Recent Submissions

  • Genomic medicine for the paediatrician.

    Hastings, Richard (Paediatrics and Child Health, 2019-04)
    Genomic medicine is the use of sequence data from an individual's entire genetic code to aid diagnosis and personalise therapeutic options. An important goal of the 100,000 genomes project in the UK is to embed the infrastructure for the widespread use of whole genome sequencing into the National Health Service. Paediatricians will be at the forefront in using this new technology in the diagnosis of children with multiple congenital anomalies, developmental delay and other suspected genetic conditions. This article provides a description of the basic concepts of genomic medicine. The types of genomic testing that are available are discussed and examples of how genomics is already being used in paediatrics are given. Finally, the challenges for genomic medicine are summarised.
  • Pregnancy and neonatal outcomes of COVID-19: The PAN-COVID study

    Rajeswary, Jyothi Mrs (European Journal of Obstetrics & Gynecology and Reproductive Biology, 2022-09)
    Objective To assess perinatal outcomes for pregnancies affected by suspected or confirmed SARS-CoV-2 infection. Methods Prospective, web-based registry. Pregnant women were invited to participate if they had suspected or confirmed SARS-CoV-2 infection between 1st January 2020 and 31st March 2021 to assess the impact of infection on maternal and perinatal outcomes including miscarriage, stillbirth, fetal growth restriction, pre-term birth and transmission to the infant. Results Between April 2020 and March 2021, the study recruited 8239 participants who had suspected or confirmed SARs-CoV-2 infection episodes in pregnancy between January 2020 and March 2021. Maternal death affected 14/8197 (0.2%) participants, 176/8187 (2.2%) of participants required ventilatory support. Pre-eclampsia affected 389/8189 (4.8%) participants, eclampsia was reported in 40/ 8024 (0.5%) of all participants. Stillbirth affected 35/8187 (0.4 %) participants. In participants delivering within 2 weeks of delivery 21/2686 (0.8 %) were affected by stillbirth compared with 8/4596 (0.2 %) delivering ≥ 2 weeks after infection (95 % CI 0.3–1.0). SGA affected 744/7696 (9.3 %) of livebirths, FGR affected 360/8175 (4.4 %) of all pregnancies. Pre-term birth occurred in 922/8066 (11.5%), the majority of these were indicated pre-term births, 220/7987 (2.8%) participants experienced spontaneous pre-term births. Early neonatal deaths affected 11/8050 livebirths. Of all neonates, 80/7993 (1.0%) tested positive for SARS-CoV-2. Conclusions Infection was associated with indicated pre-term birth, most commonly for fetal compromise. The overall proportions of women affected by SGA and FGR were not higher than expected, however there was the proportion affected by stillbirth in participants delivering within 2 weeks of infection was significantly higher than those delivering ≥ 2 weeks after infection. We suggest that clinicians’ threshold for delivery should be low if there are concerns with fetal movements or fetal heart rate monitoring in the time around infection. The proportion affected by pre-eclampsia amongst participants was not higher than would be expected, although we report a higher than expected proportion affected by eclampsia. There appears to be no effect on birthweight or congenital malformations in women affected by SARS-CoV-2 infection in pregnancy and neonatal infection is uncommon. This study reflects a population with a range of infection severity for SARS-COV-2 in pregnancy, generalisable to whole obstetric populations.
  • 80 The cost of smoking in pregnancy - A retrospective study. Source

    Hills, A; Allison, C (European Journal of Obstetrics & Gynecology & Reproductive Biology, 2022-03)
    Introduction and study aims: The UK Department of Health aims to reduce smoking at time of delivery (SATOD) to below 6% by 2022. Sherwood Forest Hospital NHS Foundation Trust (SFHFT) had a SATOD of 16.5% in 2019-2020. The aim was to demonstrate how smoking continues to affect patients, to motivate and engage staff in smoking cessation strategies. Methods: Retrospective study of 25 non-smokers’ and 25 smokers’ who had delivered at SFHFT in the first quarter of 2020, comparing antenatal contacts and pregnancy-related complications. Inclusion criteria were maternal age (18 - 40 years) and BMI (18 - 25). Data was collected from Orion (electronic maternity pathway). The two groups were then compared using the Mann-Whitney U test. Results: The smoking group were 9 times less likely to attend appointments and had an average of 5.28 growth scans (compared to non-smokers 0.96 scans). They were 3 times more likely to have an antenatal complication - small for gestation age (SGA) [RR 9], fetal growth restriction (FGR) [RR 10], low Papp-A, antepartum haemorrhage, preterm birth, oligohydramnios and reduced fetal movements. Smokers were more likely to be induced for SGA/FGR (RR 5.5), have a baby below the 10th centile (RR3) and develop intrapartum complications (RR 1.45). Smokers were 3.6 times less likely to breast feed. All findings were clinically significant (p≤0.05). The cost of continued smoking in pregnancy for SFHFT is £1,731,560 per year. Conclusion: Despite increased surveillance in SATOD pregnancies, the short and long term consequences for these women and their babies are significant. It has previously been demonstrated that babies born with low birth weights are at increased risk of adult diseases, hence the true financial burden is therefore far greater and the continued need to decrease SATOD is clear.
  • Does decentralisation of surgical management improve outcomes for paediatric testicular torsion?.

    Ellis, Ricky
    Summary 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 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.
  • Chameleon project: a children’s end-of-life care quality improvement project

    Clements, Helena (BMJ Open Quality, 2021-12)
    In response to there being no specialist paediatric palliative care (PPC) team in a region of England, we undertook a 12-month quality improvement project (funded by National Health Service England’s Marginal Rate Emergency Threshold and Readmission fund) to improve children’s end-of-life care. Improvements were implemented during two plan–do–study–act (PDSA) cycles and included specialist experts, clinical champions, focused education and training, and tools and materials to support identification, care planning and communication. A lead paediatrician with expertise in PPC (10 hours/week) led the project, supported by a PPC nurse (3 days/week) and a network administrator (2 days/week). Children who died an expected death were identified from the child death review teams. Numbers of non-elective hospital admissions, bed days, and costs were identified. Twenty-nine children died an expected death during the 12 months of the project and coincidentally 29 children died an expected death during the previous 12 months. The median number of non-elective admissions in the last 12 months of life was reduced from two per child to one. There was a reduction in specialist hospital (14%) and district general hospital (38%) bed days. The percentage of children who died an expected death who had anticipatory care plans rose from 50% to 72%. The results indicate that a network of clinicians with expertise in PPC working together across a region can improve personalised care planning and reduce admissions and bed days for children in their last year-of-life with reduced bed utilisation costs.
  • Treatment of Multisystem Inflammatory Syndrome in Children

    Struik, Siske (New England Journal of Medicine, 2021-07)
    Background: Evidence is urgently needed to support treatment decisions for children with multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2. Methods: We performed an international observational cohort study of clinical and outcome data regarding suspected MIS-C that had been uploaded by physicians onto a Web-based database. We used inverse-probability weighting and generalized linear models to evaluate intravenous immune globulin (IVIG) as a reference, as compared with IVIG plus glucocorticoids and glucocorticoids alone. There were two primary outcomes: the first was a composite of inotropic support or mechanical ventilation by day 2 or later or death; the second was a reduction in disease severity on an ordinal scale by day 2. Secondary outcomes included treatment escalation and the time until a reduction in organ failure and inflammation. Results: Data were available regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021; 490 met the World Health Organization criteria for MIS-C. Of the 614 children with suspected MIS-C, 246 received primary treatment with IVIG alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone; 22 children received other treatment combinations, including biologic agents, and 39 received no immunomodulatory therapy. Receipt of inotropic or ventilatory support or death occurred in 56 patients who received IVIG plus glucocorticoids (adjusted odds ratio for the comparison with IVIG alone, 0.77; 95% confidence interval [CI], 0.33 to 1.82) and in 17 patients who received glucocorticoids alone (adjusted odds ratio, 0.54; 95% CI, 0.22 to 1.33). The adjusted odds ratios for a reduction in disease severity were similar in the two groups, as compared with IVIG alone (0.90 for IVIG plus glucocorticoids and 0.93 for glucocorticoids alone). The time until a reduction in disease severity was similar in the three groups. Conclusions: We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue. (Funded by the European Union's Horizon 2020 Program and others; BATS ISRCTN number, ISRCTN69546370.).
  • Presenting features of patients with ataxia-telangiectasia (A-T): A scoping review.

    Yule, Alexander (Archives of Disease in Childhood, 2021)
    Background Ataxia-telangiectasia (A-T) is a rare autosomal recessive, progressive, multi-system disease caused by mutations in the ataxia-telangiectasia mutated (ATM) gene on chromosome 11q.26. There are 2 types of A-T; the more severe phenotype of classical A-T with a complete absence of ATM protein kinase, and the milder phenotype of variant A-T in which there is some residual protein kinase activity. A-T has a wide spectrum of manifestations including cerebellar ataxia, movement disorders, ocular telangiectasia, recurrent infections, and an increased risk of malignancy. Although textbook narratives exist describing the clinical features of A-T, no attempt has been made to collate the available information to give a complete picture of the presenting features of this rare disease. Objectives To describe the presenting features of A-T and determine any difference in presenting features between classical and variant A-T. Methods 17 searches were carried out in each of 5 databases (Ovid SP (Medline), EMBASE, Web of Science, PubMed, Scopus). The Cochrane Library was also searched. The search protocol is available. The inclusion criteria were all dates, all languages, all ages, human subjects, and clinical relevance. The exclusion criteria were: no reference to A-T within the article, not an original article, animal studies, article not clinically relevant. Results Search returned 194,890 articles; 14,622 titles and abstracts were reviewed after removing 180,268 duplicates. Full text review of 1,163 articles was performed and 1,039 studies were included (13,459 exclusions, 124 excluded after full text review). The presenting symptoms (first symptom) were reported in 1209 cases with a total of 1702 signs or symptoms included. The most common presenting complaint reported was an abnormal gait (n=931), followed by recurrent infections (n=223), speech difficulties (n=113) and movement disorder and other co-ordination difficulties (n=69). Cerebellar ataxia was the most common pattern of abnormal gait. Although cerebellar ataxia was the most common first presenting feature, chronologically we found other symptoms that presented at an earlier age included recurrent infections and other neurological signs and symptoms. The age of onset of presenting symptoms will be presented in more detail. The median age of diagnosis for classical A-T was 6 years (IQR 3 – 9 years) and for variant it was much later in life with a median age of 30 years 6 months (IQR 19.25–40.25 years). Conclusions A-T has a wide variety of presenting features which is further complicated by a wide difference in the age of diagnosis of between classical and variant A-T. The most common presenting feature was an abnormal gait of which cerebellar ataxia was the most common pattern. However other symptoms appear to present earlier including telangiectasia and recurrent infections and dystonia in variant A-T. It is hoped that by developing a better understanding of the spectrum of presenting features of A-T may reduce the age of diagnosis of both forms of A-T.
  • 1449 Drug drills: improving paediatric team performance and confidence when prescribing and preparing unfamiliar emergency medications

    Shephert, Jennifer; Hesketh, Emma; Hammond, Sophie; Macdonald, Daniella (Archives of Disease in Childhood, 2021)
    Background Emergency medications are infrequently required in district general paediatric departments, however when they are it is important for them to be given in a timely manner. Feedback from local simulation scenarios revealed that prescribing and preparing unfamiliar emergency medications was something that both medical and nursing teams felt anxious about. Regular simulation practice is therefore essential for improving patient care and safety in emergency scenarios. Objectives The aim of this project was to improve paediatric team ability and confidence when prescribing and preparing unfamiliar emergency medications in order to improve patient care and safety. Methods A series of ‘drug drills’ involving emergency medication were created: asthma (salbutamol and magnesium sulphate); sedation (morphine and midazolam); duct dependent cardiac disease (prostaglandin) and septic shock (adrenaline and noradrenaline). Doctors timed how long it took to prescribe the medication after reading a scenario. Nursing staff subsequently timed how long it took them to prepare and administer the medication. Participants completed an online survey after the ‘drug drill’ and were asked to record how long it took for them to complete the drill, and whether they felt more or less confident prescribing/preparing these medications. They were also encouraged to provide feedback and learning points to be shared amongst the team to facilitate shared learning. In future,‘drug drills’ will be repeated to assess whether our performance and confidence has improved as a result of extra practice and group feedback. Results To date, ‘drug drills’ have been completed by 19 doctors and 12 nurses. Preliminary results and feedback have been positive with 100% of staff saying they felt more confident prescribing/preparing medication after completion. As a result of the feedback received, changes have already been implemented to help staff in future. For example, we have increased the stock number of 50ml syringes in the resuscitation room as this consistently delayed drug preparation. Also, prescription and administration guidelines are now available on a tablet in the resuscitation room for ease of access. Conclusions Staff had improved confidence after completing the ‘drug drills’, which is expected to translate into better performance and patient care. We aim to repeat these drills in the future to see if our prescribing and preparation times have improved, and whether we have leant from learning points that were identified from feedback.
  • Targeted learning through paediatric simulation

    Spencer, Emma Elizabeth; Shephert, Jennifer (Archives of Disease in Childhood, 2021)
    Background Simulation is regularly run with the paediatric multi-disciplinary team at a district general hospital. This facilitates learning on an individual and team level, while improving processes of patient care in a safe environment. In this quality improvement project themes were noted in simulation involving paediatric resuscitation, therefore targeted interventions were put in place to make improvements. Objectives Intervention One: Covid-19 has altered healthcare professionals approach to patient contact through the use of personal protective equipment (PPE) to ensure infection control. The Advanced Life Support Group endorsed guidance that in emergencies the patient should be assumed to have Covid-19 and full PPE should be used by responders. In paediatrics breathing support is essential; therefore unplanned simulation was run with staff to practice this skill while maintaining the safe use of PPE. Intervention Two: In simulated cardiac arrest the time taken to administer the first Adrenaline dose was over 13 minutes. Delays in administering Adrenaline in paediatric, in-hospital cardiac arrest with a non-shockable rhythm is associated with decreased survival, ROSC and survival with a favourable neurological outcome. ‘The Arrest to Adrenaline Race’ was launched with the aim to decrease the time taken to administer Adrenaline; so that in a real life scenario the patient would have the best chance of survival. Methods Intervention One: In simulation it took 156 seconds until the patient was first bagged after responders correctly donned PPE, which would have a detrimental impact to successful resuscitation. ‘The Amber Bagging Race’ was launched where teams of healthcare professionals practiced the procedure in a race scenario; from recognition of a deteriorated patient, to the correct use of PPE and then successful bagging. Intervention Two: Healthcare professionals engaged in race scenarios with a manikin, where they timed the process taken from recognition of an arrested patient, initiating resuscitation, obtaining interosseous access and administering Adrenaline at the correct prescribed dose for weight. Results Intervention One: Over two weeks thirteen teams participated and the average time to bag was reduced to 56 seconds in week one and 41 seconds in week two. In a second unplanned paediatric resuscitation following ‘The Amber Bagging Race’ the time taken to bag the patient was 46 seconds; a significant improvement in clinical practice. Intervention Two: Over two weeks fourteen teams participated and the average time taken to administer Adrenaline reduced to 324 seconds in week one and 138 seconds in week two. In further simulation scenarios following ‘The Arrest to Adrenaline Race’ the time taken to administer Adrenaline averaged 5 minutes and 23 seconds. Conclusions Conclusion: Simulation identified key areas for improvement in paediatric resuscitation and targeted interventions enabled specific practice of skills, with the aim to improve patient care in a real life scenario. Learning was disseminated to the wider team and processes were altered to further improvements in patient safety. The races brought an atmosphere of fun to the ward, improving engagement and morale. People are often fearful of simulation; an environment of fun rather than fear is conducive to more effective learning.
  • Episiotomy and Initiation of Human Milk Feeds: A Retrospective Observational Study

    Servante, Juliette (Breastfeeding Medicine, 2021-05)
    Objective: To investigate the association, in the United Kingdom, between having an episiotomy during childbirth and giving human milk by any modality as an infant's first feed. We also identified maternal demographic factors and perinatal experiences associated with increased chance of the infant's first feed being human milk. Study Design: Retrospective observational cohort study at two large maternity units within district general hospitals in the United Kingdom. Population: Mothers giving birth vaginally to singleton babies at ≥34 weeks and ≥1,800 g. Methods and Main Outcome Measures: Deidentified data from hospital records were analyzed. The odds ratio (OR) of a mother giving human milk for an infant's first feed after episiotomy versus no episiotomy was calculated using a chi-squared test. Logistic regression was used to investigate and then control for confounders known to affect breastfeeding. Results: A total of 13,906 women met the inclusion criteria (2,113 had had an episiotomy and 11,793 had not). Human milk was given as a first feed to 70% of infants in the study population. Women whose infants received their first feed as human milk were on average older, had lower body mass index, lived in an area of less socioeconomic deprivation, and had fewer previous births than those women who gave formula milk as the first feed to their infant. The occurrence of an episiotomy during delivery was not associated with a change in the odds of the infant receiving human milk for the first feed (OR: 1.12 [confidence interval, CI: 0.96-1.38]). Where a woman had skin-to-skin care with her infant straight after birth, the infant was more likely to receive human milk as a first feed (OR: 4.23 [CI: 3.59-4.98]). Conclusion: There is no link between episiotomy during delivery and the odds of a woman giving human milk as the first feed to her infant.
  • Worldwide differences in childhood type 1 diabetes: The SWEET experience

    Ngwu, Ursula
    Objective To study worldwide differences in childhood diabetes, comparing relevant indicators among five regions within the SWEET initiative. Subjects We investigated 26 726 individuals with type 1 diabetes (T1D) from 54 centers in the European region; 7768 individuals from 30 centers in the Asia/Middle East/Africa region; 2642 people from five centers in Australia/New Zealand; 10 839 individuals from seven centers in North America, and 1114 patients from five centers in South America. Methods The SWEET database was analyzed based on the following inclusion criteria: T1D, time period 2015-2019, and age < 21 years, with analysis of the most recent documented year of therapy. For the statistical analysis, we used multivariable linear and logistic regression models to adjust for age (<6 years, 6- < 12 years, 12- < 18 years, 18- < 21 years), gender, and duration of diabetes (<2 years, 2- < 5 years, 5- < 10 years, ≥10 years). Results Adjusted HbA1c means ranged from 7.8% (95%-confidence interval: 7.6-8.1) in Europe to 9.5% (9.2-9.8) in Asia/Middle East/Africa. Mean daily insulin dose ranged from 0.8 units/kg in Europe (0.7-0.8) and Australia/New Zealand (0.6-0.9) to 1.0 unit/kg 0.9-1.1) in Asia/Middle East/Africa. Percentage of pump use was highest in North America (80.7% [79.8-81.6]) and lowest in South America (4.2% [3.2-5.6]). Significant differences between the five regions were also observed with regards to body mass index SD scores, frequency of blood glucose monitoring and presence of severe hypoglycaemia. Conclusions We found significant heterogeneity in diabetes care and outcomes across the five regions. The aim of optimal care for each child remains a challenge.
  • Observational Study of Pulse Transit Time in Children With Sleep Disordered Breathing.

    Yanney, Michael P.; Kurc, Miguel; Tilbrook, Sean; Ali, Nabeel (2020-05)
    Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study. Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and "abnormal other." Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study. Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62-0.90) and specificity 0.79 (C.I. 0.49-0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67-0.92) and specificity 0.37 (95% C.I. 0.17-0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31-0.46) and specificity 0.98 (C.I. 0.97-1.00). Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.
  • Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial.

    HALT-IT Trial Collaborators; Sherwood Forest Hospitals NHS Foundation Trust (2020-06)
    Summary Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial.
  • Epilepsy deaths in children: Improvements driven by data and surveillance in pediatrics.

    Dunkley, Colin (2019-09)
    Epilepsy-related death in children and young people deserves understanding and intervention along with epilepsy-related deaths in adults. Risk of death from epilepsy varies at different ages, and the specific calculations of risk remains complex and varies between studies. There have been several UK studies examining factors associated with epilepsy-related deaths. A UK national audit with other national initiatives has evidenced improving quality of care and more recently allowed service provision factors associated with reduced epilepsy-related death to be evidenced. A national program of health education, formalized epilepsy networks, commissioned surgical pathways, and patient information resources around risk and participation are examples of quality improvement initiatives. Epilepsy-related death is a key outcome, and there remains many difficulties and opportunities at local, regional, and national level to better understand and improve this outcome for children and young people and the adults that they should become. This paper is for the Special Issue: Prevent 21: SUDEP Summit - Time to Listen.
  • Effectiveness of a behavioural intervention involving regular weighing and feedback by community midwives within routine antenatal care to prevent excessive gestational weight gain: POPS2 randomised controlled trial.

    Ohadike, Corah (2019-09)
    Objectives: To assess the effectiveness of a brief behavioural intervention based on routine antenatal weighing to prevent excessive gestational weight gain (defined by US Institute of Medicine). Design: Randomised controlled trial. Setting: Antenatal clinic in England. Participants: Women between 10+0 and 14+6 weeks gestation, not requiring specialist obstetric care. Interventions: Participants were randomised to usual antenatal care or usual care (UC) plus the intervention. The intervention involved community midwives weighing women at antenatal appointments, setting maximum weight gain limits between appointments and providing brief feedback. Women were encouraged to monitor and record their own weight weekly to assess their progress against the maximum limits set by their midwife. The comparator was usual maternity care. Primary and Secondary Outcome Measures: Excessive gestational weight gain, depression, anxiety and physical activity. Results: Six hundred and fifty-six women from four maternity centres were recruited: 329 women were randomised to the intervention group and 327 to UC. We found no evidence that the intervention decreased excessive gestational weight gain. At 38 weeks gestation, the proportions gaining excessive gestational weight were 27.6% (81/305) versus 28.9% (90/311) (adjusted OR 0.84, 95% CI: 0.53 to 1.33) in the intervention and UC group, respectively. There were no significant difference between the groups in anxiety or depression scores (anxiety: adjusted mean -0.58, 95% CI:-1.25 to -0.8; depression: adjusted mean -0.60, 95% CI:-1.24 to -0.05). There were no significant differences in physical activity scores between the groups. Conclusions: A behavioural intervention delivered by community midwives involving routine weighing throughout pregnancy, setting maximum weight gain targets and encouraging women to weigh themselves each week to check progress did not prevent excessive gestational weight gain. There was no evidence of psychological harm.
  • Association of quality of paediatric epilepsy care with mortality and unplanned hospital admissions among children and young people with epilepsy in England: a national longitudinal data linkage study.

    Dunkley, Colin (2019-09)
    Background: Concerns have been raised about variation in care quality and outcomes among children and young people with epilepsies in England. We aimed to investigate the association between quality of paediatric care, hospital admissions, and all-cause deaths among epilepsy patients. Methods: In this longitudinal data linkage study of paediatric epilepsy services in England, we linked unit-level data from round 1 (2009-11) and round 2 (2013-14) of the Epilepsy12 national clinical audit, with death registrations from the UK Office for National Statistics and data for unplanned hospital admissions from Hospital Episode Statistics. We investigated the association between unit-level performance in involving a paediatrician with epilepsy expertise, an epilepsy specialist nurse, and a paediatric neurologist (where appropriate) in round 1 and the proportion of adolescents (aged 10-18 years) with epilepsy admitted to each unit who subsequently died during the study period (April 1, 2009, to March 31, 2015). We also investigated whether change in Epilepsy12 performance between the two audit rounds was associated with changes in the standardised ratio of observed-to-expected unplanned epilepsy admissions over the same period. Findings: In 99 units with data for the analyses relating to paediatricians with epilepsy expertise and epilepsy specialist nurses, 134 (7%) of 1795 patients died during the study period, 88 (5%) of whom died after the transition to adult service. In 55 units with data for the analyses relating to paediatric neurologists, 79 (7%) of 1164 patients died, 54 (5%) of whom did so after the transition. In regression models adjusting for population, unit, and hospital activity characteristics, absolute reductions in total mortality risk (6·4 percentage points, 95% CI 0·1-12·7) and mortality risk after transition (5·7 percentage points, 0·6-10·8) were found when comparing units where all versus no eligible patients were seen by a paediatric neurologist. Units where all eligible patients were seen by a paediatric neurologist were estimated to have absolute reductions of 4·6 percentage points (0·3-8·9) in total mortality and of 4·6 percentage points (1·2-8·0) in post-transition mortality, compared with units where no or some eligible patients were seen by a paediatric neurologist. There was no significant association between performance on being seen by an epilepsy specialist nurse or by a paediatrician with epilepsy expertise and mortality. In units where access to an epilepsy specialist nurse decreased, the standardised ratio of epilepsy admissions increased by a mean of 0·21 (0·01-0·42). Interpretation: Among adolescents with epilepsy, greater involvement of tertiary specialists in paediatric care is associated with decreased all-cause mortality in the period after transition to adult services. Reduced access to an epilepsy specialist nurse was associated with an increase in paediatric epilepsy admissions.
  • . Evaluation of the Implementation of the Saving Babies’ Lives Care Bundle in early adopter NHS Trusts in England.

    Sherwood Forest Hospitals NHS Foundation Trust (Maternal and Fetal Health Research Centre, University of Manchester., 2018-11)
    This report presents the findings from the Saving Babies Lives Project Impact and Results Evaluation (SPiRE) conducted by the Tommy's Stillbirth Research Centre at the University of Manchester commissioned by NHS England in May 2016. The report describes the results of a comprehensive evaluation involving nineteen NHS trusts in England that have been implementing the Saving Babies' Lives Care Bundle (SBLCB) since April 2015, which aims to reduce the incidence of stillbirth by implementing best practice in four aspects of maternity care. This report describes the degree of implementation, the clinical and service outcomes and the economic impact(s) following a maximum two year implementation period in these early adopter Trusts and crucially, whether implementation of the SBLCB translates into fewer stillbirths. ... Stillbirth rates, clinical and service outcomes, element outcomes, estimated costs relating to SBLCB implementation and local guideline appraisal are reported. Information about the impact of implementation of the SBLCB on staff and services is described. participating trusts were assigned a letter for anonymization in the analysis. ... During the time period analysed in the early adopter Trusts there was a statistically significant reduction in stillbirth of 20%; this reduction was also seen in term stillbirths. Due to variations in the timing and level of implementation of the various elements of the SBLCB this reduction cannot be unambiguously related to its implementation. However, it is highly plausible that the SBLCB contributed to the fall in stillbirths.
  • Children and Young People-Mental Health Safety Assessment Tool (CYP-MH SAT) study: Protocol for the development and psychometric evaluation of an assessment tool to identify immediate risk of self-harm and suicide in children and young people (10-19 years) in acute paediatric hospital settings.

    Sherwood Forest Hospitals NHS Foundation Trust; CYP-MH SAT Study Steering Group (2018-04)
    INTRODUCTION: Currently, no standardised, evidence-based assessment tool for assessing immediate self-harm and suicide in acute paediatric inpatient settings exists. AIM: The aim of this study is to develop and test the psychometric properties of an assessment tool that identifies immediate risk of self-harm and suicide in children and young people (10-19 years) in acute paediatric hospital settings. METHODS AND ANALYSIS: Development phase: This phase involved a scoping review of the literature to identify and extract items from previously published suicide and self-harm risk assessment scales. Using a modified electronic Delphi approach, these items will then be rated according to their relevance for assessment of immediate suicide or self-harm risk by expert professionals. Inclusion of items will be determined by 65%-70% consensus between raters. Subsequently, a panel of expert members will convene to determine the face validity, appropriate phrasing, item order and response format for the finalised items.Psychometric testing phase: The finalised items will be tested for validity and reliability through a multicentre, psychometric evaluation. Psychometric testing will be undertaken to determine the following: internal consistency, inter-rater reliability, convergent, divergent validity and concurrent validity. ETHICS AND DISSEMINATION: Ethical approval was provided by the National Health Service East Midlands-Derby Research Ethics Committee (17/EM/0347) and full governance clearance received by the Health Research Authority and local participating sites. Findings from this study will be disseminated to professionals and the public via peer-reviewed journal publications, popular social media and conference presentations.
  • Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study.

    Sherwood Forest Hospitals NHS Foundation Trust (2018-07)
    OBJECTIVE: To report perception of fetal movements in women who experienced a stillbirth compared with controls at a similar gestation with a live birth. DESIGN: Case-control study. SETTING: 41 maternity units in the UK. PARTICIPANTS: Cases were women who had a late stillbirth >/=28 weeks gestation (n=291) and controls were women with an ongoing pregnancy at the time of the interview (n=733). Controls were frequency matched to cases by obstetric unit and gestational age. METHODS: Data were collected using an interviewer-administered questionnaire which included questions on maternal perception of fetal movement (frequency, strength, increased and decreased movements and hiccups) in the 2 weeks before the interview/stillbirth. Five fetal movement patterns were identified incorporating the changes in strength and frequency in the last 2 weeks by combining groups of similar pattern and risk. Multivariable analysis adjusted for known confounders. PRIMARY OUTCOME MEASURE: Association of maternally perceived fetal movements in relation to late stillbirth. RESULTS: In multivariable analyses, women who reported increased strength of movements in the last 2 weeks had decreased risk of late stillbirth compared with those whose movements were unchanged (adjusted OR (aOR) 0.18, 95% CI 0.13 to 0.26). Women with decreased frequency (without increase in strength) of fetal movements were at increased risk (aOR 4.51, 95% CI 2.38 to 8.55). Daily perception of fetal hiccups was protective (aOR 0.31, 95% CI 0.17 to 0.56). CONCLUSIONS: Increased strength of fetal movements and fetal hiccups is associated with decreased risk of stillbirth. Alterations in frequency of fetal movements are important in identifying pregnancies at increased risk of stillbirth, with the greatest risk in women noting a reduction in fetal activity. Clinical guidance should be updated to reflect that increase in strength and frequency of fetal movements is associated with the lowest risk of stillbirth, and that decreased fetal movements are associated with stillbirth.
  • Core Health Outcomes in Childhood Epilepsy (CHOICE): Development of a core outcome set using systematic review methods and a Delphi survey consensus.

    Dunkley, Colin (2019-05)
    Objective: Establishing a core set of outcomes to be evaluated and reported in intervention trials aims to improve the usefulness of health research. There is no established core outcome set (COS) for childhood epilepsies. The aim of this study was to select a COS to be used in evaluative research of interventions for children with rolandic epilepsy (RE). Methods: We followed guidance from the COMET (Core Outcome Measures in Effectiveness Trials) Initiative. First, we identified outcomes that had been measured in research through a systematic review. Second, young people with RE, parents, and professionals were invited to take part in a Delphi survey in which participants rated the importance of candidate outcomes. Last, a face‐to‐face meeting was convened to seek consensus on which outcomes were critical to include and to ratify the final COS. Results: From 37 eligible papers in the review, we identified and included 48 candidate outcomes in the survey. We sent invitations to 165 people registered to take part in the survey; of these, 102 (62%) completed Round 1, and 80 (78%) completed Round 2 (three young people, 16 parents, 61 professionals). In Round 2 we included four additional outcomes suggested by participants in Round 1. The consensus meeting included two young people, four parents, and nine professionals who were eligible to vote and ratified the COS as 39 outcomes across 10 domains. Significance: Our methodology was a proportionate and pragmatic approach toward producing a COS for evaluating research on interventions aiming to improve the health of children with RE.

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