Leading paediatricians publish case definition for illness affecting children during COVID-19

Royal College of Paediatrics and Child Health, 1st May, 2020

Leading paediatricians in the UK have set out a working definition of an inflammatory syndrome affecting a very small number of children and which may be associated with COVID-19.

They hope that by more clearly describing what is currently known about the condition, doctors will be able to identify potential cases as quickly as possible to begin effective treatment.

Convened by the Royal College of Paediatrics and Child Health (RCPCH), the group has produced a case definition of the type of symptoms that may be seen in these children, the diagnostic tests to be used in potential cases, and the treatments to be given.

The expert group has stressed that it remains unclear whether COVID-paediatric multi-system inflammatory syndrome is caused by COVID-19 and reiterates that it has affected an extremely small number of children in the UK and throughout the world.

As knowledge about the condition continues to grow, the definition may change in the weeks and months ahead. Around 20 children in the UK and a small number across Europe, are thought to have had the condition. Of those who required intensive care, many have now made a good recovery although some still need very intensive therapy.

Possible cases have also been seen in the US and other countries. Why some countries have seen no cases remains unclear. It may be because of a lack of recognition of the syndrome, because doctors didn’t write up a case description, or because the condition is extremely rare.

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Recent Dynamed Paediatrics updates

Dynamed is updated daily with reviews of newly published research and guidelines, below are just some of the more recent updates in paediatrics.

 

6 MAY 2020

FDA issues Emergency Use Authorization (EUA) permitting emergency use of remdesivir for treatment of suspected or confirmed COVID-19 in children and adults hospitalized with severe disease (FDA Emergency Use Authorization 2020 May 1)

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5 MAY 2020

methylphenidate associated with increased risk of anorexia and insomnia in children with ADHD (JAMA Pediatr 2019 Jul 1)

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1 MAY 2020

mycophenolate mofetil might be associated with increased relapses but decreased hypertrichosis and gum hypertrophy compared to cyclosporine in children with steroid-sensitive nephrotic syndrome (Cochrane Database Syst Rev 2020 Apr 16)

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1 MAY 2020

rituximab may decrease risk of relapse but may increase risk of infusion reaction in children with steroid-sensitive nephrotic syndrome (Cochrane Database Syst Rev 2020 Apr 16)

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1 MAY 2020

EPO started at ≤ 5 days may not reduce red blood cell transfusions and may increase risk of any-stage retinopathy of prematurity compared to starting at 21-26 days in preterm or low-birth-weight infants (Cochrane Database Syst Rev 2020 Feb 11)

View in Evaluation and Management of the Premature Infant

1 MAY 2020

levamisole may decrease risk of relapse in children with steroid-sensitive nephrotic syndrome (Cochrane Database Syst Rev 2020 Apr 16)

View in Nephrotic Syndrome in Children

1 MAY 2020

umbilical cord milking may increase risk of ≥ grade III intraventricular hemorrhage compared to delayed cord clamping but may have similar risk as immediate cord clamping in preterm infants born ≤ 37 weeks gestation (Arch Dis Child Fetal Neonatal Ed 2020 Mar 9 early online)

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1 MAY 2020

alkylating agents may decrease risk of relapse in children with steroid-sensitive nephrotic syndrome (Cochrane Database Syst Rev 2020 Apr 16)

View in Nephrotic Syndrome in Children

1 MAY 2020

umbilical cord milking may reduce need for red blood cell transfusion compared to immediate cord clamping without increasing risk of adverse events in preterm infants born < 37 weeks gestation (Arch Dis Child Fetal Neonatal Ed 2020 Mar 9 early online)

View in Evaluation and Management of the Premature Infant

1 MAY 2020

rinse-free handwashing program at school may reduce absenteeism due to acute gastrointestinal illness in preschool and school children (Cochrane Database Syst Rev 2020 Apr 9)

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28 APR 2020

interventional sialendoscopy reported to be successful in 100% of children (11 glands) with submandibular gland sialadenitis and 74% of children (38 glands) with parotid gland sialadenitis in 29 children with recurrent salivary gland swelling (Ann Otol Rhinol Laryngol 2019 Apr)

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28 APR 2020

crisaborole (Staquis) authorized by European Commission for treatment of mild to moderate atopic dermatitis in patients ≥ 2 years old with ≤ 40% body surface area affected (European Medicines Agency 2020 Apr 22)

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27 APR 2020

wide spectrum of clinical features and disease severity in children with SARS-CoV-2 infection in China (J Formos Med Assoc 2020 Apr 16 early online)

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27 APR 2020

wide spectrum of clinical features and disease severity in children with SARS-CoV-2 infection in China (J Formos Med Assoc 2020 Apr 16 early online)

View in COVID-19 (Novel Coronavirus)

24 APR 2020

single and multiple doses of albendazole associated with similar parasitological cure rates in children and adults with Ascaris infection (Cochrane Database Syst Rev 2020 Apr 14)

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24 APR 2020

albendazole and mebendazole associated with similar parasitological cure rates in children and adults with Ascaris infection (Cochrane Database Syst Rev 2020 Apr 14)

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24 APR 2020

ivermectin and albendazole associated with similar parasitological cure rates in children and adults with Ascaris infection (Cochrane Database Syst Rev 2020 Apr 14)

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24 APR 2020

in infants and children with hyperopia, prescription spectacles might decrease risk of strabismus, insufficient evidence to evaluate effect on amblyopia (Cochrane Database Syst Rev 2020 Apr 2)

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23 APR 2020

optimal glucocorticoid regimen to manage patients ≤ 21 years old with congenital adrenal hyperplasia due to 21-hydroxylase deficiency is unclear, and no evidence to evaluate prevention of adrenal crises (Cochrane Database Syst Rev 2020 Mar 19)

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22 APR 2020

selumetinib (Koselugo) FDA approved for treatment of neurofibromatosis type 1 in children ≥ 2 years old with symptomatic inoperable plexiform neurofibromas (FDA Press Release 2020 Apr 10)

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Less-invasive surfactant administration (LISA)

Paediatrics and Child Health
Volume 30, Issue 4, April 2020, Pages 144-148

Abstract

Less-invasive surfactant administration (LISA) is a technique whereby surfactant is given via a thin catheter inserted in the trachea. Although some current guidance has been to administer LISA in preterm infants with respiratory distress syndrome (RDS) without endotracheal intubation, the use of LISA differs across the world. The LISA technique allows the infant to remain on non-invasive ventilation support and avoids intubation and therefore mechanical ventilation. Practicalities around the procedure such as the use of premedication or the administration on delivery suite as prophylaxis are yet to be fully studied. Through recent meta-analyses, LISA has been shown to reduce the combined outcome of bronchopulmonary dysplasia (BPD) and mortality in preterm infants. This article summarises the evidence and discusses the practicalities of LISA in a clinical setting.

Link to article page here

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Predictive monitoring in neonates

Image: Wikimedia Commons

Paediatrics and Child Health
Volume 30, Issue 4, April 2020, Pages 139-143

Abstract

Premature infants are physiologically immature and are particularly vulnerable to systemic illnesses. Instability of vital signs related to immaturity of organ systems are common but may also represent early manifestations of serious illness. While vital signs are frequently or continuously monitored in critically unwell neonates, changes in these parameters are subtle in the early phase of illness such as sepsis and difficult to interpret using traditional neonatal monitoring tools. Recent advances in identifying trends and patterns of vital signs in the pre-clinical phase of the illness, particularly in the field of heart rate characteristics monitoring has opened up the potential to improve outcomes through rapid and timely investigations and early intervention. This article reviews the current evidence in predictive monitoring of neonates and discusses potential clinical implications.

Link to article page here

Palliative care in the neonatal intensive care unit

Paediatrics and Child Health
Volume 30, Issue 4, April 2020, Pages 124-128

Abstract

With increasing facilities for antenatal diagnosis, lowering gestation for intiation of intensive care, palliative care in the perinatal period is increasingly recognized as a specialist area. There have been standards and pathways developed in the UK that provides guidance to health professionals. Providing holistic perinatal palliative care depends on close multiprofessional working between the neonatal team and the palliative care professionals who are being integrated into the core neonatal services. Even though most neonates will continue to receive end of life care within the NICU, there are increasing number of families who choose to have end of life care either at home or a hospice. There is a need to develop services across the regions to provide equitable access to excellent clinical care as well as ongoing support to families following loss of a neonate. This short article explores the issues raised in the provision of palliative care in the perinatal period and offers practical guidance for paediatricians in this emerging area.

Link to article page here

Members or DBTH libraries can request full text via our Article / Book request service here

Parental involvement in decision-making in the neonatal intensive care unit: a review of the international evidence

Paediatrics and Child Health
Volume 30, Issue 4, April 2020, Pages 119-123

Abstract

The aim of this review was to establish the current evidence base regarding parental involvement in decision-making in the NICU. The review question was set as ‘What is known about the process of parental participation in clinical decision-making in the NICU?’ The findings of this critical literature review illustrate the process of decision-making for parents in NICU. The available evidence base was minimal. The parental role in decision-making is variable with current literature suggesting that the informed parental role, allowing parents to make the ultimate decision, is increasingly desired. Despite this there is still a requirement for medical and shared decision-making for some families. Regardless of the role parents assume it is evident that there will always be an array of emotional complexities to follow. Most feelings and emotional responses reported by parents were negative. The literature suggests several reasons for these feelings. A lack of parental knowledge and experience in NICU leading to confusion as to whether the right decision has been made alongside parents having a heightened awareness of the potential for suffering and harm for their baby. There are the added pressures of time and the weight of responsibility. The burden appears to be unequally distributed between parents. Several studies illustrate the transfer of responsibility from the father to mothers.

Link to article page here

Members or DBTH libraries can request full text via our Article / Book request service here

Oral nystatin prophylaxis to prevent systemic fungal infection in very low birth weight preterm infants: a randomized controlled trial

Image: Wikimedia Commons

BMC Pediatrics volume 20, Article number: 170 (2020)

Abstract

Background

Systemic fungal infection (SFI) is one of leading causes of morbidity and mortality in very low birth weight (VLBW) preterm infants. Because early diagnosis of SFI is challenging due to nonspecific manifestations, prophylaxis becomes crucial. This study aimed to assess effectiveness of oral nystatin as an antifungal prophylaxis to prevent SFI in VLBW preterm infants.

Methods

A prospective, open-labelled, randomized controlled trial was performed in a neonatal intensive care unit (NICU) of an academic hospital in Indonesia. Infants with a gestational age ≤ 32 weeks and/or birth weight of ≤ 1500 g with risk factors for fungal infection were assessed for eligibility and randomized to either an intervention group (nystatin) or control group. The intervention group received 1 ml of oral nystatin three times a day, and the control group received a dose of 1 ml of sterile water three times a day. The incidence of fungal colonization and SFI were observed and evaluated during the six-week study period. Overall mortality rates and nystatin-related adverse drug reactions during the study period were also documented.

Results

A total of 95 patients were enrolled. The incidence of fungal colonization was lower among infants in nystatin group compared to those in control group (29.8 and 56.3%, respectively; relative risk 0.559; 95% confidence interval 0.357–0.899; p-value = 0.009). There were five cases of SFI, all of which were found in the control group (p-value = 0.056). There was no difference in overall mortality between the two groups. No adverse drug reactions were noted during the study period.

Conclusions

Nystatin is effective and safe as an antifungal prophylactic medication in reducing colonization rates in the study population. Whilst the use of nystatin showed a potential protective effect against SFI among VLBW preterm infants, there was no statistical significant difference in SFI rates between groups.

 

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Patient and family experience with chronic transfusion therapy for sickle cell disease: A qualitative study

BMC Pediatrics volume 20, Article number: 172 (2020)

Abstract

Background

There is a limited understanding of the patient and family experience of Chronic Transfusion Therapy (CTT) for prevention of complications of Sickle Cell Disease (SCD). We sought to understand patient and family experience with CTT using qualitative methods.

Methods

Fifteen parents of children < 18 years old and nine children 12–18 years old with SCD who were receiving CTT for > 1 year were interviewed using a semi-structured interview format, and interviews were analyzed using open coding methods.

Results

Four themes created a narrative of the patient and family experience of CTT: 1) Burden of CTT, 2) Coping with CTT, 3) Perceived benefits and risks of CTT, and 4) Decision making regarding CTT. Participants reported substantial burden of CTT, including the impact of CTT on daily life and family, distress about venous access, burden of chelation therapy, and anxiety about CTT complications. Participants described how they coped with CTT. Participants reported increased energy, decreased pain, fewer hospitalizations, and stroke prevention with CTT, but also recognized complications of CTT, though awareness was limited in adolescents. Parents described sharing in the informed decision-making process with their healthcare provider about CTT, but adolescent patient participants reported that they were not involved in this process.

Conclusions

CTT is associated with significant patient and family burden. Support from family, healthcare providers and school may help individuals cope with some of this burden. These findings provide the basis for future studies to identify strategies to mitigate the burden of CTT and improve the patient experience with this therapy. Future studies should also systematically assess patient knowledge about the key components of CTT and chelation using quantitative assessments.

 

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Lactic acid level as an outcome predictor in pediatric patients with intussusception in the emergency department

BMC Pediatrics volume 20, Article number: 184 (2020)

Abstract

Background

Intussusception decreases blood flow to the bowel, and tissue hypoperfusion results in increased lactic acid levels. We aimed to determine whether lactic acid levels are associated with pediatric intussusception outcomes.

Methods

The electronic medical records of our emergency department pediatric patients diagnosed with intussusception, between January 2015 and October 2018, were reviewed. An outcome was considered poor when intussusception recurred within 48 h of reduction or when surgical reduction was required due to air enema failure.

Results

A total of 249 patients were included in the study, including 39 who experienced intussusception recurrence and 11 who required surgical reductions; hence, 50 patients were included in the poor outcome group. The poor and good outcome groups showed significant differences in their respective blood gas analyses for pH (7.39 vs. 7.41, P = .001), lactic acid (1.70 vs. 1.30 mmol/L, P < .001), and bicarbonate (20.70 vs. 21.80 mmol/L, P = .036). Multivariable logistic regression analyses showed that pH and lactic acid levels were the two factors significantly associated with poor outcomes. When the lactic acid level cutoff values were ≥ 1.5, ≥2.0, ≥2.5, and ≥ 3.0 mmol/L, the positive predictive values for poor outcomes were 30.0, 34.6, 50.0, and 88.9%, respectively.

Conclusion

Lactic acid levels affect outcomes in pediatric patients with intussusception; higher lactic acid levels are associated with higher positive predictive values for poor outcomes.

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The difficulties experienced during the preparation and administration of oral drugs by parents at home: a cross-sectional study from Palestine

BMC Pediatrics volume 20, Article number: 198 (2020)

Abstract

Background

Failure to properly administer drugs to children at home may cause adverse events, which makes it a challenging job for parents or caregivers. The main goal of this study was to investigate the problems and difficulties that parents or caregivers faced when administering oral drugs to their children at home.

Methods

A cross-sectional study was conducted using a questionnaire consisting of ‘yes/no’ and multiple-response questions to assess parents’ experiences and problems with administering medication to their children at home. Data was collected from parents who visited primary health care centres in Nablus. Descriptive analysis was conducted to describe the characteristics of the sample.

Results

We interviewed 420 parents. 91.9% of the parents used drugs without prescription from a doctor, and the most commonly used non-prescription medicines were antipyretics (n=386, 100%), influenza drugs (n=142, 36.8%), cough drugs (n=109, 28.2%) and antibiotics (n= 102, 26.4%). The study showed that 21.7% of parents used teaspoon and 7.1% used tablespoon in administering liquid medications to their children. When the children refused taking liquid medications, almost two-thirds of the parents (65.7%) insisted their children take them, 21.5% mixed it with juice, 5.2% mixed it with food and 4.7% mixed it with milk. 12.4% of the parents reported that they gave drugs in doses higher than prescribed by the doctor to treat their children more quickly. Also, our study revealed that 80.5% of the parents gave medications at incorrect intervals.

Conclusions

This study has shown that there is a proportion of caregivers or parents who administer oral drugs to their children incorrectly, which may involve giving them at the wrong intervals or doses, using incorrect instruments, or mixing them with food, juice or milk. The development of educational programs that will provide parents with education about medication administration is therefore recommended.

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