RSS 1.0Paediatrics
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Using Verbal De-escalation to Manage Children With Autism in the Emergency Department.No abstract available.
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Does decentralisation of surgical management improve outcomes for paediatric testicular torsion?INTRODUCTION: In testicular torsion (TT), delayed emergency scrotal exploration (ESE) increases the risk of orchidectomy. Transfer of a patient with suspected TT from a district general hospital (DGH) to a paediatric surgical centre (PSC) delays ESE and potentially puts them at increased risk of testicular loss. Prior to 1st January 2017, all boys under aged <16 years presenting to a DGH within the East Midlands Clinical Network (EMCN) would be referred to the PSC. From this date, it was agreed within the EMCN that boys aged ≥5 years with suspected TT presenting to a network DGH would be managed locally, barring exceptional circumstances. Boys aged <5 years would be referred to the PSC for management. AIM: This study aimed to assess the impact of decentralisation of ESE for suspected TT on orchidectomy rates in the EMCN. METHODS: All patients who underwent ESE under the care of paediatric surgery in the PSC, and all patients <16 years old who underwent ESE in 4 EMCN DGHs between January 2017 and December 2019 were identified. Neonatal cases and inpatient referrals were excluded. Comparison was made with published data on ESE performed in the PSC over the 9 years 2008-2016 prior to decentralisation. RESULTS: In the 9 years prior to decentralisation, there were 110 cases of TT in the PSC. In the subsequent 3 years, there were 40 in the PSC and 37 in the DGHs. The orchidectomy rate of boys with TT presenting to DGHs and undergoing exploration locally (16%, 6/37) contrasts with the rate in those transferred from DGHs to the PSC for exploration (58%, 15/26). The difference is highly significant (p = 0.00059, RR 0.28 [95% CI 0.13-0.63]) and indicates that in the EMCN, avoiding hospital transfer and performing ESE at the presenting DGH reduces the risk of orchidectomy by 72%. CONCLUSION: Decentralisation of the provision of ESE in boys with TT has resulted in a significantly lower orchidectomy rate in boys undergoing ESE in the presenting hospital than when transferred to the PSC. This study reinforces existing literature that demonstrates the effect of delayed ESE on orchidectomy rate, and supports the recommendations of national guidelines in the UK that transfer of boys to a PSC for ESE should only occur in exceptional circumstances.
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Paediatric rhombencephalitis presenting with bradycardia: a good recovery despite cardiac involvement.Rhombencephalitis is a rare condition, often caused by infection, commonly presenting with myoclonic jerks, ataxia and cranial nerve palsy. Typically, it has a high morbidity and mortality, with worse prognosis associated with cardiopulmonary involvement. Herein, we present the case of a 10-year-old boy, presenting with headache, vomiting, symptomatic bradycardia and rapidly progressing ophthalmoplegia from a sixth nerve palsy, without additional brainstem symptoms. Previously, pericarditis, myocarditis and heart failure have been associated with rhombencephalitis, but not bradycardia. The cause of his rhombencephalitis was presumed viral, but despite extensive screening, the virus responsible was never isolated. Following treatment with intravenous antibiotics and antivirals in a high dependency unit, he recovered well with no neurological deficit on discharge and marked radiological improvement on MRI 4 weeks later. Although rare, rhombencephalitis should be considered in a child presenting with neurological symptoms, particularly alongside a cranial nerve palsy, developing over a rapid time course.
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The indirect impact of COVID-19 on child health.Since the detection of COVID-19 in December 2019, the rapid spread of the disease worldwide has led to a new pandemic, with the number of infected individuals and deaths rising daily. Early experience shows that it predominantly affects older age groups with children and young adults being generally more resilient to more severe disease (1-3). From a health standpoint, children and young people are less directly affected than adults and presentation of the disease has shown different characteristics. Nonetheless, COVID-19 has had severe repercussions on children and young people. These indirect, downstream implications should not be ignored. An understanding of the issues is essential for those who hope to advocate effectively for children to prevent irreversible damage to the adults of the future. This article reviews some of the evidence of harm to children that may accrue indirectly as a result of pandemics. It explores the physical and psychological effects, discusses the role of parenting and education, offering practical advice about how best to provide support as a health care professional.
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Eye pathologies in neonatesIn the United Kingdom, newborn assessment incorporates a screening eye examination for any structural abnormalities, observation of neonate's visual behaviour and direct ophthalmoscopy examination looking for red reflex. Early identification and immediate management of eye related pathologies should commence soon after birth as early diagnosis and prompt intervention may have significant impact on the prognosis for many potentially blinding but treatable disorders such as congenital cataracts and retinoblastoma. If left undetected and untreated, such problems may potentially lead to irreversible damage to the vision which persists into adulthood resulting in lack of self-confidence together with difficulties in educational attainment and job opportunities.
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Impact of Telephone Reminders on Attendance Rate at Paediatric ClinicsBackground: Non-attendance in clinics has major economic impact in the national health service. Literature review indicates that main reason for non-attendance is forgetfulness and reminders reduce the non-attendance rate (NAR). Objectives: We aimed to evaluate the NAR at the paediatric outpatient clinics after implementation of telephone reminders. Patients and Methods: NAR was reviewed for 6 months (February-July 2013) and compared with the NAR for similar duration in 2014 (before and after implementation of telephone reminders). Within 2014 data, comparison was also made for patients who confirmed attendance during telephone reminders versus those left a voice message and patients who were not contactable. Results: Total number of patients in 6 months were 4156 [2674 follow-up (F/U), 1482 New] in 2013 and 4732 [3100 F/U, 1632 New] in 2014. Overall NAR in 2014 was significantly lower (5.1%) than in 2013 (P = < 0.001)). The difference for follow up appointments was 6.9% (P = < 0.001), and 1.75% for new appointments (P = 0.147). Patients who confirmed attendance were more likely to attend their appointment (97.9%) compared with those left a voice message (91.4%) and those that were not contactable (82.1%). Conclusions: Our results validate that telephonic confirmation of clinic appointment plays a significant role in reducing the NAR in paediatric out-patient clinic setting.
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Pain evaluation in preterm infants using skin conductance algesimeterPain asessment is a challenge in patients who are unable to communicate verbally, e.g. neonates. Consequently, they may receive less effective analgesic treatment. Visual, behavioural and physiological pain scales are used clinically but they are not always reliable, especially in premature infants. Some studies have been published on the reliability and efficacy of a Skin Conductance Algesimeter (SCA) in monitoring pain in infants. However, the data is limited by small sample size and lack of utility in specific situations such as in ventilated children and during potentially painful procedures.
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When to do paediatric gastrointestinal endoscopy?Over the last few decades, paediatric gastroenterology has rapidly developed into a well-established sub-specialty. Improvements in training and equipment have led to enhanced safety with fewer complications following endoscopies. In specialized units, diagnostic and therapeutic upper gastrointestinal endoscopy and proctosigmoidoscopy/colonoscopy are regularly performed under conscious sedation or general anaesthesia. Emerging guidelines and new advances in the diagnostic tools are being incorporated into routine paediatric gastrointestinal endoscopy practice.
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Use of enteral nutritional supplementation: a survey of level II and III neonatal units in EnglandEnteral nutritional supplementation is widely used in preterm babies on Neonatal Units (NNUs). There is little published evidence on appraising their long-term efficacy. We evaluated the current practice of enteral nutritional supplementation in 96 level II and III NNUs in England. 96%, 98%, 98% and 56% units use breast milk fortification (BMF), iron, multivitamins and folic acid supplementation respectively. Iron, multivitamins and folic acid supplements are routinely commenced in babies < 35 weeks gestation by 73%, 68% and 39% NNUs respectively. Seventy eight percent NNUs only use BMF for babies that are not gaining weight. Continuing variable practice of enteral nutritional supplementation and current use of anecdotal evidence and best guess recommendations highlights the need for a unified approach and collaborative multinational research to produce standardised guidelines.
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An audit of the effectiveness of PCSK9 inhibition in reducing cholesterol in patients attending lipid clinicsIntroduction: Evolocumab and alirocumab are monoclonal antibodies that inhibit PCSK-9 and reduce LDl-C. This audit assessed the effectiveness of PCSK9 inhibitor administration in patients attending lipid clinics at regional and local centres. Methods: Data from patients in treated in accord with NICE Technology Appraisals TA394 and TA396 was obtained from the lipid clinics at Guy's & St. Thomas' Hospitals and Queen's Hospital, Burton-on-Trent. All patients had undergone a cardiovascular assessment and lipid measurements. Results: The 75 patients were aged 61.1+/-12.1 (average+/-SD) years and 33% were female. The indications for prescription were Familial Hypercholesterolaemia (75%); intolerance to >3 statins (67%), coronary heart disease with LDL-C>4 mmol/L (33%); multivascular disease and LDL-C>3.50 mmol/L (26%) and other (9%). Scripts were issued for Evolocumab (140mg; n=52) and Alirocumab (n=17; 12 receiving 150 mg and 5 75 mg respectively). Data was available for 43 patients who had completed more than 3 months treatment. Pre-treatment total cholesterol (TC) was 7.94+/-2.37 mmol/L, LDL-cholesterol (LDLC) 5.44+/-1.90 mmol/L, triglycerides (TG) median 1.89 (range 0.5-34.8) mmol/l and HDL-C 1.39+/-0.38 mmol/L. Post-treatment levels were TC 5.91+/-2.45 mmol/l, LDL-C 3.30+/-1.63 mmol/L, TG 1.67 (0.63-27.8) mmol/l and HDLC 1.42+/-0.4 mmol/L. The average reductions in lipids were a median 41 (range 90 to-35) %; (2.07+/-1.17 mmol/L) for LDL-C, and 27 (range 52 to-19)% (2.10+/-1.48 mmol/L) for TC respectively. Discontinuations were reported in 7 patients and 3 reported adverse effects (myalgia). A <25% LDL-C response was seen in 19% of patients. Conclusion: Treatment with PCSK9 inhibitor therapy is associated with a 41% reduction in LDL-C in qualifying patients who tolerate the medication but 19% fail to respond.
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Pre-hospital assessment of a child under one year old with fever.Parents often bring children with a fever to primary and emergency care settings. This article uses a case study to explore the assessment of children with a fever in pre-hospital settings using the three-minute toolkit, National Institute for Health and Care Excellence fever guidelines and the baby check score. It also highlights some educational resources for parents, designed to help them recognise when to seek clinical advice for their children.
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Term admissions to neonatal units in England: A role for transitional care? A retrospective cohort studyTo identify the primary reasons for term admissions to neonatal units in England, to determine risk factors for admissions for jaundice and to estimate the proportion who can be cared for in a transitional setting without separation of mother and baby. Design: Retrospective observational study using neonatal unit admission data from the National Neonatal Research Database and data of live births in England from the Office for National Statistics. Setting: All 163 neonatal units in England 2011-2013. Participants: 133 691 term babies born >=37 weeks gestational age and admitted to neonatal units in England. Primary and secondary outcomes: Primary reasons for admission, term babies admitted for the primary reason of jaundice, patient characteristics, postnatal age at admission, total length of stay, phototherapy, intravenous fluids, exchange transfusion and kernicterus. Results: Respiratory disease was the most common reason for admission overall, although jaundice was the most common reason for admission from home (22% home vs 5% hospital). Risk factors for admission for jaundice include male, born at 37 weeks gestation, Asian ethnicity and multiple birth. The majority of babies received only a brief period of phototherapy, and only a third received intravenous fluids, suggesting that some may be appropriately managed without separation of mother and baby. Admission from home was significantly later (3.9 days) compared with those admitted from elsewhere in the hospital (1.7 days) (p<0.001). Conclusion: Around two-thirds of term admissions for jaundice may be appropriately managed in a transitional care setting, avoiding separation of mother and baby. Babies with risk factors may benefit from a community midwife postnatal visit around the third day of life to enable early referral if necessary. We recommend further work at the national level to examine provision and barriers to transitional care, referral pathways between primary and secondary care, and community postnatal care.
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The Alvarado score in acute appendicitis: A 3-year audit to evaluate the usefulness in predicting negative appendicectomies in <=16 s at QHBFTTo evaluate the diagnostic accuracy of the Alvarado score in reducing the rate of negative appendicectomy at Queen's Hospital, a small district general hospital in England. Methodology The retrospective, analytical study included all children who were <=16 years old with a preliminary diagnosis of acute appendicitis undergoing appendicectomy subsequently. Children with other causes of acute abdominal pain were excluded from the study. A total of 118 patients were included. Based on their calculated Alvarado scores, they were stratified into two groups: Group A (Alvarado score <6) and Group B (Alvarado score >=6). Alvarado scores were compared with the histopathology reports, the gold standard for diagnosing acute appendicitis. The data gathered was then subjected to statistical analysis to measure our objective. Results Out of the 118 patients (85 males, 33 females), 46 belonged to Group A and 72 to Group B. Final diagnosis of acute appendicitis from histopathology reports was confirmed in 94 cases (79.6%). The overall sensitivity and positive predictive value of Alvarado score for acute appendicitis were 92% and 94% respectively. The area under the ROC curve was 0.9 indicating a highly accurate test. The sensitivity was only slightly higher for males with a score of <6 than females (94.9% vs. 89.5%, p < 0.05). However, for scores >=6, sensitivity among males was significantly higher than females (79% vs. 62.6%; p < 0.05). A multivariate analysis revealed that anorexia, right iliac fossa tenderness and rebound tenderness are significantly correlated with a correct diagnosis of acute appendicitis (p = 0.025, 0.037 and 0.026 respectively). Conclusion The presence of a high Alvarado score (>=6) is highly predictive of acute appendicitis. In women of childbearing age and Alvarado scores of <6, other pathologies that mimic appendicitis must be considered. An US scan of abdomen and pelvis should be considered in a woman of child-bearing age before proceeding to a surgical intervention.
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12 Years data on resistance pattern of uropathogensUrinary tract infection (UTI) is a common bacterial infection in infants and children. Traditionally, Trimethoprim has been the first line antibiotic of choice for the treatment of Coliform UTI. Empirical antibiotic treatment in UTI in children should be based on local surveillance data on the epidemiology and resistance patterns of common uropathogens. This has been endorsed in the guideline on UTI in children by National Institute for Health and Care Excellence in the UK. Aim To evaluate the resistance pattern to commonly used antibiotics in children with culture proven UTI. Methods We retrospectively analysed all cases with proven UTI from 2002-2013. Cases were identified by the clinical coding system and data obtained from the Hospital Information Support System. Results 1151 cases were identified; 95% (1090/1151) had pure growth of E.coli. Microbiology results were analysed to evaluate the sensitivities to commonly used antibiotics. Increasing resistance to Trimethoprim (TMP) and Co-Amoxiclav was observed during 2002-2008. Change in antibiotic policy has resulted in some decline in TMP resistance (Table below) over the recent years. Conclusion This comprehensive data on children with culture proved UTI supports the use of cefalexin as empirical treatment of choice for all presumed UTIs (pending culture results) in our region. Alternatively, TMP can be used (provided that urine sensitivity is known before commencing antibiotic treatment) if it is sensitive to coliform. It is vital to continue to monitor the resistance pattern to ensure early identification of emergence of drug resistance. (Table Presented).
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Pain evaluation in the pretermAssessment of pain is a challenge in neonatal setting. Visual, behavioural and physiological pain scales are not always reliable in premature infants. Few studies with limited sample size have been published on the reliability and efficacy of Skin Conductance Algesimeter (SCA) in monitoring pain in infants and children. Aim To identify the clinical usefulness of SCA as a reliable and valid measure of pain intensity and stress response in preterm infants. Methods Parents of all preterm infants admitted to the neonatal unit were invited to participate in the study. The usefulness of SCA was compared with simultaneous measurement of 'Premature Infant Pain Profile' (PIPP) and 'Face, Legs, Activity, Cry and Consolability (FLACC) scores during invasive and/or painful procedures. Results 85 measurements were recorded. PIPP and FLACC scores started low, increased during the procedure and decreased afterwards. For all SCA measurements, there was an increase in score pre-pro and a decrease in score pro-post. However, the standard deviation for variations was wider for some measurements than for others. Paired t-test comparing Delta pre-pro with Delta pro-post for all measurements {PIPP, FLACC, Area (small) and Peaks/sec} individually showed statistically significant differences (p < 0.05). For Area (small), there was no significant correlation between SCA data and PIPP/FLACC scores. Conclusions SCA, PIPP and FLACC scores increased during the painful procedures. Although the SCA, PIPP and FLACC data is mathematically correlated, at a clinical level, the correlation is too imprecise to use the SCA to predict or measure behavioural responses to noxious stimuli in neonates.
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New born observation track and trigger (NOTT) chart-Burton experienceUse of early warning system scores and track and trigger charts is widespread in adult and paediatric hospitalised patients. Its use in neonatal group is not well recognised. Lack of well established normal ranges for biophysical variables in preterm/term neonates illustrate difficulties in establishing a scoring system that can potentially be used on the neonatal units (NNU) and postnatal wards (PNW). We have recently developed NOTT chart for use in newborn babies on PNW. Aim To validate NOTT chart in order to enable early identification of neonates in need of urgent medical assessment and intervention. Methods A service evaluation was carried out to evaluate the efficacy of NOTT chart. All admissions from PNW to NNU (Feb-Aug 2013) were evaluated. Notes of all babies on PNW (2 weeks duration in Nov 2013) were also reviewed. Results There were 24 NNU admissions from PNW between Feb-Aug 2013. Sensitivity of NOTT chart's 'medium' and 'high' score was 96% (22/23). Charts of 42 babies on PNW were examined in Nov 2013. 7/42 babies scored 'medium' or 'high' out of which, 3 were admitted to NNU. Specificity of NOTT chart was 90%. Positive and negative predictive value was 43% and 100% respectively. Conclusions NOTT is an effective screening tool to identify any deterioration in the condition of a new born so prompt and timely assessment and medical intervention could be carried out. It is a useful tool for information sharing and provides a one stop solution for unifying all neonatal observations on PNW.
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Investigation and management of vitamin d deficiency/insufficiency-a service evaluationIntroduction Vitamin D is essential for bone and skeletal health. The major natural source of Vitamin D is from skin exposure to sunlight. Current evidence suggests that there isn't enough ambient ultraviolet sunlight from October to April in UK (UK). Similarly, there are reports of rickets re-emerging in parts of UK. There is no internationally agreed consensus regarding cut off value denoting Vitamin D insufficiency/deficiency. Variable practice exits in treating symptomatic and asymptomatic children with Vitamin D insufficiency/deficiency. Aim To evaluate our current practice in investigating and managing children with subnormal Vitamin D levels (<50 nmol/l). Method We carried out a retrospective data review on all patients <17 years of age who had vitamin D levels checked in a District General Hospital setting. Data was collected from 2008-2012 and analysed using Microsoft excel. Results Vitamin D levels were checked on 136 occasions in 89 patients (60% male). 41% of the values were above 50 nmol/l while 20% were <20 nmol/l. ~3/4 values of <20 nmol/l were from children of Indian and Pakistani origin. 80% of patients with values <50 were treated with oral Vitamin D supplementation. Treatment dose varied from 400-10000 IU/day to 20000-40000 IU/week (ergocalciferol or cholecalciferol). Conclusion Our data reiterates lack of unified guidance and variable practice amongst clinicians managing Vitamin D deficiency/insufficiency. Careful attention is required when managing South Asian children with chronic illnesses. There is urgent need for multicentre/national research and unified guideline for prevention and treatment of Vitamin D deficiency in children.
