Safety netting in the Emergency Department (ED) is key to the
practice of safe medicine. Following the article by de Vos-Kerkhof (1),
we present further evidence to suggest that there is a lack of
standardised safety netting. In addition, we found a disparity between
paediatric trainees' perception of their safety netting practice and what
they actually documented in the medical notes.
Safety netting in the Emergency Department (ED) is key to the
practice of safe medicine. Following the article by de Vos-Kerkhof (1),
we present further evidence to suggest that there is a lack of
standardised safety netting. In addition, we found a disparity between
paediatric trainees' perception of their safety netting practice and what
they actually documented in the medical notes.
In a retrospective case notes review of 100 consecutive ED
attendances to our hospital seen by the paediatric team and discharged
from ED, only 16% had documentation that the families had been told about
the existence of uncertainty around the diagnosis and the course of the
illness. This compares unfavourably with the fact that 73% of surveyed
paediatric trainees reported that they routinely mentioned this to
families. Furthermore, the signs and symptoms to look for had only been
documented in 27% of cases, though 88% of trainees reported discussing
this with the family. 39% of the notes reviewed had no specific safety
netting documentation of any kind.
It is clear that for non-consultant paediatricians, who are the
clinicians seeing most referred children in ED, a gap exists between the
safety netting that they report undertaking and what is documented. This
may be in part because they provided verbal safety netting advice without
documenting it but it also suggests that safety netting procedures are
poor, despite the clinical and medico-legal imperative for adequate safety
netting and documentation advocated by the National Institute for Health
and Care Excellence(2).
Clearly training for junior doctors on safety netting and its
documentation needs to improve. A safety netting checklist and more high
quality patient information leaflets may help clinicians to offer adequate
advice and information to families at the time of discharge.
(297 words)
1. de Vos-Kerkhof E, Geurts DH, Wiggers M, Moll HA and Oostenbrink R.
Tools for 'safety netting' in common paediatric illnesses: a systematic
review in emergency care. Archives of Disease in Childhood. 2016; 101: 131
-9.
2. Fields E, Chard J, Murphy MS and Richardson M. Assessment and
initial management of feverish illness in children younger than 5 years:
summary of updated NICE guidance. BMJ (Clinical Research Ed). 2013; 346:
f2866.
Khan et al. make a strong case for investment in point-of-care
lactate testing in low and middle income countries (LMICs) (1). They
believe that this would identify children at high risk of death, and would
save lives because these children could receive earlier resuscitation.
Unfortunately the optimal management of children with hyperlactataemia in
LMICs is far from clear. Although Khan et al. extrapolate from findings i...
Khan et al. make a strong case for investment in point-of-care
lactate testing in low and middle income countries (LMICs) (1). They
believe that this would identify children at high risk of death, and would
save lives because these children could receive earlier resuscitation.
Unfortunately the optimal management of children with hyperlactataemia in
LMICs is far from clear. Although Khan et al. extrapolate from findings in
well-resourced settings to suggest that early fluid resuscitation would be
beneficial, this is contrary to the findings of the FEAST study in which
bolus fluid resuscitation in African children with signs of shock produced
an increase in mortality (2). Of note, this effect was also observed in
the subgroup of children with hyperlactataemia.
Not only is hyperlactataemia a consequence of sepsis, but it is also
a defining feature of severe malaria which is a common cause of death in
many LMICs (3). Unlike the situation in sepsis, the pathophysiology of
hyperlactataemia in malaria is thought to involve microvascular
obstruction by parasitized red blood cells, microvascular dysfunction, and
anaemia (4,5). Aggressive fluid resuscitation is discouraged in severe
malaria, and detailed physiological studies in adults with severe malaria
showed that fluid resuscitation failed to reduce microvascular obstruction
and lactate concentrations (5). However, when hyperlactataemia is
associated with severe malarial anaemia, blood transfusion can be
lifesaving (3).
It is likely that point of care lactate testing in LMICs would
achieve the goal of identifying children at higher risk of death, but it
is far from certain whether this would be accompanied by the improved
outcomes that would be needed to justify the investment. Amongst children
with malaria it may identify the need for parenteral artesunate or blood
transfusion, but in children with sepsis further research is needed to
define the optimal management strategies when intensive care is limited or
unavailable.
1. Khan M, Brown N, Mian AI. Point-of-care lactate measurement in
resource-poor settings. Arch Dis Child 2016;101(4):297-8.
2. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in
African children with severe infection. N Engl J Med 2011;364(26):2483-95.
3. World Health Organization. Guidelines for the treatment of malaria.
Third edition, 2015.
4. Miller LH, Ackerman HC, Su XZ, et al. Malaria biology and disease
pathogenesis: insights for new treatments. Nature medicine 2013;19(2):156-
67.
5. Hanson JP, Lam SW, Mohanty S, et al. Fluid resuscitation of adults with
severe falciparum malaria: effects on Acid-base status, renal function,
and extravascular lung water. Crit Care Med 2013;41(4):972-81.
We agree that sirolimus may help children with Congenital
Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus
is, however, unlicensed, with little long term experience, and the
mechanism by which it reduces hypoglycaemia remains speculative. As
sirolimus is an immunosuppressant, its use in young infants has to be
carefully monitored in specialist centres under strict protocols. We are,
therefore, re...
We agree that sirolimus may help children with Congenital
Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus
is, however, unlicensed, with little long term experience, and the
mechanism by which it reduces hypoglycaemia remains speculative. As
sirolimus is an immunosuppressant, its use in young infants has to be
carefully monitored in specialist centres under strict protocols. We are,
therefore, reluctant to advocate the routine use of sirolimus in
Congenital Hyperinsulinism until more evidence has accumulated.
My child also has CSID. She is about to be 8 yrs old and has been on
Sucraid for the last 6-7 yrs. I am looking for an alternative to this
medication as sometimes we cannot get the medication and have to go a
strict diet until we can get some again. I will look into this alternative
and post results later.
We read with interest the review by Amirthalingam[1] and colleagues
of the potential value of a UK varicella vaccination programme. They cite
Blumental[2] and colleagues' article in the same issue which assessed the
burden of varicella and outlined some of the known complications, such as
bacterial skin and soft tissue infections, pneumonia, and neurological
complications including meningitis and encephalitis. The Blumen...
We read with interest the review by Amirthalingam[1] and colleagues
of the potential value of a UK varicella vaccination programme. They cite
Blumental[2] and colleagues' article in the same issue which assessed the
burden of varicella and outlined some of the known complications, such as
bacterial skin and soft tissue infections, pneumonia, and neurological
complications including meningitis and encephalitis. The Blumental study
included complications occurring up to 21 days after onset of the
chickenpox rash. We wish to highlight further potential complications that
are possibly excluded from that definition but may be a significant
benefit of vaccination.
There is evidence that varicella infection is associated with an
increased risk of focal cerebral arteriopathy and arterial ischemic stroke
(AIS). In a UK study of incidence, Thomas[3] and colleagues identified 49
children with AIS following chickenpox and found that, in children, the
incidence of AIS during the following 6 months was four times that of
controls (summary incidence ratio = 4.07; 95% CI 1.96-8.45). The estimated
incidence ratio in adults was 2.13 (95% CI 1.05-4.36). Considering
varicella vaccination in a cohort of more than 3 million children, Donahue
and colleagues found no association with ischemic stroke.[4]
We believe that neurological complications of AIS, which can occur
many weeks after infection, were not considered in the review by
Amirthalingam and colleagues. Most of the complications that they reported
are transient or readily treatable, although meningoencephalitis can leave
long-term neurodevelopmental sequelae. There is a high risk of long-term
disability from childhood AIS and this places significant financial burden
on healthcare systems. We believe that this relatively uncommon but
important complication should be considered when determining the cost-
effectiveness of a varicella vaccination programme for the UK.
References
1- Amirthalingam G, Ramsay M. Should the UK introduce a universal
childhood varicella vaccination programme? Arch Dis Child. 2016
Jan;101(1):2-3.
2- Blumental S, Sabbe M, Lepage P; Belgian Group for Varicella.
Varicella paediatric hospitalisations in Belgium: a 1-year national
survey. Arch Dis Child. 2016 Jan;101(1):16-22
3- Thomas SL, Minassian C, Ganesan V, Langan SM, Smeeth L. Chickenpox
and risk of stroke: a self-controlled case series analysis. Clin Infect
Dis. 2014 Jan;58(1):61-8.
4- Donahue JG, Kieke BA, Yih WK, Berger NR, McCauley JS, Baggs J,
Zangwill KM, Baxter R, Eriksen EM, Glanz JM, Hambidge SJ, Klein NP, Lewis
EM, Marcy SM, Naleway AL, Nordin JD, Ray P, Belongia EA; Vaccine Safety
DataLink Team. Varicella vaccination and ischemic stroke in children: is
there an association? Pediatrics. 2009 Feb;123(2):e228-34.
The ADC Archivist recently reported that Freedman et al had revealed
that "old-fashioned clinical examination" missed about 20% of cases of
significant dehydration in children.[1] Their assessment of this work was
not surprising because the meta-analysis in the Journal of Pediatrics
carries the headline message that even the "most accurate, noninvasive"
methods could only "identify dehydration suboptimally", and it was a...
The ADC Archivist recently reported that Freedman et al had revealed
that "old-fashioned clinical examination" missed about 20% of cases of
significant dehydration in children.[1] Their assessment of this work was
not surprising because the meta-analysis in the Journal of Pediatrics
carries the headline message that even the "most accurate, noninvasive"
methods could only "identify dehydration suboptimally", and it was a high
quality analysis which only included studies that had accurately
quantified the degree of dehydration by serial weighings.[2] However,
Freedman et al's conclusions are misleading because they only selected
papers for analysis that had evaluated a rapid triaging tool, and none
which had undertaken standard full clinical examinations.
The four papers that qualified for Freedman et al's statistical
reanalysis had used the 'Clinical Dehydration' and 'Gorelick' scores to
detect dehydration secondary to gastroenteritis. The individual components
of these tests were not mentioned in their meta-analysis paper, but either
can be performed quickly on a fully-clothed infant in less than a minute.
They rely on scoring (a) the child's general appearance (seeking signs of
thirst, restlessness, lethargy and irritability, drowsiness, limpness,
cold, sweatiness, or coma), (b) whether the eyes look sunken, (c) if the
tongue feel moist, and (d) if tears are reduced or absent, all on simple
scales. They do not include any of the following components of routine
clinical examinations: capillary refill time, pulse rate and volume,
respiratory pattern, peripheral coolness, or skin turgor. As such, these
authors are not entitled to list their triage-type scoring as being the
"most accurate, noninvasive" clinical tests for dehydration. By presenting
their data as they did, Freedman et al may have produced a false-
impression among paediatricians about the sensitivity of full, careful
clinical examinations for evaluating fluid-balance status, and by
reviewing it as they did the ADC Archivist may have inadvertantly
perpetuated this confusion.
References
1. Archivist. Assessing dehydration. Archives of Diesease in
Childhood 2015;100:999.
2. Freedman SB, Vandermeer B, Milne A, Hartling L. Diagnosing clinically
significant dehydration in children with acute gastroenteritis using
noninvasive methods: a meta-analysis. Journal of Pediatrics 2015;166:908-
16.
Monika Bajaj and Amaka Offiah are to be commended for their
thoughtful and helpful review of the benefits and risks of skeletal
imaging in cases of suspected child abuse.(1) The diagnosis of child
abuse is a complex process which requires an evidence-informed approach
combining clinical acumen with collaborative multi-agency working.
Skeletal imaging, including CT scans, provide a valuable tool for the
clinician, but,...
Monika Bajaj and Amaka Offiah are to be commended for their
thoughtful and helpful review of the benefits and risks of skeletal
imaging in cases of suspected child abuse.(1) The diagnosis of child
abuse is a complex process which requires an evidence-informed approach
combining clinical acumen with collaborative multi-agency working.
Skeletal imaging, including CT scans, provide a valuable tool for the
clinician, but, as Bajaj and Offiah point out, is not without its risks.
The clinician must take a lead in informing the parents and other
professionals of the potential benefits of imaging, the inherent risks,
and the statutory responsibilities under which we work.
The concept of informed consent in such situations is problematic.
What reasonable parent will subject their child to a potentially harmful
procedure to rule out abuse which they 'know' has not happened?
Conversely, what reasonable parent, having abused their child, will
consent to a test which may help to prove that abuse? Parents must be
informed of the small but real risks associated with skeletal imaging and
that these need to be balanced against the clinical imperative to identify
or exclude injury and the statutory duty to investigate cases of possible
harm. Where parents do not give their consent to such imaging, the case
needs to be discussed with the multi-disciplinary team, and a decision
made as to whether to work with the increased uncertainty inherent in not
having a skeletal survey or CT scan, or whether to seek a court order to
obtain such investigations outwith parental consent.
Such decisions need to be made in the light of the known short- and
long-term harms caused by child abuse. These include a small risk of
fatality from severe physical abuse, and the much more prevalent ongoing
harm suffered by children living in contexts of ongoing physical or
emotional abuse and neglect. The risk of fatality, while clearly
significant, should not be overstated. Our current analysis of Serious
Case Reviews in England from 2009-14 suggests an average of 28-33 deaths
per year directly caused by child abuse (Sidebotham, unpublished data).
In their article, Bajaj and Offiah state that 'Data from Child Death
Reviews has identified "deliberately inflicted injury, abuse or neglect"
as the single largest category of childhood deaths with modifiable factors
in England.'(2) In fact, these data show that this is the category with
the highest proportion of deaths considered modifiable (65% compared to
20% overall). However, of the 784 child deaths for which child death
overview panels considered there to be modifiable factors present, only 28
(3.6%) were due to deliberately inflicted injury, abuse or neglect. This
compares to 185 sudden unexpected and unexplained deaths (24% of all
deaths with modifiable factors present); 178 deaths from perinatal or
neonatal events (23%); and 145 (18%) from trauma and other external
factors. Far from being the 'single largest category of childhood deaths
with modifiable factors', deaths from child abuse make up a very small
proportion of those child deaths which we, as a society, may be able to
prevent.
References
1. Bajaj M, Offiah AC. Imaging in suspected child abuse: necessity or
radiation hazard? Arch Dis Child. 2015;100(12):1163-8.
2. Department for Education. Child death reviews: year ending 31st March
2012. London: Department for Education, 2013.
This editorial is a very helpful review of the current state of the
debate.
I am concerned that zoster is under diagnosed in childhood because of
lack of familiarity in both primary and secondary care. Anecdotally it is
not uncommon in a paediatric unit, in otherwise well children, but does
cause significant concern and use of resources. This needs to be
accurately captured as it may shift the economic modelling...
This editorial is a very helpful review of the current state of the
debate.
I am concerned that zoster is under diagnosed in childhood because of
lack of familiarity in both primary and secondary care. Anecdotally it is
not uncommon in a paediatric unit, in otherwise well children, but does
cause significant concern and use of resources. This needs to be
accurately captured as it may shift the economic modelling used to decide
whether to go ahead with varicella vaccination.
In their excellent review on the hypoglycaemia in childhood the
authors suggest that for the management of the hyperinsulinaemic
hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who
do not respond to diazoxide may respond to the octreotide but the efficacy
of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11
are associated with severe HH that is unresponsive to...
In their excellent review on the hypoglycaemia in childhood the
authors suggest that for the management of the hyperinsulinaemic
hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who
do not respond to diazoxide may respond to the octreotide but the efficacy
of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11
are associated with severe HH that is unresponsive to medical treatment
with diazoxide and octreotide. The treatment option for patients with
medically unresponsive forms of diffuse HH is a subtotal pancreatectomy,
but some patients who have undergone surgery continue to have recurrent
hypoglycemia, whereas diabetes mellitus and exocrine pancreatic
insufficiency develop in others (1).
The authors of the review make no mention of the possible use of the
mammalian target of rapamycin (mTOR) inhibitor sirolimus recently reported
to be effective and safe for the severe, diffuse form of HH that had been
unresponsive to maximal doses of diazoxide and octreotide (2-5). No major
adverse reactions were observed during the 1-year follow-up period in the
first 4 cases described (2). This finding is reinforced by the latest
cases report of others infant (3,4) and older children (5).
The suggested method of action of sirolimus includes the reduction of
beta-cell proliferation, inhibition of insulin production, and induced
peripheral insulin resistance (4). The sirolimus-sensitive mTORC1 pathway
is present in the exocrine pancreas and the relatively sirolimus-resistant
IGF1R/mTORC2/Akt pathway is overexpressed in the beta-cells, thereby
suggesting that sirolimus is effective in treating diffuse HH by reducing
the transdifferentiation of exocrine elements to insulin-producing cells
(5).
Even if further studies are needed, primarily to identify long-term
sequelae and side effects, sirolimus appears to be a promising therapeutic
option to treat children with severe HH unresponsive to diazoxide and
octreotide.
Federico Marchetti, Vanna Graziani
Department of Paediatrics, S. Maria delle Croci Hospital, Ravenna,
Italy.
48121 Ravenna, Italy
e-mail: fedemarche@tin.it
References
1. Ghosh A, Banerjee I, Morris AAM. Recognition, assessment and
management of hypoglycaemia in childhood Arch Dis Child Published Online
First: 30 December 2015 doi:10.1136/archdischild-2015-308337
2. Senniappan S, Brown RE, Hussain K. Sirolimus in severe
hyperinsulinemic hypoglycemia. N Engl J Med 2014;370(25):2448-9.
3. Abraham MB, Shetty VB, Price G, et al. Efficacy and safety of
sirolimus in a neonate with persistent hypoglycaemia following near-total
pancreatectomy for hyperinsulinaemic hypoglycaemia. J Pediatr Endocrinol
Metab 2015;28(11-12):1391-8
4. Meder U, Bokodi G, Balogh L, et al. Severe hyperinsulinemic
hypoglycemia in a neonate: response to sirolimus therapy. Pediatrics.
2015;136(5):e1369-72
5. Minute M, Patti G, Tornese G, Faleschini E, Zuiani C, Ventura A.
Sirolimus therapy in congenital hyperinsulinism: a successful experience
beyond infancy. Pediatrics. 2015;136(5):e1373-6
Safety netting in the Emergency Department (ED) is key to the practice of safe medicine. Following the article by de Vos-Kerkhof (1), we present further evidence to suggest that there is a lack of standardised safety netting. In addition, we found a disparity between paediatric trainees' perception of their safety netting practice and what they actually documented in the medical notes.
In a retrospective case...
Khan et al. make a strong case for investment in point-of-care lactate testing in low and middle income countries (LMICs) (1). They believe that this would identify children at high risk of death, and would save lives because these children could receive earlier resuscitation. Unfortunately the optimal management of children with hyperlactataemia in LMICs is far from clear. Although Khan et al. extrapolate from findings i...
We agree that sirolimus may help children with Congenital Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus is, however, unlicensed, with little long term experience, and the mechanism by which it reduces hypoglycaemia remains speculative. As sirolimus is an immunosuppressant, its use in young infants has to be carefully monitored in specialist centres under strict protocols. We are, therefore, re...
My child also has CSID. She is about to be 8 yrs old and has been on Sucraid for the last 6-7 yrs. I am looking for an alternative to this medication as sometimes we cannot get the medication and have to go a strict diet until we can get some again. I will look into this alternative and post results later.
Conflict of Interest:
None declared
We read with interest the review by Amirthalingam[1] and colleagues of the potential value of a UK varicella vaccination programme. They cite Blumental[2] and colleagues' article in the same issue which assessed the burden of varicella and outlined some of the known complications, such as bacterial skin and soft tissue infections, pneumonia, and neurological complications including meningitis and encephalitis. The Blumen...
The ADC Archivist recently reported that Freedman et al had revealed that "old-fashioned clinical examination" missed about 20% of cases of significant dehydration in children.[1] Their assessment of this work was not surprising because the meta-analysis in the Journal of Pediatrics carries the headline message that even the "most accurate, noninvasive" methods could only "identify dehydration suboptimally", and it was a...
Monika Bajaj and Amaka Offiah are to be commended for their thoughtful and helpful review of the benefits and risks of skeletal imaging in cases of suspected child abuse.(1) The diagnosis of child abuse is a complex process which requires an evidence-informed approach combining clinical acumen with collaborative multi-agency working. Skeletal imaging, including CT scans, provide a valuable tool for the clinician, but,...
This editorial is a very helpful review of the current state of the debate.
I am concerned that zoster is under diagnosed in childhood because of lack of familiarity in both primary and secondary care. Anecdotally it is not uncommon in a paediatric unit, in otherwise well children, but does cause significant concern and use of resources. This needs to be accurately captured as it may shift the economic modelling...
Dear Editor
In their excellent review on the hypoglycaemia in childhood the authors suggest that for the management of the hyperinsulinaemic hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who do not respond to diazoxide may respond to the octreotide but the efficacy of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11 are associated with severe HH that is unresponsive to...
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