Cancer outcomes in children and young people have improved dramatically over the last few decades with over 80% of those diagnosed now being cured of their disease. Of those who die, approximately half will do so from treatment related complications many of which are avoidable.
This report deliberately focuses on a sample of patients who were a high-risk group who died or who had an unexpected admission to intensive care. The rationale being that this is where care-planning, service provision and communication should excel. Any remediable factors in care for this group would benefit all children, teenagers and young adults receiving SACT.
One of the recommendations from this report is that the audit and quality improvement methods, with action plans, are essential for on-going improvement but require access to data. Electronic prescribing was not universal at the time of data collection and many hospitals had no ready access to information on which patients had received SACT and their outcomes. Along with adequately trained staff, good team working and clear local leadership, such implementations are key drivers for improving care for this vulnerable population.
To evaluate television and simultaneous electronic devices use in adolescents with musculoskeletal pain and musculoskeletal pain syndromes.
Methods
A cross-sectional study was performed in 299 healthy adolescents of a private school. All students completed a self-administered questionnaire, including: demographic data, physical activities, musculoskeletal pain symptoms, and use of simultaneous television/electronic devices (computer, internet, electronic games, and cell phones). Seven musculoskeletal pain syndromes were also evaluated: juvenile fibromyalgia, benign joint hypermobility syndrome, myofascial syndrome, tendinitis, bursitis, epicondylitis, and complex regional pain syndrome.
Results
Inter-rater agreement between pretest and retest was 0.83. Musculoskeletal pain and musculoskeletal pain syndrome were found in 183/299 (61%) and 60/183 (33%), respectively. The median age (15 [10–18] vs. 14 [10–18] years, p = 0.032) and years of education (10 [5–12] vs. 9 [5–12] years, p = 0.011) were significantly higher in adolescents with musculoskeletal pain when compared with those without this condition. The frequencies of female gender (59% vs. 47%, p = 0.019), cell phone use (93% vs. 81%, p = 0.003), and simultaneous use of at least two electronic devices (80% vs. 67%, p = 0.011) were significantly higher in the former group. Further comparisons between adolescents with and without musculoskeletal pain syndromes revealed that the frequency of female gender was significantly higher in the former group (75% vs. 25%, p = 0.002), and with a significantly reduced median of weekends/holidays electronic games use (1.5 [0–10] vs. 3 [0–17] h/day, p = 0.006).
Conclusions
A high prevalence of musculoskeletal pain/syndromes was observed in female adolescents. Musculoskeletal pain was mostly reported at a median age of 15 years, and students used at least two electronic devices. Reduced use of electronic games was associated with musculoskeletal pain syndromes.
To investigate the association between pacifier use and bottle-feeding and unfavorable behaviors during breastfeeding.
Method
A cross-sectional study was conducted with 427 babies/mothers. Socio-demographic, perinatal data, and information about the use of artificial nipples(pacifier and/or bottle) were collected through a questionnaire. The breastfeeding aspects regarding position, affectivity, sucking behavior, baby responses, and breast anatomy were evaluated through observation during breastfeeding. The chi-squared test and the multiple linear regression analysiswere used to investigate the association between the variables.
Results
The aspects of breastfeeding that showed higher percentages of the category “poor” were sucking behavior (22.5%) and position (22.2%). The group of infants who used pacifiers and/or bottle showed higher percentages in the poor and fair categories when compared with the good category for all five breastfeeding aspects evaluated (p < 0.001). The linear regression analysisrevealed that the increase in the number of unfavorable behaviors regarding position, affectivity, sucking behavior, and baby responses were independently associated with both pacifier and bottle use (β positive, p < 0.05), while breast anatomy was independently associated only with bottle use.
Conclusion
The findings suggest that the use of pacifiers and/or bottle-feeding may be associated with unfavorable behaviors during breastfeeding, especially the use of bottle-feeding.
Objective. Triage is a tool developed to identify patients who need immediate care and those who can safely wait. The aim of this study was to assess the validity and interrater reliability of a modified version of the pediatric South African triage scale (pSATS) in a single-center tertiary pediatric emergency department in Norway.
Methods. This prospective, observational study included all patients with medical conditions, referred to the pediatric emergency department of a tertiary hospital in Norway from September 1, 2015, to November 17, 2015. Their assigned triage priority was compared with rate of hospitalization and resource utilization. Validity parameters were sensitivity, specificity, positive and negative predictive value, and percentage of over- and undertriage. Interrater agreement and accuracy of the triage ratings were calculated from triage performed by nurses on written case scenarios.
Results. During the study period, 1171 patients arrived at the hospital for emergency assessment. A total of 790 patients (67 %) were triaged and included in the study. The percentage of hospital admission increased with increasing level of urgency, from 30 % of the patients triaged to priority green to 81 % of those triaged to priority red. The sensitivity was 74 %, the specificity was 48 %, the positive predictive value was 52 %, and the negative predictive value was 70 % for predicting hospitalization. The level of over- and undertriage was 52 % and 26 %, respectively. Resource utilization correlated with higher triage priority. The interrater agreement had an intraclass correlation coefficient of 0.99 by Cronbach’s alpha, and the accuracy was 92 %.
Conclusions. The modified pSATS had a moderate sensitivity and specificity but showed good correlation with resource utilization. The nurses demonstrated excellent interrater agreement and accuracy when triaging written case scenarios.
Objective We aimed to measure the prevalence and incidence of latent tuberculosis infection (LTBI) and tuberculosis (TB) disease in children in close contact with patients with drug-resistant TB (DR-TB) in a country with high DR-TB prevalence.
Design and setting This is a prospective cohort study of paediatric contacts of adult patients with pulmonary DR-TB in Armenia. Children were screened using tuberculin skin test, interferon-gamma release assay and chest X-ray at the initial consultation, and were reassessed every 3–6 months for a period of 24 months. Children did not receive preventive treatment.
Main outcome measures Prevalence and incidence of LTBI and TB disease; factors associated with prevalent LTBI.
Results At initial evaluation, 3 of the 150 children included were diagnosed with TB disease (2.0%). The prevalence of LTBI was 58.7%. The incidence of LTBI was 19.9 per 100 children per year, and was especially high during the first 6 months of follow-up (33.3 per 100 children per year). No additional cases with incident disease were diagnosed during follow-up. After adjustment, prevalent LTBI was significantly associated with the child’s age, sleeping in the same house, higher household density, the index case’s age, positive smear result and presence of lung cavities.
Conclusions Children in close contact with patients with DR-TB or in contact with very contagious patients had an increased risk of prevalent LTBI. Although none of the children developed TB disease during a 2-year follow-up period, screening for symptoms of TB disease, based on the prevalence of disease at recruitment, together with follow-up and repeated testing of non-infected contacts, is highly recommended in paediatric contacts of patients with DR-TB.
Source: Journal of the Pediatric Infectious Diseases Society
Background
Reliance on tests that detect only the presence of toxigenic Clostridium difficile can result in overdiagnosis and overtreatment of C difficile infection (CDI). The C difficile polymerase chain reaction (PCR) cycle threshold (CT) can sensitively predict the presence of free C difficile toxins; however, the clinical application for this testing strategy remains unexplored. We evaluated the impact of dual PCR and toxin result reporting, as predicted by the CT, on CDI management and outcomes in children.
Methods
Before the intervention, results for C difficile testing at Lucile Packard Children’s Hospital Stanford were reported as PCR positive (PCR+) or negative (PCR−) according to the GeneXpert C diff Epi tcdB PCR assay (Cepheid, Sunnyvale, California). Beginning October 5, 2016, the presence of free toxins, as predicted by the CT, was reported also. The CDI treatment rates 1 year before and 18 months after implementation of toxin reporting were compared. Demographic and treatment-related data were collected, and patient outcomes were followed up 8 weeks later.
Results
CDI treatment decreased 22% after the intervention (96% [preintervention] vs 74% [postintervention]; P < .001). During the postintervention period, there were 152 PCR+C difficile results, and 94 (62%) of them were toxin positive (toxin+) according to the CT. Of the 58 PCR+/toxin-negative (toxin−) results, 38 (66%) did not result in CDI treatment. Seven (18%) of the untreated PCR+/toxin− patients underwent repeat testing within 8 weeks, and 5 (13%) of them were subsequently PCR+/toxin+ and treated. No CDI-related complications were identified.
Conclusions
Addition of the CT-predicted C difficile toxin result to PCR reporting reduces the proportion of PCR+ children treated for CDI.
Source: Journal of the Pediatric Infectious Diseases Society
Background
Biomarkers can facilitate safe antibiotic discontinuation in critically ill patients without bacterial infection.
Methods
We tested the ability of a biomarker-based algorithm to reduce excess antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) without bacterial infections (uninfected) in our pediatric intensive care unit (PICU). The algorithm suggested that PICU clinicians stop antibiotics if (1) C-reactive protein <4 mg/dL and procalcitonin <1 ng/mL at SIRS onset and (2) no evidence of bacterial infection by exam/testing by 48 hours. We evaluated excess broad-spectrum antibiotic use, defined as administration on days 3–9 after SIRS onset in uninfected children. Incidence rate ratios (IRRs) compared unadjusted excess length of therapy (LOT) in the 34 months before (Period 1) and 12 months after (Period 2) implementation of this algorithm, stratified by biomarker values. Segmented linear regression evaluated excess LOT among all uninfected episodes over time and between the periods.
Results
We identified 457 eligible SIRS episodes without bacterial infection, 333 in Period 1 and 124 in Period 2. When both biomarkers were below the algorithm’s cut-points (n = 48 Period 1, n = 31 Period 2), unadjusted excess LOT was lower in Period 2 (IRR, 0.53; 95% confidence interval, 0.30–0.93). Among all 457 uninfected episodes, there were no significant differences in LOT (coefficient 0.9, P = .99) between the periods on segmented regression.
Conclusions
Implementation of a biomarker-based algorithm did not decrease overall antibiotic exposure among all uninfected patients in our PICU, although exposures were reduced in the subset of SIRS episodes where biomarkers were low.
Corticosteroids reduce symptoms of croup in children within two hours and continue to do so for at least 24 hours. They also cut the amount of time children spend in hospital by 15 hours and reduce return visits or readmissions from about 20% to 10%.
This Cochrane review assessed the effectiveness of corticosteroids such as dexamethasone and budesonide compared with placebo. It updates a previous review which concluded that corticosteroids reduce symptoms of croup at six hours.
The review also found that dexamethasone is more effective than budesonide at reducing croup symptoms at 6 and 12 hours – and lessens the need for adrenaline. However, rates of return visits and/or readmissions were similar, and there was no additional benefit from combining the two drugs.
The findings support recommendations that all children with mild, moderate, or severe croup should be treated immediately with corticosteroids.
The Chief Nurse and Nursing Team at Great Ormond Street Hospital for Children NHS Foundation Trust led on the introduction and embedding of the Paediatric Early Warning System (PEWS) across the Trust. The PEWS system has led to improved outcomes and experience through early identification of triggers to deterioration in children and young people at the Trust.
Where to look
Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) is an acute specialist paediatric hospital providing care to children and young people with rare, complex and difficult-to-treat conditions. The early identification of patients at risk of clinical deterioration and matching the severity of illness to the appropriate level of care are key elements of high-quality medical care (Gold et al 2014).
Central to GOSH’s paediatric assessment functions when caring for unwell children and young people was the Trust’s Children’s Early Warning System (CEWS) which assisted staff to identify deterioration within a child or young person within their care. The CEWS system monitored key vital signs such as a patient’s heart rate, systolic blood pressure, capillary refill time and respiratory rate.
However, the nurse leaders, with other clinicians in the multidisciplinary team (MDT) at GOSH identified unwarranted variation in the signs of deterioration that were being captured and measured. They observed that it would be optimal to enhance the system to also include clinical items such as oxygen delivery, breathing work and hypertension. The nursing leads, in collaboration with the MDT identified an opportunity to use the early warning score evidence base to improve practice at the Trust, to improve deterioration rates and outcomes for children and young people in their care.
What to change
The clinical leads at the Trust worked in partnership to develop the Paediatric Early Warning Score (PEWS) system, to provide a replicable assessment of a child’s clinical status while hospitalised. The Chief Nurse and nursing team, as a part of the MDT conducted a review of the evidence to compare the predictive performance of 18 paediatric ‘track and trigger’ early warning score systems that were routinely used across the health and care sectors. Analysis of over 1.7 million clinical observations were collated and the data demonstrated clinical sensitivity in the PEWS, suggesting it could be utilised as a tool to identify deterioration in children and young people.
Chapman et al (2017) highlight that the PEWS system is a comprehensive step towards reducing the unwarranted variation in the recognition and response to a seriously unwell child and with this evidence, the MDT recommended it was implemented at GOSH.
How to change
Between March and May 2018, the move to the PEWS system began, following a period of piloting. This period gave nursing staff an opportunity to use the new PEWS system and provide feedback to the project group leading the change. These suggestions were then incorporated into the model and the improved version was rolled-out across the Trust.
An e-learning module and a bespoke PEWS training session were developed to support understanding and use of the new system and a Train-the-Trainer approach adopted to help cascade this efficiently.
Paediatrics 