For children with a first presentation of nephrotic syndrome, an extended sixteen-week treatment regimen with prednisolone does not reduce the risk of relapse compared with the standard eight-week course. Most children will experience a relapse with either regimen, but the longer course may delay it by a month or so which may, in turn, reduce the resource use, such as emergency department visits, shorter admissions and less need to see the GP. This can also make the longer course cheaper overall.
Nephrotic syndrome is a condition where the kidneys leak large amounts of protein into the urine. This can result in a range of problems, including swelling, blood clots and a higher chance of getting infections. Corticosteroids are known to be effective in treating the condition, but concerns about their side effects have led to differences of opinion about how long to continue initial treatment.
This NIHR-funded study suggests that while the clinical benefits are similar, patients and commissioners might prefer the longer courses for the slight benefit in quality of life and cost-saving from fewer, shorter hospital admissions.
Children with neurodisability are at risk of nutritional impairment due to a number of factors including feeding and swallowing difficulties, gastrointestinal disorders, disorders of movement and posture, immobility, medication, adverse food related sensory experience and behavioural feeding difficulties. Undernutrition has a negative impact on growth, general health indices, bone health, muscle strength, immunity and wound healing and brain and cognitive development. Regular multidisciplinary assessment including the routine measurement of body composition and micronutrient status are recommended to inform appropriate nutritional support and intervention. Intervention may include management of tone, posture and positioning for feeding, comorbid gastrointestinal disease, seizure management, alteration to medications or use of a sensory diet as well as changes to protein and energy intake, dietary fluid and fibre content, micronutrient supplementation, or establishment of an appropriate enteral feeding route in children unable to safely maintain nutritional needs orally. Children having nutritional support should have regular multidisciplinary follow up as clinically indicated, and when the clinical situation changes. This article aims to briefly review the most important aspects of nutrition in children with neurodisability and offer practical advice to health care practitioners involved in their care.
Jornal de Pediatria (Versão em Português), Volume 95, Issue 4, July–August 2019, Pages 385-400
This study aimed to assess the quality of systematic reviews on prevention and non-pharmacological treatment of overweight and obesity in children and adolescents.
A search was done in electronic databases (Medline via PubMed, Web of Science, Scopus, LILACS, the Cochrane Library, and Clinical Trials), including only systematic reviews with meta-analysis. Reviews were selected by two researchers, and a third one solved the divergences. PRISMA statement and checklist were followed.
Summary of data
A total of 4574 records were retrieved, including 24 after selection. Six reviews were on obesity prevention, 17 on obesity treatment, and one on mixed interventions for prevention and treatment of obesity. The interventions were very heterogeneous and showed little or no effects on weight or body mass index. Mixed interventions that included dieting, exercise, actions to reduce sedentary behavior, and programs involving the school or families showed some short-term positive effects. Reviews that analyzed cardiovascular risk factors demonstrated significant improvements in the short-term.
The systematic reviews of interventions to prevent or reduce obesity in children and adolescents generally showed little or no effects on weight or body mass index, although cardiovascular profile can be improved. Mixed interventions demonstrated better effects, but the long-term impact of obesity treatments of children and adolescents remains unclear.
Archives of Disease in Childhood Published Online First: 14 June 2019.
Part 1: what’s in a name?
Many working in paediatrics will have noticed that the population of children we are treating is continually evolving and, in many cases, becoming more complex. With advancements in medical care and technology, more children are surviving with chronic, life threatening or life limiting conditions and these children clearly have different needs to those who are usually well but present with a discreet episode of acute illness.
This year I have been tasked with working to improve the care of these ‘complex’ children within a large hospital trust. It is clear that the treatment of this group of patients can be challenging for a number of reasons. These children often have multiple comorbidities, multiple teams involved in their care and are more at risk of multiple and/or prolonged hospital admissions, in some ways making them comparable with the frail elderly. In addition, they often also have additional emotional, developmental and social needs to consider. Given all of these challenges, there is a risk of care being suboptimal, fragmented and even unsafe. It is therefore imperative that we continue to seek to streamline and enhance care for these vulnerable patients and their families.
Do continuous vancomycin infusions achieve therapeutic target levels more often than intermittent dosing in neonates?
Archives of Disease in Childhood Published Online First: 07 August 2019
A 13-day-old baby born at a gestational age of 26 weeks in the neonatal intensive care unit is noted to have an increasing oxygen requirement, frequent apnoeas and to develop temperature instability. You note that she has had a central line in situ for 12 days for feeding intolerance and parenteral nutrition. Central line sepsis is considered as one of the differential diagnoses and your unit policy is to use vancomycin to treat this. You wonder whether to use an intermittent dosing regimen or a continuous infusion of vancomycin.
Clinical bottom line
Continuous vancomycin infusions achieve therapeutic target levels more often than intermittent dosing regimens (grade A).
Continuous infusions, when used with a loading dose, require a lower average daily dose, achieve target levels earlier and require fewer dose adjustments (grade D).
The area under the curve over 24 hours/minimal inhibitory concentration should be used to assess antibiotic efficacy rather than measuring target levels.
Tyldesley-Marshall N, Greenfield S, Neilson S, et al
Qualitative study: patients’ and parents’ views on brain tumour MRIs
Archives of Disease in Childhood Published Online First: 07 August 2019.
Background MRI is essential to the clinical management of children and young people with brain tumours. Advances in technology have made images more complicated to interpret, yet more easily available digitally. It is common practice to show these to patients and families, but how they emotionally respond to, understand and value, seeing brain tumour MRIs has not been formally studied.
Methods Qualitative semi-structured interviews were undertaken with 14 families (8 patients, 15 parents) purposively sampled from paediatric patients (0 to 18 years) attending a large UK children’s hospital for treatment or monitoring of a brain tumour. Transcripts were analysed thematically using the Framework Method.
Results Four themes were identified: Receiving results (waiting for results, getting results back, preferences to see images), Emotional responses to MRIs, Understanding of images (what they can show, what they cannot show, confusion) and Value of MRIs (aesthetics, aiding understanding, contextualised knowledge/emotional benefits, enhanced control, enhanced working relationships, no value). All families found value in seeing MRIs, including reassurance, hope, improved understanding and enhanced feeling of control over the condition. However emotional responses varied enormously.
Conclusions Clinical teams should always explain MRIs after ‘framing’ the information. This should minimise participant confusion around meaning, periodically evident even after many years. Patient and parent preferences for being shown MRIs varied, and often changed over time, therefore clinicians should identify, record and update these preferences. Time between scanning and receiving the result was stressful causing ‘scanxiety’, but most prioritised accuracy over speed of receiving results.
Can fetal echocardiograms reliably predict the need for urgent balloon atrial septostomy in transposition of the great arteries?
Archives of Disease in Childhood
A term neonate is admitted to the neonatal unit with an antenatal diagnosis of transposition of the great arteries with intact ventricular septum (TGA/IVS) and a 6 mm patent foramen ovale, identified by fetal echocardiogram at 34 weeks gestational age. The preductal and postductal oxygen saturations (SpO2) are 45% and 55% in 100% oxygen. Prostaglandin therapy is commenced at 5 ng/kg/min. In view of unresponsive hypoxaemia, the baby is intubated, mechanically ventilated and prostaglandin dose is escalated to 50 ng/kg/min. However, little improvement in oxygen saturations is noted. You then question the need for urgent balloon atrial septotomy (BAS) although fetal echocardiogram suggested adequate mixing at the atrial connection.
Clinical bottom line
There are no consistent markers on fetal echocardiography that reliably predict the need for BAS in TGA (grade D).