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