All posts by dbhcurrentawareness

An Update on the Management of Neonatal Brachial Plexus Palsy—Replacing Old Paradigms – A JAMA Review

Abstract

Importance  Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, “all neonatal brachial plexus palsy recovers,” “wait a year to see if recovery occurs,” and “don’t move the arm.” Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

Observations  Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

Conclusions and Relevance  Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Link to article page here

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Does Infusion Rate Affect Neurologic Outcomes in Pediatric DKA? NEJM

ketoacidosis nejm

Many treatment protocols for diabetic ketoacidosis in children advocate slow rehydration to prevent brain injury, but whether the speed of administration of intravenous fluids influences outcomes remains unclear. New research findings are summarized in a short video.

Click here for video

The needs of children and families after brain injury – from understanding to action – RCPCH blog

Dr Anne Gordon, Consultant Occupational Therapist in Paediatric Neuroscience at the Evelina London Children’s Hospital and Trustee of the Stroke Association, has written a guest blog about the needs of children and their families following brain injury, providing an insight into what we can do to better manage their health and wellbeing needs.

It may be more helpful to consider [children’s] support needs and abilities as different rather than better.

While the consequences of brain injury on children and families are increasingly recognised in the research literature, the adoption of learning in clinical practice lags behind. Workshops run to inform the RCPCH and Stroke Association childhood stroke guidelines revealed that timely provision of individualised information, support and resources is the experience of few, and access to individualised, evidence-informed rehabilitation close to home remains patchy.

We do know, however, from longitudinal studies and those that have sought the perspective of children, young people and their parents/carers, that related health conditions and needs emerge over time. Environmental, family, attitudinal and social factors are only some of the factors that may interact with the increasing demands on young people as they develop and progress through education and on to adult life.

Link to full blog here

Diagnostic tests for autism spectrum disorder (ASD) in preschool children – Cochrane review

autism-2457327_960_720 Pixabay
Image: Pixabay

Background

Autism spectrum disorder (ASD) is a behaviourally diagnosed condition. It is defined by impairments in social communication or the presence of restricted or repetitive behaviours, or both. Diagnosis is made according to existing classification systems. In recent years, especially following publication of the Diagnostic and Statistical Manual of Mental Disorders ‐ Fifth Edition (DSM‐5; APA 2013), children are given the diagnosis of ASD, rather than subclassifications of the spectrum such as autistic disorder, Asperger syndrome, or pervasive developmental disorder ‐ not otherwise specified. Tests to diagnose ASD have been developed using parent or carer interview, child observation, or a combination of both.

Objectives

Primary objectives

1. To identify which diagnostic tools, including updated versions, most accurately diagnose ASD in preschool children when compared with multi‐disciplinary team clinical judgement.

2. To identify how the best of the interview tools compare with CARS, then how CARS compares with ADOS.

a. Which ASD diagnostic tool ‐ among ADOS, ADI‐R, CARS, DISCO, GARS, and 3di ‐ has the best diagnostic test accuracy?

b. Is the diagnostic test accuracy of any one test sufficient for that test to be suitable as a sole assessment tool for preschool children?

c. Is there any combination of tests that, if offered in sequence, would provide suitable diagnostic test accuracy and enhance test efficiency?

d. If data are available, does the combination of an interview tool with a structured observation test have better diagnostic test accuracy (i.e. fewer false‐positives and fewer false‐negatives) than either test alone?

As only one interview tool was identified, we modified the first three aims to a single aim (Differences between protocol and review): This Review evaluated diagnostic tests in terms of sensitivity and specificity. Specificity is the most important factor for diagnosis; however, both sensitivity and specificity are of interest in this Review because there is an inherent trade‐off between these two factors.

Secondary objectives

1. To determine whether any diagnostic test has greater diagnostic test accuracy for age‐specific subgroups within the preschool age range.

Authors’ conclusions

We observed substantial variation in sensitivity and specificity of all tests, which was likely attributable to methodological differences and variations in the clinical characteristics of populations recruited.

When we compared summary statistics for ADOS, CARS, and ADI‐R, we found that ADOS was most sensitive. All tools performed similarly for specificity. In lower prevalence populations, the risk of falsely identifying children who do not have ASD would be higher.

Now available are new versions of tools that require diagnostic test accuracy assessment, ideally in clinically relevant situations, with methods at low risk of bias and in children of varying abilities.

Link to full article here

Antibiotics for prolonged wet cough in children – Cochrane review

Background

Cough is a frequent symptom presenting to doctors. The most common cause of childhood chronic (greater than fours weeks’ duration) wet cough is protracted bacterial bronchitis (PBB) in some settings, although other more serious causes can also present this way. Timely and effective management of chronic wet or productive cough improves quality of life and clinical outcomes. Current international guidelines suggest a course of antibiotics is the first treatment of choice in the absence of signs or symptoms specific to an alternative diagnosis. This review sought to clarify the current evidence to support this recommendation.

Objectives

To determine the efficacy of antibiotics in treating children with prolonged wet cough (excluding children with bronchiectasis or other known underlying respiratory illness) and to assess risk of harm due to adverse events.

Authors’ conclusions

Evidence suggests antibiotics are efficacious for the treatment of children with chronic wet cough (greater than four weeks) with an NNTB of three. However, antibiotics have adverse effects and this review reported only uncertainty as to the risk of increased adverse effects when they were used in this setting. The inclusion of a more robust study strengthened the previous Cochrane review and its results.

Link to full article here

E‐Health interventions for anxiety and depression in children and adolescents with long‐term physical conditions – Cochrane review

Background

Long‐term physical conditions affect 10% to 12% of children and adolescents worldwide; these individuals are at greater risk of developing psychological problems, particularly anxiety and depression. Access to face‐to‐face treatment for such problems is often limited, and available interventions usually have not been tested with this population. As technology improves, e‐health interventions (delivered via digital means, such as computers and smart phones and ranging from simple text‐based programmes through to multimedia and interactive programmes, serious games, virtual reality and biofeedback programmes) offer a potential solution to address the psychological needs of this group of young people.

Objectives

To assess the effectiveness of e‐health interventions in comparison with attention placebos, psychological placebos, treatment as usual, waiting‐list controls, or non‐psychological treatments for treating anxiety and depression in children and adolescents with long‐term physical conditions.

Authors’ conclusions

At present, the field of e‐health interventions for the treatment of anxiety or depression in children and adolescents with long‐term physical conditions is limited to five low quality trials. The very low‐quality of the evidence means the effects of e‐health interventions are uncertain at this time, especially in children aged under 10 years.

Although it is too early to recommend e‐health interventions for this clinical population, given their growing number, and the global improvement in access to technology, there appears to be room for the development and evaluation of acceptable and effective technologically‐based treatments to suit children and adolescents with long‐term physical conditions.

Full article here

Ultrasound shows potential for confirming the diagnosis of pneumonia in children – NIHR Signal

pneumonia google images
Image: Google images copyright free

Ultrasound scans of the lungs can be more accurate than chest X-rays for diagnosing pneumonia in children in some circumstances.

A review of the published evidence found that lung ultrasound was more sensitive (missed fewer cases) and about as specific (gave about the same number of false alarms) as chest X-ray, when used to confirm suspected community-acquired pneumonia in children. While pneumonia is a clinical diagnosis, X-ray is often used for confirmation.

Ultrasound also spares the child from the radiation associated with X-ray imaging.

Many emergency departments already use ultrasound, so it might be practical to train paediatric staff to use it as a first-line test. However, the study found variation in the specific ultrasound findings that teams used to diagnose pneumonia, suggesting more work needs to be done to clarify diagnostic criteria.

Link to article here