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Recognition of the acutely ill infant

The national investigation

The HSIB was notified of a three-month-old infant who was admitted in to a hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B). HSIB has now completed an investigation regarding the recognition of the acutely ill infant.

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Reference event

The HSIB was notified of a three-month-old infant who was admitted in to a hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B).

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Investigation summary

The investigation focused on understanding and describing circumstances in which the acutely ill infant is not recognised and/or acted upon.

This involved a review of staff training and preparedness for recognising and responding to the sick infant. The investigation explored how clinical information is communicated along with the transfer of information between people. This included the voice of the parent/carer and handover of information between staff. 

The investigation considered the system and environmental influences that impact on the decision making process, taking into account the contextual factors that influence the effectiveness of existing track and trigger tools for acutely ill infants. 

Link to full article here

Interpreting abnormal liver tests: a cased-based discussion

Paediatrics and Child Health
Volume 31, Issue 12, December 2021

Abstract
Elevated liver enzymes are commonly seen by paediatricians in clinical practice. For many clinicians, interpreting deranged liver enzymes can be challenging. There is a lack of an evidence based approach to this. Alterations in liver enzymes may be a normal physiological response to an intercurrent illness or in certain cases may also reflect an underlying liver condition. In this review, we will aim to provide, through a series of cases, a guide on the approach of deranged liver enzymes to conditions that health care professionals may ‘commonly’ encounter.

DOI: 10.1016/j.paed.2021.10.001

Biliary tract malformations of infancy

Paediatrics and Child Health
Volume 31, Issue 12, December 2021

Abstract
Biliary malformations in children are rare, but important to recognize. Diagnostic delay compromises outcomes. Some may be diagnosed prenatally, others in the newborn period, usually with clinical presentation of jaundice, with or without abdominal pain and fever. A strong level of suspicion is needed with any patient. Abdominal ultrasound, which is widely available, is an excellent initial imaging tool. Further work up may include magnetic resonance cholangiopancreatography (MRCP) to completely define the biliary tree. Surgical management is the primary treatment for many biliary disorders.

DOI: 10.1016/j.paed.2021.09.003

Paediatric acute liver failure: a practical approach

Paediatrics and Child Health
Volume 31, Issue 12, December 2021

Abstract
Acute liver failure (ALF) in the paediatric patient is a multisystem complex disorder, which occurs in the absence of chronic liver disease. Globally, viruses remain a common cause but drugs, metabolic and autoimmune conditions are important triggers. In up to half of cases no specific cause is identified. The definition entails a coagulopathy with a Prothrombin time (PT) ≥ 15seconds or International Normalized Ratio (INR) ≥ 1.5 not corrected by vitamin K in the presence of hepatic encephalopathy (HE) or a PT ≥ 20 or INR ≥2 or above regardless of HE. HE can be difficult to recognize in children and is defined differently than HE in adults. Timely recognition of ALF improves outcomes and allows time to undertake investigations, provide supportive therapy and arrange transfer to a specialist paediatric liver centre with transplant capacity. The purpose of this article is to review the aetiologies of ALF in children and outline an approach to investigation, management and treatment.

DOI: 10.1016/j.paed.2021.10.002

Viral hepatitis in children: what do we know in 2021?

Paediatrics and Child Health, Volume 31, Issue 12, December 2021

Abstract

Viruses are a common cause of hepatitis in children. Hepatitis A and E cause acute infections while Hepatitis B, C and D can lead to chronic infection with increased morbidity and mortality due to chronic liver disease and hepatocellular carcinoma in later life. Acute infections may be fulminant causing acute liver failure necessitating a liver transplant. Our understanding of these viruses continues to evolve, and this review aims to summarize the current strategies in diagnosis, prevention and use of anti-viral drugs to treat these infections.

DOI:L 10.1016/j.paed.2021.09.002

Intussusception in preterm neonates: A systematic review of a rare condition

BMC Pediatr 21, 587 (2021).

Background

While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly uncommon and often overlooked. This is due to the fact that they share many clinical characteristics. The initial misdiagnosis of intussusception in preterm neonates (IPN) especially has led to a delay in their management, which increases the risk of developing compromised bowel. Additionally, it is difficult to reach a diagnosis as neonatal intussusception does not have any classical radiological signs even when contrast enema is used. This systematic review is based on the published literature including case reports and case series to review the clinical features of IPN and how to differentiate it from NEC in order to shed the light on this rare disease and how having a high index of suspicion would help practitioners to make an early and accurate diagnosis

Methods

A systematic literature search to report all cases of relevant articles that reported IPN till date. All cases that were born before 37 weeks gestational age, presented within the neonatal period and having well established documentation were included in the study. Any case that did not have these criteria was excluded from our study.

Results

Only 52 cases met these criteria during the period from 1963 till date. An average of 10 days had elapsed before the cases were confirmed to have IPN either clinically or intraoperatively. The most frequent manifestations were abdominal distension and bilious gastric residuals, occurring in 85% and 77% of the cases respectively, followed by bloody stools in 43% of cases. However, this triad was present only in approximately one-third of the cases. Only 13 cases were diagnosed as having intussusception preoperatively. About two thirds of the intussusception were located in the ileum. Pathological lead point was present in 7 cases only; 4 of them were due to Meckel’s diverticulum. Nine cases only out of the 52 cases with IPN died.

Conclusion

It is crucial to detect the clues for diagnosis of intussusception because in contrast to NEC, it is unresponsive to conservative management, affects the viability of the bowel and surgery is essential.

Full text here

Five-year follow-up of new cases after a coeliac disease mass screening

Archives of Disease in Childhood Published Online First: 17 December 2021.

Abstract

Objective We previously performed a population-based mass screening of coeliac disease in children aged 12 years in two birth cohorts resulting in 296 seropositive children, of whom 242 were diagnosed with coeliac disease after duodenal biopsies. In this follow-up study, we wanted to identify new cases in the screening population that tested negative—either converting from potential coeliac disease (seropositive but normal duodenal mucosa) or converting from seronegative at screening to diagnosed coeliac disease.

Methods All seropositive children were invited to a follow-up appointment 5 years after the screening with renewed serological testing and recommended endoscopic investigation if seropositive. Seronegative children in the screening study (n=12 353) were linked to the National Swedish Childhood Coeliac Disease Register to find cases diagnosed in healthcare during the same period.

Results In total, 230 (77%) came to the follow-up appointment, including 34 of 39 with potential coeliac disease. Of these, 11 (32%) had converted to coeliac disease. One new case was found in the National Swedish Childhood Coeliac Disease Register who received the diagnosis through routine screening in children with type 1 diabetes.

Conclusions There is a high risk of conversion to coeliac disease among those with potential disease. However, a negative screening test was associated with a very low risk for a clinical diagnosis within a follow-up period of 5 years.

Full text here

Safeguarding children: are we getting it right?

Archives of Disease in Childhood Published Online First: 21 December 2021. 

Safeguarding children is of paramount importance in modern society. Professionals work hard to identify potential problems in the community, and all National Health Service (NHS) workers, teachers and social workers undergo rigorous safeguarding training to detect and try to prevent child maltreatment. However, recent media coverage of two cases has highlighted the myriad challenges in this field, particularly the impact of clinical decision making in suspected physical abuse, and raises the question: are we getting it right?

The Sunday Times recently covered two court cases in which children were removed from their parents following a provisional diagnosis of maltreatment. One child had bruising and a rib fracture diagnosed by local radiologists adhering to the Royal College of Paediatrics and Child Health (RCPCH) guidelines, but an expert radiologist appearing in the family court disagreed. In a different case of a child with more than one fracture, the court decided that the fractures had been caused accidentally.1 2 The children were returned to their parents. The implication in the media articles was that a different initial diagnosis would have spared these families from distress and the court process. This raises several overlapping issues in this field, including diagnostic uncertainty, when it is appropriate to remove a child following an initial diagnosis and the court’s overarching non-medical role in safeguarding our children.

doi: 10.1136/archdischild-2021-323211

Effect of Care Coordination Using an Allied Health Liaison Officer for Chronic Noncomplex Medical Conditions in Children – A Multi-center Randomized Clinical Trial

JAMA Pediatr. Published online December 28, 2021.

Key Points

Question  Does care coordination improve quality-of-life outcomes in children with chronic noncomplex medical conditions (non-CMCs) and their families?

Finding  In this multicenter randomized clinical trial of 81 children, care coordination significantly improved overall child, overall family, and family functioning quality-of-life outcomes at 12 months after diagnosis.

Meaning  In this randomized clinical trial, care coordination improved the quality of life of children with non-CMCs and their families, and an orientation among health services to provide such a coordination model could lead to longer-term improved clinical outcomes.Abstract

Importance  There is a paucity of high-quality evidence on the effect of care coordination on health-related quality of life among children with chronic noncomplex medical conditions (non-CMCs).

Abstract

Objective  To examine whether care coordination delivered by an Allied Health Liaison Officer results in improved quality-of-life (QOL) outcomes for children with chronic non-CMCs and their families.

Design, Setting and Participants  This multicenter, open label, randomized clinical trial was conducted in pediatric outpatient clinics at 3 Australian hospitals with tertiary- and secondary-level pediatric care facilities. A total of 81 children with chronic non-CMCs and their families participated in the trial for a period of up to 12 months between October 2017 to October 2020. Primary care reviews were offered at 1 week, 3 months, and 6 months after diagnosis.

Interventions  Eligible children were randomized 1:1 to receive care coordination or standard care. Families of children receiving care coordination were provided access to an Allied Health Liaison Officer, who was responsible for facilitation of health care access across hospital, education, primary care, and community sectors.

Main Outcomes and Measures  The primary outcomes were scores on the Pediatric Quality of Life Inventory (PedsQL), version 4.0, and the PedsQL Family Impact Module, version 2.0, measured at 6 and 12 months. An intent-to-treat approach was used to analyze the data.

Results  Of 81 children (mean [SD] age, 8.2 [3.5] years; 55 [67.9%] male), 42 (51.9%) were randomized to care coordination and 39 (48.1%) to standard care. Compared with standard care, care coordination resulted in greater improvements in overall PedsQL scores (difference in score changes between groups, 7.10; 95% CI, 0.44-13.76; P = .04), overall PedsQL Family Impact Module scores (difference in score changes between groups, 8.62; 95% CI, 1.07-16.16; P = .03), and family functioning QOL (difference in score changes between groups, 15.83; 95% CI, 5.05-26.62; P = .004) at 12 months after diagnosis.

Conclusions and Relevance  In this randomized clinical trial, care coordination improved the quality of life of children with chronic non-CMCs and their families. Further studies should explore specific non-CMCs that may benefit most from care coordination and whether an orientation among health services to provide such a coordination model could lead to longer-term improved clinical outcomes.

doi:10.1001/jamapediatrics.2021.5465