• 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)
    • Term admissions to neonatal units in England: A role for transitional care? A retrospective cohort study

      Manzoor, Azhar (2017)
      To 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.
    • 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.
    • Unexpected term admissions to neonatal unit

      Ahmed, Mansoor; Sobithadevi, D N; Manzoor, Azhar (2016-11)
    • 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.
    • 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.