• Does decentralisation of surgical management improve outcomes for paediatric testicular torsion?

      Smart, Thomas
      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.
    • Early management of sepsis

      Ahmed, Mansoor; Aziz, O (2016-11)
    • 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.
    • Eye pathologies in neonates

      Ahmed, Mansoor (2016-12)
      In 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.
    • 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.
    • The indirect impact of COVID-19 on child health.

      Ashikalli, Louicia (2020-09)
      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.
    • 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.
    • 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.
    • Maintenance intravenous fluids for hospitalised children

      Ahmed, Mansoor; Sobithadevi, D N (2016-11)
    • Management of early-onset neonatal infections

      Ahmed, Mansoor; Manzoor, Azhar; Naydeva-Grigorova, T (2015-01)
    • 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.
    • Newborn infants with bilious vomiting: a national audit of neonatal transport services.

      Ojha, Shalini (2017-05)
      OBJECTIVE: The precautionary approach to urgently investigate infants with bilious vomiting has increased the numbers referred to transport teams and tertiary surgical centres. The aim of this national UK audit was to quantify referrals and determine the frequency of surgical diagnoses with the purpose to inform the consequent inclusion of these referrals in the national 'time-critical' data set. METHODS: A prospective, multicentre UK-wide audit was conducted between 1 August, 2015 and 31 October, 2015. Term infants aged ≤7 days referred for transfer due to bilious vomiting were included. Data at the time of transport and outcomes at 7 days after transfer were collected by the local teams and transferred anonymously for analysis. RESULTS: Sixteen teams contributed data on 165 cases. Teams that consider such transfers as 'time-critical' responded significantly faster than those that do not classify bilious vomiting as time-critical. There was a surgical diagnosis in 22% cases, and 7% had a condition where delayed treatment may have caused bowel loss. Most surgical problems could be predicted by clinical and/or X-ray findings, but two infants with normal X-ray features were found to have a surgical problem. CONCLUSION: The results support the need for infants with bilious vomiting to be investigated for potential surgical pathologies, but the data do not provide evidence for the default designation of such referrals as 'time-critical.' Decisions should be made by clinical collaboration between the teams and, where appropriate, swift transfer provided.
    • Paediatric rhombencephalitis presenting with bradycardia: a good recovery despite cardiac involvement.

      Stokes, V; Surridge, Jason (BMJ, 2021)
      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.
    • 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.
    • 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.
    • 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.
    • Pre-hospital assessment of a child under one year old with fever.

      Wilkinson, Ann (2017-03)
      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.
    • Prophylactic oral vitamin k in neonates

      Ahmed, Mansoor; Rao, H (2016-11)