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Anxious mothers… anxious babies
Excessive crying is common in infancy and the aetiology and threshold for referral/consultation complex with at its extreme associations with child abuse, early weaning and maternal depression. Petzoldt and colleagues, in a prospective cohort (n=306), report the relationship between maternal anxiety and depressive disorders and excessive infant crying (>3 hours per day on ≥3 days per week for ≥3 weeks). 29/286 (10.1%) reported excessive infant crying. Infants of mothers with anxiety disorders prior to pregnancy were at higher risk (OR 2.54, 95% confidence intervals 1.11–5.78). Risk was increased when additional incident anxiety disorders during pregnancy were considered (OR 3.02, 95% confidence interval 1.25–7.32) and until 16 months post partum (OR 2.87, 95% confidence interval 1.13–7.28). In this cohort maternal depressive disorders were not associated with increased infant crying. The association between maternal anxiety and excessive crying was not explained by socio-demographic and perinatal confounders. This association between anxiety and infant crying is important and has been little studied. The authors recommend consideration of maternal screening during the perinatal period in order to help target appropriate support and potential impact.
In an accompanying editorial Harriet Hiscock discusses the findings and implications and reflects on the complex aetiology of infant crying which include a combination of environmental, behavioural and genetic factors. She finishes on a sensitive note – these issues need to be dealt with in a careful and considered manner so that we don't end up making anxious mums more anxious by blaming them for their infant's crying. See pages 800 and 793.
Inattention and ADHD in children born preterm
Children born preterm are at increased risk of ADHD. It has been suggested that inattention is core deficit (rather than hyperactivity/impulsivity). Inattention may be less easy to recognise and is an early risk factor for poor academic performance. Brogan and colleagues report the outcome of screening children at age 8 to 10 years (117 very preterm, less than 32 weeks; 77 term born controls) using the Strength and Difficulties questionnaire (SDQ), Du Paul ADHD rating scale and teacher report of special educational needs. Parents and teachers rated very preterm children with higher SDQ hyperactivity/inattention scores than term born infants (parents RR 4.0, 95% confidence interval 1.4–11.4). Examining ADHD dimensions further parents and teachers reported significantly more inattention symptoms than controls (parents RR 4.8, 95% confidence interval 1.4–16); in contrast there was no significant excess of hyperactivity/impulsivity. The effect persisted when children with SEN were excluded. This study suggests that very preterm children are at greater risk of inattention than hyperactivity/impulsivity. This has important implications for the recognition and management of ADHD in children born preterm. See page 834.
Managing difficult asthma
It is interesting to look at the evidence base for commonly used treatments. Starsky and colleagues discuss intravenous salbultamol for childhood asthma. It is an interesting read. Certainly more research is needed – there is very little data regarding efficacy and significant potential toxicity including lactic acidosis and tachycardia which by increasing respiratory workload could exacerbate respiratory failure. Important research questions include – is the treatment efficacious and safe, what is the optimal intravenous bolus, what are the best doses across the age range, should inhaled treatment be stopped during intravenous treatment, what are the risks of treatment at high dose and how is this best monitored. See page 873.
Adolescent inpatient data (1999–2010)
There is much debate on how best to deliver health care for adolescents particularly during transition. Hargreaves and colleagues by analysis of finished consultant episodes (FCE) from English patients aged 10 to 19 between 1999 and 2010 provide interesting and important data. Female inpatient activity increases steadily between age 10 years (70.9/1000) and 19 years (281.7/1000) of which 155.9/1000 were for non obstetric care. The non obstetric care increase was across all health domains. Male inpatient activity increases from 84.6/1000 to 104.5/1000 mainly as a consequence of injuries. Over the 11 years adolescent FCE's have increased by 14.2%. Adolescents are admitted over a wide range of specialities. This data further supports the need for clinicians with specific knowledge skills and expertise in adolescent medicine. See page 830.
Withdrawal of intensive care outside the intensive care unit
The majority of children who die in hospital do so in an intensive care environment although this doesn't necessarily have to be the case particularly if planned. Laddie and colleagues review their experience of planned withdrawal of ventilatory support outside the intensive care setting with the intent of developing guidance for practice. Over a 10 year period 18 children were considered. Three died prior to transfer. Transfer locations included home (5), hospice (8), and other (2). The primary diagnoses varied, all had multi system pathologies. Outcome following transfer is discussed in detail including practical, ethical and resource issues. Most children (12) died within 13 hours of extubation, although one child survived post extubation and was later discharged from palliative care services. The authors discuss and provide guidance for specific phases – introduction of withdrawal, preparation prior to transfer, extubation, care post extubation and care post death. Planning withdrawal of intensive care support is challenging and resource intensive. The authors recommend the development of local collaborations and guidance which can potentially enable parents to consider a preferred place for their child to die which may be outside the intensive care unit. In an accompanying editorial Anton Mayer discusses giving patients a choice on a difficult journey exploring further some of the many challenging practical and ethical issues. See pages 812 and 795.
In F&N this month
Managing palliation in the neonatal unit
The important topic of managing palliation in the neonatal unit is addressed in a leading article (see page 349) which summarises guidance developed by the Chelsea and Westminster NHS trust in conjunction with the Royal College of Paediatrics and Child Health. It is evidence based and practical with guidance on care of the family, pain relief, monitoring, fluids and feeds, withdrawal of care, addressing conflict and supporting the families during and post bereavement. Good palliative care requires a committed multidisciplinary team. The authors highlight the need for education and training, guidance implementation and improved research into this important area so that we can do our best for the vulnerable infants and families in whom disease is not responsive to curative treatment.
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