The behaviour and wellbeing of children and adults with severe intellectual disability and complex needs: the Be-Well checklist for carers and professionals

Paediatrics and Child Health

Volume 30, Issue 12, December 2020, Pages 416-424

Abstract

Children and adults with severe intellectual disability and complex needs often show behaviours and distress that carers and professionals find difficult to identify causes for, manage and decrease. The prevailing view is that these behaviours and distress are learned and consequently interventions focus on behavioural techniques. In this article we summarise the findings of research that indicate that behaviour and distress in this population are influenced by transient and stable characteristics or conditions that can interact with aspects of learning, be independent of learning, and interact with each other. These transient and stable characteristics or conditions are: pain and discomfort, sensory sensitivity, anxiety and low mood, sleep problems, atypical emotional regulation, specific cognitive difference, and differences in social behaviour. To aid carers and professionals, we present a checklist of the elements of an assessment process that covers these transient and stable characteristics or conditions and other relevant influences on behaviour and distress such as seizures, medication, learning and communication. We also draw attention to the benefit of identifying the cause of intellectual disability to inform the assessment process.

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Feasibility of developing children’s Pill School within a UK hospital

Archives of Disease in Childhood Published Online First: 23 November 2020. doi: 10.1136/archdischild-2020-319154

Abstract

Objective We assessed the feasibility of introducing an intervention (children’s Pill School—PS) within a UK hospital to provide swallowing training for children, identified the proportion of children who can be switched from oral liquid medicines to pills and assessed children/parents’ opinions about the PS training.

Methods 30 inpatient children (aged 3–18 years; taking oral liquid medicines; their liquid medications assessed suitable for switching to pills; can (and their parents) speak/understand English were included. Training sessions were delivered using hard sweets of different sizes.

Results 87% (26) of children successfully learnt how to swallow pills after one training session (mean duration 14.5 min), and 92% (24) were discharged on pills. 75 prescribed oral liquid medications were deemed suitable for switching to pills. Of these, 89% (67) were switched successfully.

Conclusion Children as young as 3 years were successful in swallowing pills after training. Providing children PS training session within hospital is feasible and acceptable to children and their parents.

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Opening doors: suggested practice for medical professionals for when a child might be close to telling about abuse

Archives of Disease in Childhood Published Online First: 24 November 2020. doi: 10.1136/archdischild-2020-320093

SUMMARY

The way medical professionals and others working with children respond when children begin to show or tell about possible abuse can determine whether they continue telling and therefore whether they can be kept safe. Medical professionals can clarify, confuse or contaminate children’s accounts, and medical professionals’ responses to children can prove crucial in later legal proceedings. This paper challenges the seemingly negative, prohibitive guidance provided to many professionals across health and education about responding to early concerns and instead offers a framework of positive, practical guidance for ‘opening doors’, based on the approach developed by the team at Triangle over many years. The content of this article and its approach is also applicable to nursing and allied health staff, teachers and professionals working with children within the safeguarding arena. The term ‘disclosure’ is challenged and reframed. A worked real-life example follows a 6 year old through a sequence of moments where a doctor has opportunities to open or close doors based on clinical experience.

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Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infections

Archives of Disease in Childhood Published Online First: 01 December 2020. doi: 10.1136/archdischild-2020-320338

Abstract

In contrast to other respiratory viruses, children have less severe symptoms when infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this review, we discuss proposed hypotheses for the age-related difference in severity of coronavirus disease 2019 (COVID-19).

Factors proposed to explain the difference in severity of COVID-19 in children and adults include those that put adults at higher risk and those that protect children. The former include: (1) age-related increase in endothelial damage and changes in clotting function; (2) higher density, increased affinity and different distribution of angiotensin converting enzyme 2 receptors and transmembrane serine protease 2; (3) pre-existing coronavirus antibodies (including antibody-dependent enhancement) and T cells; (4) immunosenescence and inflammaging, including the effects of chronic cytomegalovirus infection; (5) a higher prevalence of comorbidities associated with severe COVID-19 and (6) lower levels of vitamin D. Factors that might protect children include: (1) differences in innate and adaptive immunity; (2) more frequent recurrent and concurrent infections; (3) pre-existing immunity to coronaviruses; (4) differences in microbiota; (5) higher levels of melatonin; (6) protective off-target effects of live vaccines and (7) lower intensity of exposure to SARS-CoV-2.

What is already known on this topic?

• Compared with older adults, severe or fatal COVID-19 disease is much less common in infants, children and young adults.
• This pattern is strikingly different to that for infection with most other respiratory viruses, for which both the prevalence and severity are higher in children.

What this study adds?

• A number of factors have been proposed to explain the difference between children and adults in the severity of COVID-19, which can be categorised into those that put adults at higher risk and those that protect children.
• Although, there are several hypotheses for the age-related difference in the severity of COVID-19, the observed age-gradient seems to most closely parallel changes in immune and endothelial/clotting function.

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Development and validation of a prediction model for invasive bacterial infections in febrile children at European Emergency Departments: MOFICHE, a prospective observational study

Archives of Disease in Childhood Published Online First: 18 November 2020. doi: 10.1136/archdischild-2020-319794

Abstract

Objectives To develop and cross-validate a multivariable clinical prediction model to identify invasive bacterial infections (IBI) and to identify patient groups who might benefit from new biomarkers.

Design Prospective observational study.

Setting 12 emergency departments (EDs) in 8 European countries.

Patients Febrile children aged 0–18 years.

Main outcome measures IBI, defined as bacteraemia, meningitis and bone/joint infection. We derived and cross-validated a model for IBI using variables from the Feverkidstool (clinical symptoms, C reactive protein), neurological signs, non-blanching rash and comorbidity. We assessed discrimination (area under the receiver operating curve) and diagnostic performance at different risk thresholds for IBI: sensitivity, specificity, negative and positive likelihood ratios (LRs).

Results Of 16 268 patients, 135 (0.8%) had an IBI. The discriminative ability of the model was 0.84 (95% CI 0.81 to 0.88) and 0.78 (95% CI 0.74 to 0.82) in pooled cross-validations. The model performed well for the rule-out threshold of 0.1% (sensitivity 0.97 (95% CI 0.93 to 0.99), negative LR 0.1 (95% CI 0.0 to 0.2) and for the rule-in threshold of 2.0% (specificity 0.94 (95% CI 0.94 to 0.95), positive LR 8.4 (95% CI 6.9 to 10.0)). The intermediate thresholds of 0.1%–2.0% performed poorly (ranges: sensitivity 0.59–0.93, negative LR 0.14–0.57, specificity 0.52–0.88, positive LR 1.9–4.8) and comprised 9784 patients (60%).

Conclusions The rule-out threshold of this model has potential to reduce antibiotic treatment while the rule-in threshold could be used to target treatment in febrile children at the ED. In more than half of patients at intermediate risk, sensitive biomarkers could improve identification of IBI and potentially reduce unnecessary antibiotic prescriptions.

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Priorities for the child public health response to the COVID-19 pandemic recovery in England

Archives of Disease in Childhood Published Online First: 09 December 2020. doi: 10.1136/archdischild-2020-320214

Abstract

Child health is at risk from the unintended consequences of the COVID-19 response and will suffer further unless it is given proper consideration. The pandemic can be conceived as a systemic shock to the wider determinants of child health, with impacts on family functioning and income, access to healthcare and education. This article outlines COVID-19 impacts on children in England. Key priorities relate to the diversion of healthcare during lockdown; interruption and return to schooling; increased health risks and long-term impacts on child poverty and social inequalities. We provide an overview of mitigation strategies and policy recommendations aimed to assist both national and local professionals across child health, education, social care and related fields to inform the policy response.

What is already known on this topic?

• Child health in England was already at crisis point pre-COVID-19.
• While the direct health impact of COVID-19 infection on children and young people is rarely severe, longer term indirect impacts are currently unclear.

What this study adds?

• Our review highlights a range of risks to child health in England, resulting from the unintended consequences of the COVID-19 response.
• Long-terms risks may result from diversion of healthcare, interruption of schooling, impact on mental health and increased social inequalities, among other things.
• A considered and multidisciplinary policy response that prioritises children’s right to health is required in order to mitigate against rising inequalities.

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Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and AdolescentsA Systematic Review

JAMA Pediatr. 2020;174(9):882-889. doi:10.1001/jamapediatrics.2020.1467

Photo by August de Richelieu on Pexels.com

Question  What are the clinical features of pediatric patients with coronavirus disease 2019 (COVID-19)?

Findings  In this systematic review of 18 studies with 1065 participants, most pediatric patients with SARS-CoV-2 infection presented with fever, dry cough, and fatigue or were asymptomatic; 1 infant presented with pneumonia, complicated by shock and kidney failure, and was successfully treated with intensive care. Most pediatric patients were hospitalized, and symptomatic children received mainly supportive care; no deaths were reported in the age range of 0 to 9 years.

Meaning  Most children with COVID-19 presented with mild symptoms, if any, generally required supportive care only, and typically had a good prognosis and recovered within 1 to 2 weeks

Abstract

Importance  The current rapid worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection justifies the global effort to identify effective preventive strategies and optimal medical management. While data are available for adult patients with coronavirus disease 2019 (COVID-19), limited reports have analyzed pediatric patients infected with SARS-CoV-2.

Objective  To evaluate currently reported pediatric cases of SARS-CoV-2 infection.

Evidence Review  An extensive search strategy was designed to retrieve all articles published from December 1, 2019, to March 3, 2020, by combining the terms coronavirus and coronavirus infection in several electronic databases (PubMed, Cochrane Library, and CINAHL), and following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Retrospective cross-sectional and case-control studies, case series and case reports, bulletins, and national reports about the pediatric SARS-CoV-2 infection were included. The risk of bias for eligible observational studies was assessed according to the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline.

Findings  A total of 815 articles were identified. Eighteen studies with 1065 participants (444 patients were younger than 10 years, and 553 were aged 10 to 19 years) with confirmed SARS-CoV-2 infection were included in the final analysis. All articles reflected research performed in China, except for 1 clinical case in Singapore. Children at any age were mostly reported to have mild respiratory symptoms, namely fever, dry cough, and fatigue, or were asymptomatic. Bronchial thickening and ground-glass opacities were the main radiologic features, and these findings were also reported in asymptomatic patients. Among the included articles, there was only 1 case of severe COVID-19 infection, which occurred in a 13-month-old infant. No deaths were reported in children aged 0 to 9 years. Available data about therapies were limited.

Conclusions and Relevance  To our knowledge, this is the first systematic review that assesses and summarizes clinical features and management of children with SARS-CoV-2 infection. The rapid spread of COVID-19 across the globe and the lack of European and US data on pediatric patients require further epidemiologic and clinical studies to identify possible preventive and therapeutic strategies.

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Infants Born to Mothers With COVID-19—Making Room for Rooming-in

JAMA Pediatr. Published online December 7, 2020. doi:10.1001/jamapediatrics.2020.5100

From the beginning of the coronavirus disease 2019 (COVID-19) pandemic, clinicians in all specialties have been challenged to offer optimal care to infected patients and good counsel to persons potentially affected by the novel virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Professional societies have also had difficulty in providing clinical guidance in the absence of the type of peer-reviewed evidence to which modern medicine has grown accustomed. Developing guidance for pregnant mothers and their newborns was particularly problematic in the initial stages of the pandemic, given that we knew little beyond this: the virus was very contagious, and it was killing people across the world. The American Academy of Pediatrics (AAP) initially recommended infection control practices that included temporary maternal-infant physical separation to protect newborns from acquiring SARS-CoV-2 infection from mothers with COVID-19 at the time of delivery. This recommendation ran counter to mother-infant rooming-in practices usually endorsed by the AAP: practices with multiple advantages to the dyad including supporting effective breastfeeding.¹ In this issue of JAMA Pediatrics, Ronchi et al² evaluate the safety of infection control practices that include rooming-in for infants born to SARS-CoV-2–infected mothers. This study adds to recent publications and registry observations that are building the evidence base that informs evolving clinical guidance.

The lessons of this study support the most recent updates to the AAP neonatal guidance,⁷ which now recommend rooming-in unless mothers are too ill to care for their newborn, and use of the updated Centers for Disease Control and Prevention time- and symptom-based approach to determine when a mother is no longer infectious to her well newborn.⁶ The AAP revised guidance also supports the critical lesson of this study: for mothers who are potentially infectious with SARS-CoV-2 at the time of delivery, preventive measures should be taken, as newborns are at risk of acquiring the virus from mothers who are truly infectious (Figure). Perinatal clinicians need to emphasize the importance of following recommended infection control and prevention practices at home as well until the mother and other caregivers meet the metrics for being noninfectious. Such practices will help protect the newborn from acquiring SARS-CoV-2 and becoming ill. In addition, a recent study examining age-related differences in nasopharyngeal SARS-CoV-2 levels found that infants and children younger than 5 years had a 10- to 100-fold greater amount of virus in their upper respiratory tract compared with adults.⁸ This finding suggests that infected infants could be a source of community spread—an additional motivation to protect them from acquiring SARS-CoV-2. In the end, families and clinicians should be reassured that our current understanding of viral dynamics and careful studies, such as that reported by Ronchi and colleagues,² is moving us slowly away from an evidence-free zone. For newborns, this accumulation of evidence is ensuring that, with proper precautions, they can stay where they belong: with their mothers.

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Obesity Genes and Weight Loss During Lifestyle Intervention in Children With Obesity

JAMA Pediatr. Published online December 14, 2020. doi:10.1001/jamapediatrics.2020.5142

Question  Are genes associated with obesity treatment success in children with obesity?

Findings  In this interventional genetic association study that included 1198 children with overweight or obesity, 5 of 56 obesity single-nucleotide variants were statistically significantly associated with changes in body weight, however, only to a minor degree.

Meaning  In this study, environmental, social, and behavioral factors seem to play a substantial role in obesity treatment strategies in children.

Abstract

Importance  Genome-wide association studies have identified genetic loci influencing obesity risk in children. However, the importance of these loci in the associations with weight reduction through lifestyle interventions has not been investigated in large intervention trials.

Objective  To evaluate the associations between various obesity susceptibility loci and changes in body weight in children during an in-hospital, lifestyle intervention program.

Design, Setting, and Participants  Long-term Effects of Lifestyle Intervention in Obesity and Genetic Influence in Children (LOGIC), an interventional prospective cohort study, enrolled 1429 children with overweight or obesity to participate in an in-hospital lifestyle intervention program. Genotyping of 56 validated obesity single-nucleotide variants (SNVs) was performed, and the associations between the SNVs and body weight reduction during the intervention were evaluated using linear mixed-effects models for each SNV. The LOGIC study was conducted from January 6, 2006, to October 19, 2013; data analysis was performed from July 15, 2015, to November 6, 2016.

Exposures  A 4- to 6-week standardized in-hospital lifestyle intervention program (daily physical activity, calorie-restricted diet, and behavioral therapy).

Main Outcomes and Measures  The association between 56 obesity-relevant SNVs and changes in body weight and body mass index.

Results  Of 1429 individuals enrolled in the LOGIC Study, 1198 individuals (mean [SD] age, 14.0 [2.2] years; 670 [56%] girls) were genotyped. A mean (SD) decrease was noted in body weight of −8.7 (3.6) kg (95% CI, −15.7 to −1.8 kg), and body mass index (calculated as weight in kilograms divided by height in meters squared) decreased by −3.3 (1.1) (95% CI, −5.4 to −1.1) (both P < .05). Five of 56 obesity SNVs were statistically significantly associated with a reduction of body weight or body mass index (all P < 8.93 × 10⁻⁴ corresponding to Bonferroni correction for 56 tests). Compared with homozygous participants without the risk allele, homozygous carriers of the rs7164727 (LOC100287559: 0.42 kg; 95% CI, 0.31-0.53 kg, P = 4.00 × 10⁻⁴) and rs12940622 (RPTOR: 0.35 kg; 95% CI, 0.18-0.52 kg; P = 1.86 × 10⁻⁵) risk alleles had a lower reduction of body weight, whereas carriers of the rs13201877 (IFNGR1: 0.65 kg; 95% CI, 0.51-0.79 kg; P = 2.39 × 10⁻⁵), rs10733682 (LMX1B: 0.45 kg; 95% CI, 0.27-0.63 kg; P = 6.37 × 10⁻⁴), and rs2836754 (ETS2: 0.56 kg; 95% CI, 0.38-0.74 kg; P = 1.51 × 10⁻⁴) risk alleles were associated with a greater reduction of body weight after adjustment for age and sex.

Conclusions and Relevance  Genes appear to play a minor role in weight reduction by lifestyle in children with overweight or obesity. The findings suggest that environmental, social, and behavioral factors are more important to consider in obesity treatment strategies.

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Cognitive behavioural therapy for anxiety disorders in children and adolescents – Cochrane review

Background

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up‐to‐date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer‐term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

Authors’ conclusions

CBT is probably more effective in the short‐term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

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