Pharmacology; Pain; General Paediatrics
Child Psychiatry; Genetics
General Paediatrics; Pharmacology
Comm Child Health; Epidemiology; Evidence Based Medicine; Health services research; Tropical Paediatrics
Distinguishing serious bacterial infection (SBI) from milder/self-limiting infections is often difficult. Interpretation of vital signs is confounded by the effect of temperature on pulse and respiratory rate. Temperature–pulse centile charts have been proposed to improve the predictive value of pulse rate in the clinical assessment of children with suspected SBI.
To assess the utility of proposed temperature–pulse centile charts in the clinical assessment of children with suspected SBI.
Study design and participants
The predictive value for SBI of temperature–pulse centile categories, pulse centile categories and Advanced Paediatric Life Support (APLS) defined tachycardia were compared among 1360 children aged 3 months to 10 years presenting with suspected infection to a hospital emergency department (ED) in England; and among 325 children who presented to hospitals in the UK with meningococcal disease.
Main outcome measure
Among children presenting to the ED, 55 (4.0%) had SBI. Pulse centile category, but not temperature–pulse centile category, was strongly associated with risk of SBI (p=0.0005 and 0.288, respectively). APLS defined tachycardia was also strongly associated with SBI (OR 2.90 (95% CI 1.60 to 5.26), p=0.0002). Among children with meningococcal disease, higher pulse and temperature–pulse centile categories were both associated with more severe disease (p=0.004 and 0.041, respectively).
Increased pulse rate is an important predictor of SBI, supporting National Institute for Health and Clinical Excellence recommendations that pulse rate be routinely measured in the assessment of febrile children. Temperature–pulse centile charts performed more poorly than pulse alone in this study. Further studies are required to evaluate their utility in monitoring the clinical progress of sick children over time.
Limited data from pharmacokinetic studies in underweight and severely malnourished children have indicated an impaired activity of their hepatic enzymes. We used the caffeine breath test to assess the metabolising activity of cytochrome P450 1A2 (CYP1A2) enzyme in underweight children.
Underweight children from the paediatric outpatient clinic, Lagos State University Teaching Hospital, Ikeja in Nigeria, were studied. After an overnight fast, 15 underweight children took 3 mg/kg labelled caffeine orally. Breath samples were collected in duplicate at −20, −10 and −1 min and at 15 min intervals for 2 h. The mean cumulative per cent dose recovered (CPDR) of labelled caffeine in the expired carbon dioxide was determined over the study period. This was repeated after 2–6 weeks of nutritional rehabilitation.
The mean areas under the enrichment-time curve before and after nutritional rehabilitation were 0.539±0.320 and 0.620±0.322 atom per cent excess minute, respectively. The difference between the two values was not statistically significant (p=0.528). The mean CPDR in the exhaled carbon dioxide of the underweight children over a period of 2 h was 7.56±4.01% and 7.95±3.68% before and after nutritional rehabilitation, respectively, and there was no significant difference in the mean values (p=0.603).
The metabolism of caffeine was not significantly affected in underweight children compared with after 2–6 weeks of nutritional rehabilitation. This suggests that hepatic CYP1A2-metabolising activity was not significantly impaired in underweight children.
Pharmacology; Therapeutics; Tropical Paediatrics
The transition from paediatric to adult care is associated with poor clinical outcomes, increased costs and low patient and family satisfaction. However, little is known about health system strategies to streamline and safeguard care for youth transitioning to adult services. Moreover, the needs of children and youth are often excluded from broader health system reform discussions, leaving this population especially vulnerable to system ‘disintegration’.
(1) To explore the international policy profile of paediatric-to-adult care transitions, and (2) to document policy objectives, initiatives and outcomes for jurisdictions publicly committed to addressing transition issues.
An international policy scoping review of all publicly available government documents detailing transition-related strategies was completed using a web-based search. Our analysis included a comparable cohort of nine wealthy Organisation for Economic Co-operation and Development (OECD) jurisdictions with Beveridge-style healthcare systems (deemed those most likely to benefit from system-level transition strategies).
Few jurisdictions address transition of care issues in either health or broader social policy documents. While many jurisdictions refer to standardised practice guidelines, a few report the intention to use powerful policy levers (including physician remuneration and non-physician investments) to facilitate the uptake of best practice. Most jurisdictions do not address the policy infrastructure required to support successful transitions, and rigorous evaluations of transition strategies are rare.
Despite the well-documented risks and costs associated with a poor transition from paediatric to adult care, little policy attention has been paid to this issue. We recommend that healthcare providers engage health system planners in the design and evaluation of system-level, policy-sensitive transition strategies.
Adolescent Health; General Paediatrics; Health services research; Paediatric Practice
The objective of this study is to review clinical outcomes of recommendations made by a multidisciplinary paediatric virtual clinic (PVC) for complex case management of paediatric HIV as a model of care within a tertiary network.
A retrospective review of the clinical outcomes of paediatric and adolescent (0–21 years) referrals to the PVC at St. Mary's Hospital, Imperial College Healthcare NHS Trust, London was performed between October 2009 and November 2013.
234 referrals were made for 182 children from 37 centres, discussed in 42 meetings (median age 13 years, IQR 10–15 years). Reasons for referral included virological failure (44%), simplification of the current regimen (24%) and antiretroviral drug complications (24%). At latest follow-up, PVC advice had been instituted in 80% of referrals. Suppression following virological failure was achieved in 48% following first referral and 57% following subsequent discussions and was maintained in 95% of children referred for regimen simplification. Following advice, dyslipidaemia resolved in 42% and liver function normalised in 73% with biochemical hepatitis. Adherence support aided resolution of viraemia in nine children and 12% of referrals resulted in additional support, including psychology, social services and mental health input.
Combined multidisciplinary virtual input with adult expertise in resistance and newer agents, paediatric knowledge of pill swallowing, childhood formulations/weight banding and parental support, assists complex treatment decision making in paediatric HIV infection. The Virtual Clinic model could be applied to the management of other rare complex diseases of childhood within a clinical network.
HIV; Information Technology; Pharmacology
Organisations in England's National Health Service (NHS) are required to have ‘did not attend’ (DNA) guidelines to help deal with the ‘unseen child’.
To map DNA and associated guidelines in paediatric services, examine differences in safeguarding response and advice in the guidelines and explore the experience of guideline users.
A mapping approach was used to locate current DNA guidelines on English NHS organisations’ websites. Analysis of the guidelines was supplemented with qualitative data from those who produce, monitor or use them.
Fewer than 8% of English NHS organisations had up-to-date guidelines in the public domain, though a further 41% stated that they had a DNA/similar policy in place or had an out-of-date guideline on their website. Advice to healthcare providers about the steps to take when a child DNAs fell into five categories: reflection and review; direct interaction with the family; indirect interaction with the family; liaison with internal colleagues; and external referral. Interviews with eight individuals led to the identification of four themes. The management of information flows was central to the effective management of DNA. Respondents also reported seeking support and advice from others. While all respondents spoke about the importance of supporting the family, the child's needs were central to dealing with non-attendance, and respondents demonstrated awareness of wider risk discourses.
We consider the implications of the work and suggest that evidence-informed guidelines developed nationally but tailored to specific services might be helpful for providers and users alike.
Health services research; Qualitative research; General Paediatrics; Health Service
N-methyl-D-aspartate receptor antibody (NMDAR-Ab) encephalitis is a well-recognised clinico-immunological syndrome that presents with neuropsychiatric symptoms cognitive decline, movement disorder and seizures. This study reports the clinical features, management and neurological outcomes of paediatric NMDAR-Ab-mediated neurological disease in the UK.
A prospective surveillance study. Children with NMDAR-Ab-mediated neurological diseases were voluntarily reported to the British Neurological Surveillance Unit (BPNSU) from November 2010 to December 2011. Initial and follow-up questionnaires were sent out to physicians.
Thirty-one children fulfilled the criteria for the study. Eight presented during the study period giving an incidence of 0.85 per million children per year (95% CI 0.64 to 1.06); 23 cases were historical. Behavioural change and neuropsychiatric features were present in 90% of patients, and seizures and movement disorders both in 67%. Typical NMDAR-Ab encephalitis was reported in 24 children and partial phenotype without encephalopathy in seven, including predominantly psychiatric (four) and movement disorder (three). All patients received steroids, 22 (71%) received intravenous immunoglobulin, 9 (29%) received plasma exchange,and 10 (32%) received second-line immunotherapy. Of the 23 patients who were diagnosed early, 18 (78%) made a full recovery compared with only 1 of 8 (13%) of the late diagnosed patients (p=0.002, Fisher's exact test). Seven patients relapsed, with four needing additional second-line immunotherapy.
Paediatric NMDAR-Ab-mediated neurological disease appears to be similar to adult NMDAR-Ab encephalitis, but some presented with a partial phenotype. Early treatment was associated with a quick and often full recovery.
Encephalitis; Autoantibody; NMDA receptors; immunotherapy; Neurology
Evaluate relationships between type of milk consumed and weight status among preschool children.
Longitudinal cohort study.
Early Childhood Longitudinal Study–Birth Cohort, a representative sample of U.S. children.
10,700 U.S. children examined at age 2 and 4 years.
Main Outcome Measures
BMI z-score and overweight/obese status as a function of milk type intake.
The majority of children drank whole or 2% milk (87% at 2 years, 79.3% at 4 years). Across racial/ethnic and SES subgroups 1%/skim-milk drinkers had higher BMI z-scores than 2%/whole-milk drinkers. In multivariable analyses, increasing fat content in the type of milk consumed was inversely associated with BMI z-score (p<0.0001). Compared to those drinking 2%/whole milk, 2- and 4-year-old children drinking 1%/skim milk had an increased adjusted odds of being overweight (age 2 OR 1.64, p<0.0001; age 4 OR 1.63 p<0.0001) or obese (age 2 OR 1.57 p<0.01; age 4 OR 1.64, p<0.0001). In longitudinal analysis, children drinking 1%/skim milk at both 2 and 4 years were more likely to become overweight/obese between these time points (adjusted OR 1.57, p<0.05).
Consumption of 1%/skim milk is more common among overweight/obese preschoolers, potentially reflecting the choice of parents to give overweight/obese children low-fat milk to drink. Nevertheless, 1%/skim milk does not appear to restrain body weight gain between 2–4 years in this age range, emphasizing a need for weight-targeted recommendations with a greater evidence basis.
Global emphasis has shifted beyond reducing child survival rates to improving health and developmental trajectories in childhood. Optimum early childhood experience is believed to allow children to benefit fully from educational opportunities resulting in improved human capital. Investment in early childhood initiatives in low-income and middle-income countries (LMICs) is increasing. These initiatives use early childhood developmental assessment tools (CDATs) as outcome measures. CDATs are also key measures in the evaluation of programmatic health initiatives in LMICs, influencing public health policy. Interpretation of CDAT outcomes requires understanding of their structure and psychometric properties. This article reviews the structure and main methods of CDAT development with specific considerations when applied in LMICs.
Neurodisability; Neurodevelopment; Outcomes research
Obsessive-compulsive disorder (OCD) in childhood and adolescence is an impairing condition, associated with a specific set of distressing symptoms incorporating repetitive, intrusive thoughts (obsessions) and distressing, time-consuming rituals (compulsions). This review considers current knowledge of causes and mechanisms underlying OCD, as well as assessment and treatment. Issues relating to differential diagnosis are summarised, including the challenges of distinguishing OCD from autism spectrum disorders and tic disorders in youth. The recommended treatments, namely cognitive behaviour therapy and serotonin reuptake inhibiting/selective serotonin reuptake inhibitor medications, are outlined along with the existing evidence-based and factors associated with treatment resistance. Finally, novel clinical developments that are emerging in the field and future directions for research are discussed.
Child Psychiatry; Child Psychology; Psychology; Outcomes research
To investigate risk factors for first long-bone fractures in children up to 5 years old in order to provide evidence about which families could benefit from injury prevention interventions.
Population-based matched nested case–control study using The Health Improvement Network, a UK primary care research database, 1988–2004.
Maternal, household and child risk factors for injury were assessed among 2456 children with long-bone fractures (cases). 23 661controls were matched to cases on general practice. Adjusted ORs and 95% CIs were estimated using conditional logistic regression.
Fractures of long-bones were independently associated with younger maternal age and higher birth order, with children who were the fourth-born in the family, or later, having a threefold greater odds of fracture compared to first-born children (adjusted OR 3.12, 95% CI 2.08 to 4.68). Children over the age of 1 year had a fourfold (13–24 months, adjusted OR 4.09 95% CI 3.51 to 4.76) to fivefold (37+ months, adjusted OR 4.88 95% CI 4.21 to 5.66) increase in the odds of a long-bone fracture compared to children aged 0–12 months. Children in families with a history of maternal alcohol misuse had a raised odds of long-bone fracture (adjusted OR 2.33, 95% CI 1.13 to 4.82) compared to those with no documented history.
Risk factors for long-bone fractures in children less than 5 years old included age above 1 year, increasing birth order, younger maternal age and maternal alcohol misuse. These risk factors should be used to prioritise families and communities for injury prevention interventions.
risk factors; fractures; epidemiology; child; preschool
Authoritative international guidelines stipulate that for minors to participate in research, consent must be obtained from their parents or guardians. Significant numbers of mature minors, particularly in low-income settings, are currently being ruled out of research participation because their parents are unavailable or refuse to provide consent despite the possibility that they might wish to do so and that such research has the potential to be of real benefit. These populations are under-represented in all types of clinical research. We propose that, for research with a prospect of direct benefit that has been approved by relevant ethics committees, the default position should be that minors who are able to provide valid consent and meet the following criteria should be able to consent for themselves regardless of age and whether they have reached majority: the minor must be competent and mature relative to the decision; their consent must be voluntary and they must be relatively independent and used to decision making of comparable complexity. In addition, the context must be appropriate, the information related to the research must be provided in a manner accessible to the minor and the consent must be obtained by a trained consent taker in surroundings conducive for decision making by the minor. In this paper, we have argued that consent by mature minors to research participation is acceptable in some situations and should be allowed.
Ethics; Adolescent Health; Tropical Paediatrics
To compare a comprehensive lifestyle intervention for overweight children performed in groups of families with a conventional single-family treatment. Two-year follow-up data on anthropometric and psychological outcome are presented.
Overweight and obese children aged 6–12 years with body mass index (BMI) corresponding to ≥27.5 kg/m2 in adults were randomised to multiple-family (n=48) or single-family intervention (n=49) in a parallel design. Multiple-family intervention comprised an inpatient programme with other families and a multidisciplinary team, follow-up visits in their hometown, weekly physical activity and a family camp. Single-family intervention included counselling by paediatric nurse, paediatric consultant and nutritionist at the hospital and follow-up by a community public health nurse. Primary outcome measures were change in BMI kg/m2 and BMI SD score after 2 years.
BMI increased by 1.29 kg/m2 in the multiple-family intervention compared with 2.02 kg/m2 in the single-family intervention (p=0.075). BMI SD score decreased by 0.20 units in the multiple-family group and 0.08 units in the single-family intervention group (p=0.046). A between-group difference of 2.4 cm in waist circumference (p=0.038) was detected. Pooled data from both treatment groups showed a significant decrease in BMI SD score of 0.14 units and a significant decrease in parent-reported and self-reported Strength and Difficulty Questionnaire total score of 1.9 units.
Two-year outcome showed no between-group difference in BMI. A small between-group effect in BMI SD score and waist circumference favouring multiple-family intervention was detected. Pooled data showed an overall improvement in psychological outcome measures and BMI SD score.
Trial registration number
Obesity; Child Psychology; Outcomes research; Comm Child Health; School Health
This study aims to identify the prevalence and pattern of bruises in preschool children over time, and explore influential variables
Prospective longitudinal study of children (<6 years) where bruises were recorded on a body chart, weekly for up to 12 weeks. The number and location of bruises were analysed according to development. Longitudinal analysis was performed using multilevel modelling.
3523 bruises recorded from 2570 data collections from 328 children (mean age 19 months); 6.7% of 1010 collections from premobile children had at least one bruise (2.2% of babies who could not roll over and 9.8% in those who could), compared with 45.6% of 478 early mobile and 78.8% of 1082 walking child collections. The most common site affected in all groups was below the knees, followed by ‘facial T’ and head in premobile and early mobile. The ears, neck, buttocks, genitalia and hands were rarely bruised (<1% of all collections). None of gender, season or the level of social deprivation significantly influenced bruising patterns, although having a sibling increased the mean number of bruises. There was considerable variation in the number of bruises recorded between different children which increased with developmental stage and was greater than the variation between numbers of bruises in collections from the same child over time.
These data should help clinicians understand the patterns of ‘everyday bruising’ and recognise children who have an unusual numbers or distribution of bruises who may need assessment for physical abuse or bleeding disorders.
Child Abuse; Injury Prevention
Prevention of hospital-acquired infections (HAI) is central to providing safe and high quality healthcare. Transmission of infection between patients by health workers, and the irrational use of antibiotics have been identified as preventable aetiological factors for HAIs. Few studies have addressed this in developing countries.
To implement a multifaceted infection control and antibiotic stewardship programme and evaluate its effectiveness on HAIs and antibiotic use.
A before-and-after study was conducted over 27 months in a teaching hospital in Indonesia. All children admitted to the paediatric intensive care unit and paediatric wards were observed daily. Assessment of HAIs was made based on the criteria from the Centers for Disease Control and Prevention. The multifaceted intervention consisted of a hand hygiene campaign, antibiotic stewardship (using the WHO Pocket Book of Hospital Care for Children guidelines as standards of antibiotic prescribing for community-acquired infections), and other elementary infection control practices. Data were collected using an identical method in the preintervention and postintervention periods.
We observed a major reduction in HAIs, from 22.6% (277/1227 patients) in the preintervention period to 8.6% (123/1419 patients) in the postintervention period (relative risk (RR) (95% CI) 0.38 (0.31 to 0.46)). Inappropriate antibiotic use declined from 43% (336 of 780 patients who were prescribed antibiotics) to 20.6% (182 of 882 patients) (RR 0.46 (0.40 to 0.55)). Hand hygiene compliance increased from 18.9% (319/1690) to 62.9% (1125/1789) (RR 3.33 (2.99 to 3.70)). In-hospital mortality decreased from 10.4% (127/1227) to 8% (114/1419) (RR 0.78 (0.61 to 0.97)).
Multifaceted infection control interventions are effective in reducing HAI rates, improving the rational use of antibiotics, increasing hand hygiene compliance, and may reduce mortality in hospitalised children in developing countries.
Hospital acquired infection; Hand hygiene; Antibiotic stewardship; Paediatrics; Developing countries
Serological studies indicate that evidence of coeliac disease (CD) exists in about 1% of all children, but we lack estimates of current diagnostic patterns among children and how they vary by socioeconomic group.
We identified all children aged 0–18 years between 1993 and 2012 who were registered with general practices across the UK that contribute to a large population-based general practice database. The incidence of CD was evaluated in each quintile of the Townsend index of deprivation and stratified by age, sex, country and calendar year.
Among 2 063 421 children, we identified 1247 CD diagnoses, corresponding to an overall CD incidence of 11.9 per 100 000 person-years, which was similar across the UK countries and higher in girls than in boys. We found a gradient of CD diagnosis across socioeconomic groups, with the rate of diagnosis being 80% higher in children from the least-deprived areas than in those from the most-deprived areas (incident rate ratio 1.80, 95% CI 1.45 to 2.22). This pattern held for both boys and girls and across all ages. Across all four countries of the UK, we found similar associations between CD and socioeconomic status. While CD incidence up to age 2 remained stable over the study period, diagnoses at older ages have almost tripled over the past 20 years.
Children living in less socioeconomically deprived areas in the UK are more likely to be diagnosed with CD. Increased implementation of diagnostic guidelines could result in better case identification in more-deprived areas.
coeliac disease; incidence; children; socioeconomic status
This study aimed to use primary care electronic health records to evaluate the prevalence of overweight and obesity in 2–15-year-old children in England and compare trends over the last two decades.
Cohort study of primary care electronic health records.
375 general practices in England that contribute to the UK Clinical Practice Research Datalink.
Individual participants were sampled if they were aged between 2 and 15 years during the period 1994–2013 and had one or more records of body mass index (BMI).
Main outcome measure
Prevalence of overweight (including obesity) was defined as a BMI equal to or greater than the 85th centile of the 1990 UK reference population.
Data were analysed for 370 544 children with 507 483 BMI records. From 1994 to 2003, the odds of overweight and obesity increased by 8.1% per year (95% CI 7.2% to 8.9%) compared with 0.4% (−0.2% to 1.1%) from 2004 to 2013. Trends were similar for boys and girls, but differed by age groups, with prevalence stabilising in 2004 to 2013 in the younger (2–10 year) but not older (11–15 year) age group, where rates continued to increase.
Primary care electronic health records in England may provide a valuable resource for monitoring obesity trends. More than a third of UK children are overweight or obese, but the prevalence of overweight and obesity may have stabilised between 2004 and 2013.
Obesity; Monitoring; Epidemiology; Growth
To pilot an in-home unintentional injury hazard assessment tool and to quantify potential injury risks for young children in a low-income urban setting.
Two low-income neighbourhoods in Karachi, Pakistan, were mapped, and families with at least one child between the ages of 12 and 59 months were identified. Using existing available home injury risk information, an in-home injury risk assessment tool was drafted and tailored to the local setting. Home injury assessments were done in June–July 2010 after obtaining informed consent.
Approximately 75.4% of mothers were educated through at least grade 12. The main risks identified were stoves within the reach of the child (n=279, 55.5%), presence of open buckets in the bathroom (n=240, 47.7%) within the reach of the child, and pedestal fans accessible to the child (n=242, 48.1%). In terms of safety equipment, a first-aid box with any basic item was present in 70% of households, but only 4.8% of households had a fire extinguisher in the kitchen.
This was the first time that an in-home, all-unintentional injury risk assessment tool was tailored and applied in the context of a low-income community in Pakistan. There was a significant burden of hazards present in the homes in these communities, representing an important opportunity for injury prevention. This pilot may have future relevance to other LMICs where child injury prevention is a critical need.
Globally, more than 875 000 children under the age of 18 die due to injury every year. The rate of child injury death is 3.4 times higher in low-income and middle-income countries than in high-income countries.
To study injury mortality burden among children under the age of 5 in Pakistan.
Demographic and Health Survey in Pakistan was conducted from September 2006 until February 2007. It included 95 000 households, out of which 3232 households had death of a child under the age of 5 from January 2005 onwards. The Child Verbal Autopsy Questionnaire (CVAQ) was administered to these households with a response rate of 96%.
For age group 0–5 years, injury was the sixth leading cause of death and was responsible for 2.5% of all deaths (n=73). For age group 1–5 years, injury was found to be the third leading cause of death (11%) after diarrhoea (18%) and pneumonia (17%). The overall under fives mortality rate due to injury was estimated at 39.5 per 100 000 per year in Pakistan. Drowning (22%), road traffic injuries (12%), burns (11%) and falls (10%) were the most common types of injury. The mortality rate was twice as high in rural areas (32 per 100 000; 95% CI 18 to 45), compared to the urban areas (15 per 100 000; 95% CI 0.3 to 29).
Injury is the third leading cause of deaths among children 1–5 in Pakistan. The burden is twice as high in rural areas.