• Use of enteral nutritional supplementation: a survey of level II and III neonatal units in England

      Ahmed, Mansoor (2013-09)
      Enteral 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.
    • Intravenous salbutamol for childhood asthma: evidence-based medicine?

      Starkey, Elizabeth (2014-09)
      Intravenous salbutamol is commonly used to treat children with severe asthma unresponsive to inhaled β2-agonist therapy. However, in this setting, there is little clinical trial data demonstrating its effectiveness. Additionally, there are significant concerns that intravenous salbutamol-dosing recommendations for children with acute asthma are excessive, and unnecessarily raise the potential for adverse reactions, such as lactic acidosis and tachycardia which, by increasing respiratory workload, exacerbate respiratory failure. Here, we review salbutamol clinical pharmacology and toxicology, evidence relating to its use in acute asthma and highlight gaps in the evidence base.
    • New born observation track and trigger (NOTT) chart-Burton experience

      Ahmed, Mansoor; Manzoor, Azhar; Phillips, Isabel (2014-10)
      Use 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.
    • 12 Years data on resistance pattern of uropathogens

      Ahmed, Mansoor; Chakupurakal, Raj (2014-10)
      Urinary 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).
    • Pain evaluation in the preterm

      Ahmed, Mansoor; Mostafa, Saleh; Pore, Padmaja; Molnar, Mihaly; Maiden, Jane; Boswell, Stephanie; Reynolds, Tim (2014-10)
      Assessment 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.
    • Investigation and management of vitamin d deficiency/insufficiency-a service evaluation

      Ahmed, Mansoor (2014-10)
      Introduction 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.
    • When to do paediatric gastrointestinal endoscopy?

      Ahmed, Mansoor; Karupaiah, Ashok (2014-11)
      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.
    • Management of early-onset neonatal infections

      Ahmed, Mansoor; Manzoor, Azhar; Naydeva-Grigorova, T (2015-01)
    • Trichilemmal cyst of the penis in a paediatric patient

      Joshi, Rashi (2015-02)
      Paediatric penile cysts are uncommon. We report a five-year-old child with an asymptomatic progressively growing cyst on the ventral aspect of the penis after a hypospadias repair. The patient presented to the Cooper Health Clinic, Dubai, United Arab Emirates, in March 2012. A complete excision of the cyst was performed. Histology results delineated a capsulated benign trichilemmal cyst. No recurrence or complications were reported in the 26 months following the excision. We recommend an early and complete excision of all penile cysts to prevent the risk of urethral obstruction, infection, inflammation and rare malignant changes. This is the first reported case of a penile trichilemmal cyst in a child.
    • Practical pharmacokinetics: what do you really need to know?

      Starkey, Elizabeth (2015-02)
      Having some understanding of pharmacokinetics is important for all clinicians when prescribing medications. Key elements to effective and safe prescribing include making sure that we don't underdose a medication making it ineffective, but also do not overprescribe a treatment known to cause toxic effects. In paediatrics, there are significant physiological and developmental differences that add to the challenges of safe prescribing. This article aims to provide the clinician with some basic paediatric pharmacokinetic principles with clinical examples to aid their prescribing skills.
    • Pain evaluation in preterm infants using skin conductance algesimeter

      Ahmed, Mansoor; Mostafa, Saleh; Pore, Padmaja; Maiden, Jane; Reynolds, Tim (2015-10)
      Pain 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.
    • Exploring difficulties in child protection practice. A west midlands survey

      Mshelbwala, Hannah (2016-04)
      Introduction Doctors and relevant professionals should have appropriate training to be able to protect vulnerable children. For best outcome, local policies need to be in place with optimisation of multiagency team support. Aim To identify difficulties in children safeguarding practice among doctors regarding training adequacy, confidence in recognition and response, and the support received from the multiagency system. Method A questionnaire based survey was carried out in the West Midlands-UK, of junior paediatricians, general practitioners and emergency doctors. Results 141 questionnaire from more than 14 hospitals/practices were analysed, of which 93 (66%) were of junior paediatricians and 48 (34%) were of general practitioners and emergency doctors. Only 5 (3.5%) did not have appropriate child protection training. However, 13% thought that the training did not meet their needs. On a scale of 1-6 (1= not confident at all; 6= very confident), doctors expressed their ability to recognise signs of physical abuse (Mean 4.48 and SD 0.87), factitious illness (Mean 3.36 and SD 1.03), emotional abuse (Mean 3.68 and SD 1.02), and neglect (Mean 4.14 and SD 0.97). Overall, 86% of doctors have confidence to initiate child protection process when they have concerns. There was however significant difference between paediatric and non-paediatric groups in the degree of confidence to initiate the process (p < 0.001). Overall, 50% (n = 71) would wait for a senior opinion before initiating the process. The degree of perceived support by seniors and other members of the multiagency system was variable between doctors groups. On a scale of 1-6 (1= not supported; 6= very supported), it ranged from 3.50-4.45 (Mean 4.21 and SD 2.0). Support by multiagency team members, in normal working hours and out of hours showed some differences. Conclusion Although child protection training is mandatory, some junior doctors and trainees might need more support. Senior advice is essential, but caution is needed to avoid referrals delay. More trained staff would reduce variation of multiagency team support out of hours. Bigger and possibly national studies on this matter, with inclusion of sexual abuse, are recommended.
    • Impact of Telephone Reminders on Attendance Rate at Paediatric Clinics

      Ahmed, Mansoor; Chinnappan, Sujatha; Gole, Evangjelia (2016-05)
      Background: 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.
    • Early management of sepsis

      Ahmed, Mansoor; Aziz, O (2016-11)
    • Prophylactic oral vitamin k in neonates

      Ahmed, Mansoor; Rao, H (2016-11)
    • Unexpected term admissions to neonatal unit

      Ahmed, Mansoor; Sobithadevi, D N; Manzoor, Azhar (2016-11)
    • Maintenance intravenous fluids for hospitalised children

      Ahmed, Mansoor; Sobithadevi, D N (2016-11)