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Medical Education Archives of Disease in Childhood current issue

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Archives of Disease in Childhood current issue - Recent Educational Updates

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Atoms
<sec id="s1"><st>Limits</st> <p>There&rsquo;s a point, somewhere near the midpoint of Ridley Scott&rsquo;s <I>Blade Runner</I> where one starts to doubt one&rsquo;s preconceptions. Morality, mortality, judgement all jostle in the heady mix, the competition becoming more ferocious as the denouement approaches. By this stage, the lines between humans and replicants muddying to the point of a blur, disentanglement into distinct factions, now being way beyond possible. Every manoeuvre has its boundaries&mdash;but, you already knew that.</p> </sec> <sec id="s2"><st>Points of care: a multi-part series</st><sec id="s2-1"><st>&lsquo;Do&rsquo; the physiology</st> <p>It&rsquo;s a mixture of bemusing, baffling, amusing and frustrating that despite multiple attempts to address it, assessment of &lsquo;simple dehydration&rsquo; is still beyond us. What do we know? In short, that clinical assessment (despite the textbook dogma&mdash;sunken fontanelle for 10% anyone?) is worse than rough and ready, biochemistry (urea, creatinine, sodium&mdash;all of them) completely uncorrelated and (as we recently published) ketones unhelpful. Point of care...


Correction: Can we distinguish the consequences of early maltreatment on child behaviour from idiopathic autism?
<p>Wolstencroft J, Mandy W, Brown-Wright L, <I>et al</I>.Can we distinguish the consequences of early maltreatment on child behaviour from idiopathic autism? <I>Archives of Disease in Childhood</I> 2023;108:392&ndash;7.</p> <p>The authors have noticed two errors were introduced into table 1 during the production process. In table 1, row Teacher SDQ Total Difficulties score, Maltreatment Group, the data should be 20.1 (6.0) and not 9.2 (7.1). In the same table, row Teacher SDQ Hyperactivity Score, Maltreatment Group the data should read 7.1 and not 71. Further, in the Methods section, Participants, it should read &lsquo;This index case group was matched on verbal IQ and age to 50 children&rsquo; and not 47 children.</p> <p>In table 2, first row, ADI should read 3di. Reference 17 referred to ADI and so is no longer relevant to this article.</p>


Must the capacitous young person also be competent to provide consent for treatment and research?
<p>Must the <I>capacitous</I> young person, in addition, be <I>competent</I> to provide consent for treatment? Drs Davies, Fisher and Birchley propose that this situation has been reached in the common law; and that the lack of legal clarity extends to medical research and guidance. And so it would, since as they point out, &lsquo;capacity&rsquo; and &lsquo;competence&rsquo; are not synonymous notions.</p> <p>A judgement, <I>In Re X</I>, handed down in January 2021<cross-ref type="bib" refid="R1">1</cross-ref> concerned a <I>Gillick</I><cross-ref type="bib" refid="R2">2</cross-ref> competent girl aged 15 years, soon to be 16. She was seeking to refuse blood transfusion for her latest sickle cell crisis. The <I>Gillick</I> case was decided on the basis that if a child establishes that she is of sufficient maturity and intelligence to understand what is involved in the treatment in question, she is competent to provide consent. The judge, Sir James Munby, past President of the Family Division of the High...


RECOVERY trial: COVID-19
<p>There have been so many papers on COVID-19 since the beginning of the 2020 pandemic and the science was quickly changing as we understood more. So far, <I>Archivist</I> has not highlighted any literature on the subject. The Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial has just been published by Faust and the RECOVERY Collaborative Group (<I>Lancet Child Adolesc Health</I> 2024;8:190&ndash;200) and they have examined the management of paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2. They used a two-stage platform, adaptive trial design involving 51 hospitals in the UK and 237 children with the diagnosis. It was randomised and open-label, with standard care for comparison. The first part compared intravenous immunoglobulin or corticosteroids with usual care, with duration of hospital stay as the outcome. Those with inflammation refractory to this initial management based on the treating clinician&rsquo;s judgement then went into the second phase to be randomised to compare...


Global epidemiology of asymptomatic colonisation of methicillin-resistant Staphylococcus aureus in the upper respiratory tract of young children: a systematic review and meta-analysis
<sec><st>Objective</st> <p>To estimate the global prevalence of asymptomatic colonisation, and determine the associated risk factors, antibiotic resistance and genotypes of methicillin-resistant <I>Staphylococcus aureus</I> (MRSA) in the upper respiratory tract of young children.</p> </sec> <sec><st>Design</st> <p>Four bibliometric databases were searched for publications between 2010 and 2022 according to the protocol registered in PROSPERO. Cross-sectional or cohort studies describing the prevalence of asymptomatic colonisation of <I>S. aureus</I> and MRSA in young children were included. Data extraction and analysis were carried out by two reviewers independently according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Pooled prevalence was estimated using a random effects model.</p> </sec> <sec><st>Setting and studies</st> <p>We included studies where children without respiratory tract infection or Staphylococcal infection were recruited from the community, children&rsquo;s institutions (ie, nurseries, kindergartens, daycare centres and preschools) and healthcare centre visits and assessed for asymptomatic colonisation with <I>S. aureus</I> and MRSA.</p> </sec> <sec><st>Main outcome measures</st> <p>The pooled prevalence of asymptomatic colonisation of <I>S. aureus</I> and MRSA of young children globally.</p> </sec> <sec><st>Results</st> <p>In this systematic review and meta-analysis of 21 416 young children, the pooled global prevalence of asymptomatic <I>S. aureus</I> colonisation was 25.1% (95% CI 21.4 to 28.8) and MRSA colonisation was 3.4% (95% CI 2.8 to 4.1). The clones of MRSA strains included healthcare-associated MRSA, community-associated MRSA and livestock-associated MRSA.</p> </sec> <sec><st>Conclusion</st> <p>This study provides evidence of increased MRSA colonisation globally among young children, underlining the critical role of asymptomatic carriers in MRSA transmission and the need for control measures.</p> </sec> <sec><st>PROSPERO registration number</st> <p>CRD 42022328385.</p> </sec>


Point-of-care ultrasound to assess degree of dehydration in children: a systematic review with meta-analysis
<sec><st>Background</st> <p>There is no perfect method to assess level of dehydration in children. There are studies with conflicting results, where point-of-care ultrasound (POCUS) measurement of diameter ratio of the inferior vena cava to the aorta (IVC/Ao) was used to predict degree of dehydration.</p> </sec> <sec><st>Objective</st> <p>To systematically review the diagnostic accuracy of POCUS measurement of IVC/Ao ratio in predicting dehydration in children.</p> </sec> <sec><st>Methods</st> <p>MEDLINE, EMBASE and Cochrane databases were searched. The primary outcome was the diagnostic accuracy of IVC/Ao ratio. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2.</p> </sec> <sec><st>Results</st> <p>Eleven studies (2679 patients) were included. The most numerous group (five studies) used percentage weight change as a reference standard; the pooled sensitivity, specificity of POCUS in this group were: 0.7 (95% CI: 0.67 to 0.73), I<sup>2</sup>: 82%; 0.53 (95% CI: 0.5 to 0.53), I<sup>2</sup>: 84%. In the remaining studies, different comparator tests were used: Clinical Dehydration Scale (two studies, 0.8 (95% CI: 0.72 to 0.86), I<sup>2</sup>: 0%; 0.56 (95% CI: 0.48 to 0.65), I<sup>2</sup>: 0%; clinical judgement (three studies, 0.78 (95% CI: 0.73 to 0.83), I<sup>2</sup>: 95%; 0.82 (95% CI: 0.77 to 0.86), I<sup>2</sup>: 93% and one study used the Dehydration: Assessing Kids Accurately score model.</p> </sec> <sec><st>Conclusion</st> <p>This systematic review and meta-analysis showed that POCUS has a moderate sensitivity and specificity for identifying dehydration in children. Its use as a complementary diagnostic tool could be promising but needs to be validated in randomised controlled trials.</p> </sec> <sec><st>PROSPERO registration number</st> <p>CRD42022346166.</p> </sec>


Smartphone use for Paediatric Calculations in Emergencies (SPaCE)
<sec><st>Background</st> <p>The preparation for critically ill children involves calculating drug and fluid volumes using the commonly taught WETFLAG (weight, energy, endotracheal tube, fluids, lorazepam, adrenaline, glucose) acronym. While smartphone applications (apps) are increasingly used for these calculations in clinical practice, limited studies have explored their accuracy and safety.</p> </sec> <sec><st>Aim</st> <p>To assess the accuracy of three calculation methods for paediatric emergency drug doses and fluid volumes: a smartphone app, reference charts and traditional calculation methods. The secondary aims were to investigate the effect on the time taken and self-reported stress levels.</p> </sec> <sec><st>Methods</st> <p>A convenience sample of healthcare professionals from four hospitals contributed. Participants calculated drug and fluid doses for fictional patients using the three different methods. The method and case order were randomised centrally. The study recorded the number of errors made during the calculations, healthcare professionals&rsquo; self-reported stress levels on a scale of 0 (no stress) to 10 (maximum stress) and the time taken for each case. The app was developed at the direct request of the study team.</p> </sec> <sec><st>Results</st> <p>Ninety-six participants calculated values for six fictional cases, resulting in 576 calculations. Traditional calculation methods showed a statistically significant higher rate of error compared with the use of a smartphone app or reference charts (mean=1, 0, 0, respectively). The smartphone app outperformed both traditional calculation methods and reference charts for time taken and user-reported stress levels.</p> </sec> <sec><st>Conclusions</st> <p>Traditional methods of &lsquo;WETFLAG&rsquo; drug and fluid calculations are associated with a statistically significant increased risk of error compared with the use of reference charts or smartphone app. The smartphone app proved significantly faster and less stressful to use compared with traditional calculation methods or reference charts.</p> </sec>


Point-of-care ultrasound as a diagnostic tool in respiratory assessment in awake paediatric patients: a comparative study
<sec><st>Background</st> <p>Chest X-ray (CXR) has typically been the main investigation in children with suspected respiratory pathology. Recent advances in lung point-of-care ultrasound (POCUS) have shown the potential for it to be comparative, if not better, than CXR. The objective of this study was to compare CXR with lung POCUS in children with respiratory illness in a ward-based setting at a paediatric teaching hospital.</p> </sec> <sec><st>Methods</st> <p>Any child &lt;18 years of age presenting to Southampton Children&rsquo;s Hospital requiring a CXR for clinical reasons also had lung POCUS performed. CXR was reported by a consultant paediatric radiologist and lung POCUS was reviewed retrospectively by a blinded POCUS clinician, with only the clinical information provided on the CXR request. Comparisons were made between the CXR and lung POCUS findings.</p> </sec> <sec><st>Results</st> <p>100 paired lung POCUS and CXR were included in the study. 30% of lung POCUS were normal with 97% of these having a normal CXR. 70% of cases had POCUS abnormalities with 96% of POCUS cases identifying comparative lung pathology. Lung POCUS therefore had a sensitivity of 98.51% and a specificity of 87.9% with a diagnostic accuracy of 95% when compared with the CXR report.</p> </sec> <sec><st>Conclusions</st> <p>Lung POCUS has excellent diagnostic accuracy. The diagnosis of normal lung on POCUS when performed by a trained practitioner can reliably reduce the need for a CXR, thus reducing CXR use and radiation exposure in children. An abnormal lung POCUS could then either give the diagnosis or lead to a CXR with the expectation of clinically relevant findings.</p> </sec>


Outcome data from 15 years of cystic fibrosis newborn screening in a large UK region
<sec><st>Background</st> <p>The West Midlands Newborn Bloodspot Screening Laboratory is one of 16 in the UK and serves two tertiary paediatric cystic fibrosis (CF) centres (Staffordshire Children&rsquo;s Hospital at Royal Stoke and Birmingham Children&rsquo;s Hospital). CF newborn bloodspot screening (NBS) in this region started in November 2006 prior to the UK national roll-out in 2007. It uses an immunoreactive trypsinogen (IRT)/DNA/IRT protocol. We report the outcomes from 15 years of CF screening.</p> </sec> <sec><st>Methods</st> <p>The West Midlands CF NBS outcomes from 1 November 2006 to 31 October 2021 were reviewed. Clinical data were also obtained for babies referred to the CF centres as &lsquo;CF suspected&rsquo;.</p> </sec> <sec><st>Results</st> <p>1 075 161 babies were screened, with 402 referred as &lsquo;CF suspected&rsquo; and 205 identified as CF carriers. Of the &lsquo;CF suspected&rsquo; babies, 268 were diagnosed with CF, 33 with CF screen positive, inconclusive diagnosis (CFSPID) and 17 as a CF carrier. Any CF-related diagnosis was excluded in 67. Outcome data were not available for 17, of whom 14 had died. Eighteen children with a negative CF NBS have subsequently been diagnosed with CF, 10 had meconium ileus and 8 were true &lsquo;affected not detected&rsquo;, presenting with respiratory symptoms or failure to thrive. This gives the West Midlands a CF birth prevalence of 1 in 4012 live births and the NBS protocol a sensitivity of 97.1% and a positive predictive value of 66.7%.</p> </sec> <sec><st>Conclusions</st> <p>This large regional data set has excellent case ascertainment and demonstrates successful performance of the CF NBS protocol, with low numbers identified as CFSPID or CF carriers.</p> </sec>


Air pollution and childhood respiratory consultations in primary care: a systematic review
<sec><st>Background</st> <p>Outdoor air pollution is a known risk factor for respiratory morbidity worldwide. Compared with the adult population, there are fewer studies that analyse the association between short-term exposure to air pollution and respiratory morbidity in children in primary care.</p> </sec> <sec><st>Objective</st> <p>To evaluate whether children in a primary care setting exposed to outdoor air pollutants during short-term intervals are at increased risk of respiratory diagnoses.</p> </sec> <sec><st>Methods</st> <p>A search in Medline, the Cochrane Library, Web of Science and Embase databases throughout March 2023. Percentage change or risk ratios with corresponding 95% CI for the association between air pollutants and respiratory diseases were retrieved from individual studies. Risk of bias assessment was conducted with the Newcastle&ndash;Ottawa Scale (NOS) for cohort or case&ndash;control studies and an adjusted NOS for time series studies.</p> </sec> <sec><st>Results</st> <p>From 1366 studies, 14 were identified as meeting the inclusion criteria. Most studies had intermediate or high quality. A meta-analysis was not conducted due to heterogeneity in exposure and health outcome. Overall, studies on short-term exposure to air pollutants (carbon monoxide (CO), sulfur dioxide (SO<SUB>2</SUB>), nitrogen dioxide (NO<SUB>2</SUB>) and particulate matter &le;10 &micro;m (PM<SUB>10</SUB>)) were associated with increased childhood respiratory consultations in primary care. In general, exposure to ozone was associated with a reduction in respiratory consultations.</p> </sec> <sec><st>Conclusions</st> <p>The evidence suggests CO, SO<SUB>2</SUB>, NO<SUB>2</SUB>, PM<SUB>10</SUB> and PM<SUB>2.5</SUB> are risk factors for respiratory diseases in children in primary care in the short term. However, given the heterogeneity of the studies, interpretation of these findings must be done with caution.</p> </sec> <sec><st>PROSPERO registration number</st> <p>CRD42022259279.</p> </sec>


Rate and predictors of insufficient sweat volume in very young infants after pilocarpine gel iontophoresis: prospective, population-based study
<sec><st>Objective</st> <p>To verify the rate and predictors of &lsquo;quantity not sufficient&rsquo; (QNS) among Brazilian infants younger than 3 months with positive newborn screening (NBS) for cystic fibrosis (CF).</p> </sec> <sec><st>Design</st> <p>Prospective, population-based study.</p> </sec> <sec><st>Setting</st> <p>Public Statewide Newborn Screening Programme where the incidence rate of CF is 1:11 000.</p> </sec> <sec><st>Patients</st> <p>Subjects with positive two-tiered immunoreactive trypsinogen.</p> </sec> <sec><st>Interventions</st> <p>Sweat induction and collection were performed in the same facility; one sweat sample was obtained per individual.</p> </sec> <sec><st>Main outcome measures</st> <p>The QNS rate and its predictors; analysis corresponded to the day of sweat collection.</p> </sec> <sec><st>Results</st> <p>Among the 975 participants, QNS rates for 10 and 15 &micro;L were 3.6% (95% CI 2.5% to 4.9%) and 8.3% (95% CI 6.6% to 10.2%). Infants weighing &gt;3056 and &gt;3845 g and with gestational age higher than 37 weeks had a greater likelihood (5.5 and 6.7, and 2.7 and 5.8 times more, respectively) of avoiding QNS than their peers.</p> </sec> <sec><st>Conclusion</st> <p>QNS rates fulfilled the requirements, but predictors differed from those recommended by the Cystic Fibrosis Foundations guidelines.</p> </sec>


Role of overnight oximetry in assessing the severity of obstructive sleep apnoea in typically developing children: a multicentre study
<sec><st>Background and objective</st> <p>Cardiorespiratory polygraphy (CRP) is the predominant technology used to diagnose obstructive sleep apnoea (OSA) in tertiary centres in the UK. Nocturnal pulse oximetry (NPO) is, however, cheaper and more accessible. This study evaluated the ability of NPO indices to predict OSA in typically developing (TD) children.</p> </sec> <sec><st>Methods</st> <p>Indices from simultaneous NPO and CRP recordings were compared in TD children (aged 1&ndash;16 years) referred to evaluate OSA in three tertiary centres. OSA was defined as an obstructive apnoea&ndash;hypopnoea index (OAHI) &ge;1 event/hour. Receiver operating characteristic curves assessed the diagnostic accuracy of NPO indices including ODI3 (3% Oxygen Desaturation Index, ODI4 (4% Oxygen Desaturation Index), delta 12 s index and minimum oxygen saturation. Two-by-two tables were generated to determine the sensitivities and specificities of whole number cut-off values for predicting OAHIs &ge;1, 5 and 10 events/hour.</p> </sec> <sec><st>Results</st> <p>Recordings from 322 TD children, 197 male (61.2%), median age 4.9 years (range 1.1&ndash;15.6), were reviewed. OAHI was &ge;1/hour in 144 (44.7%), &ge;5/hour in 61 (18.9%) and &ge;10/hour in 28 (8.7%) cases. ODI3 and ODI4 had the best diagnostic accuracy. ODI3 &ge;7/hour and ODI4 &ge;4/hour predicted OSA in TD children with sensitivities/specificities of 57.6%/85.4% and 46.2%/91.6%, respectively. ODI3 &ge;8/hour was the best predictor of OAHI &ge;5/hour (sensitivity 82.0%, specificity 84.3%).</p> </sec> <sec><st>Conclusion</st> <p>Raised ODI3 and ODI4 predict OSA in TD children with high specificity but variable sensitivity. NPO may be an alternative to diagnose moderate-severe OSA if access to CRP is limited. Low sensitivities to detect mild OSA mean that confirmatory CRP is needed if NPO is normal.</p> </sec>


Pattern and prognostic factors for kidney function progression in survivors of children with acute kidney injury: a cohort study
<sec><st>Objective</st> <p>To examine the pattern of kidney function progression after acute kidney injury (AKI) and identify the associated risk factors.</p> </sec> <sec><st>Design</st> <p>A prospective cohort study was conducted from June 2020 to June 2021 on children aged 1 month to &lt;18 years admitted to the paediatric intensive care unit (PICU). Acute kidney disease (AKD) was defined as AKI persisting from 7 to 90 days after diagnosis. The natural history and prognostic factors of kidney function progression were determined.</p> </sec> <sec><st>Results</st> <p>Among the 253 admissions with a median (IQR) age of 4.9 (9.7) years, the AKI and AKD incidence was 41.9% and 52.2% respectively. The incidence of estimated glomerular filtration rate (eGFR) &lt;90 mL/min/1.73 m<sup>2</sup> was 6.7% at 90 days and 11.9% at latest follow-up. Severe and prolonged AKI and higher degree of nephrotoxic medication exposure were associated with AKD development. The severity and duration of AKI and AKD significantly predicted kidney function non-recovery. Children with both entities exhibited a higher peak-to-baseline serum creatinine level ratio at 90 days (1.6 vs 1.0, p&lt;0.001), and a more pronounced decline in eGFR (21% vs 19%, p=0.028) during the follow-up period compared with those without AKI/AKD. They also had an increased risk of having eGFR &lt;90 mL/min/1.73 m<sup>2</sup> at 90 days (HR 14.9 (95% CI 1.8 to 124.0)) and latest follow-up (HR 3.8 (95% CI 1.1 to 13.1)).</p> </sec> <sec><st>Conclusions</st> <p>AKI and AKD are prevalent among critically ill children and pose substantial risk for non-recovery of kidney function among PICU survivors. A structural follow-up visit for AKI survivors to monitor kidney function progression is advocated.</p> </sec>


Patient and parent perspectives on paediatric cancer multidisciplinary team working and national advisory panels in the UK: a qualitative research study
<sec><st>Objective</st> <p>The concept of patient-centred care is central to the role of cancer multidisciplinary teams (MDTs) and particularly pertinent with the recent rise in number of virtual national advisory panels (NAPs) for childhood cancer in the UK. We sought to explore patient and caregiver views regarding MDT working and NAPs.</p> </sec> <sec><st>Methods</st> <p>Three focus groups were undertaken between March 2019 and January 2020.</p> </sec> <sec><st>Results</st> <p>Sixteen participants attended. All regarded MDTs and NAPs highly, while highlighting patient involvement in decision-making should not be diluted by this process. The importance of personalised consultations was stressed, acknowledging that information-sharing preferences may change with circumstance and time. Most participants felt they had not been actively involved in decisions, including those made following MDT or NAP discussions. Group suggestions to improve patient-centred care included a clinician knowing them presenting their case, referral proformas to include family-related factors and an advocate attending meetings to represent the patient/family view.</p> </sec> <sec><st>Conclusion</st> <p>Several changes have been driven forward by this work, including the modification of NAP referral proformas to include additional information. Patient and parent perspectives are now embedded into a best practice model for the NAPs to promote personalised recommendations at national level.</p> </sec>


Early educational attainment in children with major congenital anomaly in the UK
<sec><st>Objective</st> <p>To describe early educational attainment and special educational needs (SEN) provision in children with major congenital anomaly (CA) compared with peers.</p> </sec> <sec><st>Design</st> <p>Analysis of educational data linked to the ongoing Born in Bradford cohort study. Confounders were identified via causal inference methods and multivariable logistic regression performed.</p> </sec> <sec><st>Setting</st> <p>Children born in Bradford Royal Infirmary (BRI), West Yorkshire.</p> </sec> <sec><st>Patients</st> <p>All women planning to give birth at BRI and attending antenatal clinic from March 2007 to December 2010 were eligible. 12 453 women with 13 776 pregnancies (&gt;80% of those attending) were recruited. Records of 555 children with major CA and 11 188 without were linked to primary education records.</p> </sec> <sec><st>Outcomes</st> <p>Key Stage 1 (KS1) attainment at age 6&ndash;7 years in Maths, Reading, Writing and Science. SEN provision from age 4 to 7 years.</p> </sec> <sec><st>Results</st> <p>41% of children with major CA received SEN provision (compared with 14% without), and 48% performed below expected standards in at least one KS1 domain (compared with 29% without). The adjusted odds of children with CA receiving SEN provision and failing to achieve the expected standard at KS1 were, respectively, 4.30 (95% CI 3.49 to 5.31) and 3.06 (95% CI 2.47 to 3.79) times greater than their peers. Those with genetic, heart, neurological, urinary, gastrointestinal and limb anomalies had significantly poorer academic achievement.</p> </sec> <sec><st>Conclusions</st> <p>These novel results demonstrate that poor educational attainment extends to children with urinary, limb and gastrointestinal CAs. We demonstrate the need for collaboration between health and education services to assess and support children with major CA, so every CA survivor can maximise their potential.</p> </sec>


National study on the risks of COVID-19 infection for paediatric kidney transplant recipients: a retrospective, cross-sectional study
<sec><st>Introduction</st> <p>During the COVID-19 pandemic, evidence emerged that immunosuppressed children were less affected by COVID-19 infections compared with immunosuppressed adults. The aim of our study was to investigate how COVID-19 infections affected paediatric kidney transplant recipients (pKTR) in the UK.</p> </sec> <sec><st>Methods</st> <p>Questionnaires regarding COVID-19 infection data and care of pKTR during the COVID-19 pandemic were sent to all 13 UK paediatric nephrology centres examining asymptomatic and symptomatic pKTR with positive COVID-19 PCR testing from 1 April 2020 to 1 December 2021.</p> </sec> <sec><st>Results</st> <p>63 pKTR who were 3.1 (range 0.1&ndash;15) years post-transplantation had COVID-19 infection with positive SARS-CoV-2 PCR RNA. Classical COVID-19 symptoms were present in half of the patients; with atypical presentations including diarrhoea (13%) and lethargy (13%) also noted, while a third of patients were asymptomatic. Eighteen patients (28%) were hospitalised including five asymptomatic patients admitted for other reasons. No patients needed ventilation or intensive care admission, and one patient received supplemental oxygen. There was evidence of acute kidney injury (AKI) in 71% of patients, but no patients needed kidney replacement therapy with haemofiltration or dialysis.</p> </sec> <sec><st>Conclusion</st> <p>We report 10.4% of the UK paediatric renal transplantation population had documented COVID-19 infections with positive SARS-CoV-2 PCR RNA with 28% of those affected requiring hospitalisation. The increased incidence of AKI, particularly after the first wave of the COVID-19 pandemic, was possibly due to increased testing. There was low morbidity and mortality compared with the adult population.</p> </sec>


Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study
<sec><st>Objective</st> <p>To describe the COVID-19 pandemic&rsquo;s impact on acute appendicitis management on children and young people (CYP).</p> </sec> <sec><st>Design</st> <p>Retrospective cohort study.</p> </sec> <sec><st>Setting</st> <p>All English National Health Service hospitals.</p> </sec> <sec><st>Patients</st> <p>Acute appendicitis admissions (all, simple, complex) by CYP (under-5s, 5&ndash;9s, 10&ndash;24s).</p> </sec> <sec><st>Exposure</st> <p>Study pandemic period: February 2020&ndash;March 2021. Comparator pre-pandemic period: February 2015&ndash;January 2020.</p> </sec> <sec><st>Main outcome measures</st> <p>Monthly appendicectomy and laparoscopic appendicectomy rate trends and absolute differences between pandemic month and the pre-pandemic average. Proportions of appendicitis admissions comprising complex appendicitis by hospital with or without specialist paediatric centres were compared.</p> </sec> <sec><st>Results</st> <p>101 462 acute appendicitis admissions were analysed. Appendicectomy rates fell most in April 2020 for the 5&ndash;9s (&ndash;18.4% (95% CI &ndash;26.8% to &ndash;10.0%)) and 10&ndash;24s (&ndash;28.4% (&ndash;38.9% to &ndash;18.0%)), driven by reductions in appendicectomies for simple appendicitis. This was equivalent to &ndash;54 procedures (&ndash;68.4 to &ndash;39.6) and &ndash;512 (&ndash;555.9 to &ndash;467.3) for the 5&ndash;9s and 10&ndash;24s, respectively. Laparoscopic appendicectomies fell in April 2020 for the 5&ndash;9s (&ndash;15.5% (&ndash;23.2% to &ndash;7.8%)) and 10&ndash;24s (&ndash;44.8% (&ndash;57.9% to &ndash;31.6%) across all types, which was equivalent to &ndash;43 (&ndash;56.1 to 30.3) and &ndash;643 (&ndash;692.5 to &ndash;593.1) procedures for the 5&ndash;9s and 10&ndash;24s, respectively. A larger proportion of complex appendicitis admissions were treated within trusts with specialist paediatric centres during the pandemic.</p> </sec> <sec><st>Conclusions</st> <p>For CYP across English hospitals, a sharp recovery followed a steep reduction in appendicectomy rates in April 2020, due to concerns with COVID-19 transmission. This builds on smaller-sized studies reporting the immediate short-term impacts.</p> </sec>


Infantile myofibromatosis in a 5-month-old boy
<p>A 5-month-old boy presented with a solitary occipital growth. The lesion was of hard consistency, immobile, painless, measuring 2<FONT FACE="arial,helvetica">x</FONT>3 cm with no relevant lymph node involvement. The overlying skin was intact. There was no relevant family history.</p> <p>Ultrasound scan revealed a bony lytic lesion. Initial CT and MRIs were suspicious of Langerhans cell histiocytosis. The lesion was indenting into cerebellar hemispheres, contacting but not indenting the venous sinuses (<cross-ref type="fig" refid="F1">figure 1</cross-ref>). No abnormal brain parenchymal signal was identified.</p> <p>Histopathology examination showed interlacing fascicles of spindle cells with myofibroblastic morphology confirming infantile myofibroma (IM). A full body MRI excluded other lesions. A follow-up MRI with contrast 2 months later showed a minor 3 mm enlargement (<cross-ref type="fig" refid="F2">figure 2</cross-ref>).</p> <p>IM is a rare tumour which presents as slow-growing, solitary or multiple lumps on the head, neck or trunk, and less commonly internal organs.<cross-ref type="bib" refid="R1">1</cross-ref> IM is caused by...


Intravenous maintenance fluid therapy
<p>For paediatricians of a certain age (including <I>Archivist</I>), their training in intravenous maintenance fluid therapy (IV-MFT) was based on a paper almost 70 years old. (Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. <I>Pediatrics</I> 1957;19:823&ndash;32). The recommendations were made from the calculated water requirement based on presumed energy expenditure of healthy breast fed infants. The equations used 1 mL of fluid provided for each kilocalorie expended and the electrolyte concentrations and glucose content of intravenous fluids were estimated to reflect the composition of human and cow&rsquo;s milk. This standard did not include medically sick children or postsurgical infants and children or those with trauma. A few decades ago, <I>&lsquo;Put up some 4 and a fifth&rsquo;</I> (ie, 4% dextrose with 0.18% saline) was a common instruction on general paediatric or surgical wards where these very patients were being managed. Since then, there have been some important...


Young people consenting to medical research
<sec id="s1"><st>Introduction: age-based consent for research</st> <p>The regulations and guidance regarding young people&rsquo;s consent to participate in medical research are complex.<cross-ref type="bib" refid="R1">1</cross-ref> Current regulations divide medical research into two types: research that involves the trial of a medication and research that does not (<cross-ref type="fig" refid="F1">figure 1</cross-ref>). Trials of medications are governed by the Medicines for Human Use (Clinical Trials) Regulations 2004,<cross-ref type="bib" refid="R2">2</cross-ref> whereas other forms of medical research operate without statutory guidance. The statute states that anyone aged 16 years or older can consent to participate in a clinical trial. Those under the age of 16 cannot consent, and consent must be provided by a parent or guardian. This age-based approach is in keeping with other legislation surrounding a young person&rsquo;s decision-making, such as age limits on learning to drive or buying a lottery ticket. This approach is pragmatic, as it is straightforward to identify which...


Are term breech babies who undergo successful external cephalic version still at increased risk of developmental dysplasia of the hip?
<sec id="s1"><st>Scenario</st> <p>A 36-hour-old neonate is undergoing their newborn and infant physical examination (NIPE). Antenatal scans showed that the baby was in the breech position at 36 weeks&rsquo; gestation. However, the mother underwent a successful external cephalic version (ECV) procedure at 37 weeks and had an uneventful normal vaginal delivery (with a cephalic presentation). There are no other risk factors for developmental dysplasia of the hips (DDH), and the baby&rsquo;s hip examination using the Ortolani and Barlow manoeuvres is normal. You wonder whether the baby still requires referral for routine hip ultrasound.</p> </sec> <sec id="s2"><st>Structured clinical question</st> <p>Is a neonate who has previously been in breech position at/near term (patient) but has undergone successful ECV (risk factor) still at increased risk of DDH (outcome)?</p> </sec> <sec id="s3"><st>Search</st> <p>Searches were conducted of Medline (via PubMed) and Embase using the following search strategy:</p> <p>(Developmental dysplasia of the hip OR DDH OR...


Towards evidence-based medicine for paediatricians
<sec><st>Grey but important</st> <p>Grey days, grey food, grey water. Moving to grey is usually miserableness and boredom. It was the centrepoint of satire for a UK prime minister in the last millennium. Systematic reviewers though&mdash;they can absolutely love a bit of grey.</p> <p>The &lsquo;grey&rsquo; literature is a term used to describe stuff that is a bit in the shadows. Reports and studies which are not entirely unpublished (those are the &lsquo;file drawer&rsquo; papers), but have not been given the shiny acknowledgement of presentation in an academic conference or Learned Journal. The grey papers might be detailed reports or technical papers from a charitable organisation or government departments. They may be submitted theses for research degrees. Or papers in preprint ... an optimistic phrase for some of those articles ... or even clinical study reports. These have not usually had the same sort of peer review as academic studies, not...


Recurrent themes from paediatric mortality and morbidity: a network perspective 2021-2023
<p>We write to raise awareness of common themes from paediatric death/incidents of harm from a network perspective. The governance group within Thames Valley &amp; Wessex Paediatric Critical Care Operational Delivery Network formed in 2017. Our multidisciplinary body (paediatricians, trainees, paediatric intensivists and paediatric nurses) provides external support to paediatric serious incident investigations at network NHS trusts. We compose anonymised, one-page learning summaries approved at Trust level and shared to disseminate learning.</p> <p>Persistent tachycardia (PT) was the most common theme (60%) identified (<cross-ref type="fig" refid="F1">figure 1</cross-ref>). We believe PT is an under acknowledged sign within healthcare with limited studies to date and no formally accepted definition. In one study,<cross-ref type="bib" refid="R1">1</cross-ref> 8% of children were discharged tachycardic with an increased risk of hospital reattendance and intervention. A more recent study<cross-ref type="bib" refid="R2">2</cross-ref> suggests PT &lsquo;<I>...is not associated with an increased risk of serious bacterial infection...</I>&rsquo; (SBI) as children who remained...


Highlights from the literature
<sec id="s1"><st>Paediatric updates for SPIRIT and CONSORT</st> <p>Setting up and running large multicentre network, randomised clinical trials (RCTs) in child health is hard work, expensive and time-consuming. To run the study within a robust research governance structure is crucial to scientific credibility, usefulness of the results and conclusions of the study, and reduces research waste. Reporting your work accurately and in a comprehensive and transparent way requires a structure and standardisation. So far, the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and Consolidated Standards of Reporting Trials (CONSORT) guidelines are there for you to follow, but these are not child specific. Inadequate reporting continues to be a major challenge to dissemination. Paediatric-specific problems related to RCTs include: (a) omission of key features on trial interventions and outcome measurements in children across the age groups; (b) the description of ethnicity, race and various social determinants of health; (c) sample...