Category Archives: Current Volume (2017)

Helping parents with the diagnosis of disability – Paediatrics & Child Health

Abstract

The impact on parents and the wider family of caring for a disabled child depends on many factors, including the child’s behaviours, available resources and the families’ coping strategies. Optimal care requires careful management of every stage from diagnosis onwards. How the diagnosis of neurodevelopmental disability is communicated to the family has long-lasting effects. When clarification of the diagnosis takes a long time, this is particularly hard for child health professionals to manage well, and a joint understanding of the process with the family is important. This short review offers guidance for the conduct of the diagnostic consultation referring to the current best evidence and drawing from personal experience. It also explains how current theory and evidence can facilitate better understanding of families’ reactions to a diagnosis, moving beyond a simple bereavement adjustment model towards a nuanced appreciation of parental reaction.

Link to article page here

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Association of Race/Ethnicity With Very Preterm Neonatal Morbidities: JAMA article

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Image: Pixabay.com
Key Points

Question  Are there racial/ethnic disparities in very preterm neonatal morbidity?

Findings  In this population-based cohort study of 582 297 very preterm birth infants, substantial disparities in necrotizing enterocolitis, intraventricular hemorrhage, bronchopulmonary dysplasia, and retinopathy of prematurity were found between black and white infants as well as between Hispanic and white infants, and disparities in retinopathy of prematurity were also notable between Asian and white infants. Disparities measured instead with a standard approach in a very preterm birth cohort were attenuated or null.

Meaning  Racial/ethnic disparities in very preterm neonatal morbidity are sizeable, and reports from very preterm birth cohorts may underestimate the magnitude of these disparities.

Link to article here

What is new in paediatric medication safety? BMJ article

Abstract

Medication-related errors are among the most common medical errors, and studies have shown that the paediatric population is particularly vulnerable. Errors can occur during any step in the medication process. This review article seeks to highlight new advancements in the field of paediatric medication safety at each stage of the medication process, from ordering and transcribing to medication dispensing and administration. We will focus on interventions that are increasingly widely used, such as computerised provider order entry with clinical decision support, barcoding technologies and safe medication administration through technologies pumps (SMART pumps), as well as innovative mobile application devices and workflow management systems that are being piloted at single institutions. By highlighting what is new in paediatric medication safety, as well as the gaps that remain, we hope to continue to foster focus on this critically important area in order to create the safest possible environment for children.

Link to full article here

Antenatal ultrasound and autism: BMJ article

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Image: Pixabay.com

Many factors have been suggested as causes for the apparent rise in prevalence of autistic spectrum disorder (ASD). Perhaps most terrifying for pregnant women is the suggestion that antenatal (AN) ultrasound may be harmful to the developing brain. There is some theoretical justification for this: high-energy sound waves have been shown to cause neuronal disruption in mouse models.

When early safety studies were done in the 1990s, the results were reassuring. But since then, more frequent and higher-energy scans have become the norm, which might increase risk. A retrospective case-control study from Boston, USA, produced apparently contradictory results, and much controversy (Rosman NP et al doi:10.1001/jamapediatrics.2017.5634) They identified 107 children with paediatrician-diagnosed ASD born between 2006 and 2014 and and two matched comparison groups: one of 104 with non-ASD developmental delay, and another of 2019 with normal development. They had detailed data on all AN scans. There were no significant differences in the total numbers of scans. Compared with both control groups, the ASD group had significantly shorter duration of US exposure in the first and second trimesters, but a significantly greater ‘mean depth of ultrasonic penetration’ in these trimesters (first trimester 12.5 cm vs 11.6 cm), but not in the third.

The authors speculate that increased depth of acoustic penetration within the fetal skull might alter germinal matrix cell migration: however it is difficult to see how this might lead to autism but not other forms of developmental delay. And it cannot explain why the ASD group received less US exposure overall. The study is criticised by an editorial, and by subsequent correspondents to JAMA Peds, pointing out that they not have allowed for many potential confounders (maternal age and obesity, socioeconomic factors etc.). One correspondent compared it to the infamous Wakefield MMR study, in that their conclusions are not borne out by their findings.

Link to article here

Myths, facts and controversies in the diagnosis and management of anaphylaxis – BMJ review

Abstract

Anaphylaxis is a serious systemic allergic reaction that is rapid in onset and may cause death. Despite numerous national and international guidelines and consensus statements, common misconceptions still persist in terms of diagnosis and appropriate management, both among healthcare professionals and patient/carers. We address some of these misconceptions and highlight the optimal approach for patients who experience potentially life-threatening allergic reactions.

Introduction

Anaphylaxis is a serious systemic allergic reaction that is rapid in onset and may cause death.1 Recent data suggest that the incidence is increasing, particularly to food.2–4 The lifetime prevalence of anaphylaxis is estimated to be between 0.5% and 2%.5Despite numerous national and international guidelines, misconceptions continue to persist among both healthcare professionals and patients/carers, which result in under-recognition and suboptimal management of this medical emergency. In this review, we address some of these misconceptions and highlight areas of best practice.

Conclusions

Anaphylaxis is a severe, potentially life-threatening systemic allergic reaction, which constitutes a clinical emergency. Common misconceptions regarding anaphylaxis are summarised in table 2. Prompt assessment and management are essential, as delays in treatment are associated with fatal outcomes. Anaphylaxis is primarily a clinical diagnosis: patients/carers and health professionals must be appropriately trained to recognise and institute appropriate treatment with intramuscular epinephrine, as part of a comprehensive management plan. Epinephrine is the first-line treatment for anaphylaxis, but is underused. Changes in posture have been documented as a trigger for decompensation and fatal anaphylaxis. New management plans incorporating this advice, and which allow the use of ‘spare’ autoinjectors in schools, are available from the BSACI and via www.sparepensinschools.uk website.

Link to full article here

Oropharyngeal colostrum in preventing mortality and morbidity in preterm infants: Cochrane review

Abstract

Background

Placing a small volume of colostrum directly onto the buccal mucosa of preterm infants during the early neonatal period may provide immunological and growth factors that stimulate the immune system and enhance intestinal growth. These benefits could potentially reduce the risk of infection and necrotising enterocolitis (NEC) and improve survival and long‐term outcome.

Objectives

To determine if early (within the first 48 hours of life) oropharyngeal administration of mother’s own fresh or frozen/thawed colostrum can reduce rates of NEC, late‐onset invasive infection, and/or mortality in preterm infants compared with controls. To assess trials for evidence of safety and harm (e.g. aspiration pneumonia). To compare effects of early oropharyngeal colostrum (OPC) versus no OPC, placebo, late OPC, and nasogastric colostrum.

 

Main results

We included six studies that compared early oropharyngeal colostrum versus water, saline, placebo, or donor, or versus no intervention, enrolling 335 preterm infants with gestational ages ranging from 25 to 32 weeks’ gestation and birth weights of 410 to 2500 grams. Researchers found no significant differences between OPC and control for primary outcomes ‐ incidence of NEC (typical risk ratio (RR) 1.42, 95% confidence interval (CI) 0.50 to 4.02; six studies, 335 infants; P = 0.51; I² = 0%; very low‐quality evidence), incidence of late‐onset infection (typical RR 0.86, 95% CI 0.56 to 1.33; six studies, 335 infants; P = 0.50; I² = 0%; very low‐quality evidence), and death before hospital discharge (typical RR 0.76, 95% CI 0.34 to 1.71; six studies, 335 infants; P = 0.51; I² = 0%; very low‐quality evidence). Similarly, meta‐analysis showed no difference in length of hospital stay between OPC and control groups (mean difference (MD) 0.81, 95% CI ‐5.87 to 7.5; four studies, 293 infants; P = 0.65; I² = 49%). Days to full enteral feeds were reduced in the OPC group with MD of ‐2.58 days (95% CI ‐4.01 to ‐1.14; six studies, 335 infants; P = 0.0004; I² = 28%; very low‐quality evidence).

The effect of OPC was uncertain because of small sample sizes and imprecision in study results (very low‐quality evidence).

No adverse effects were associated with OPC; however, data on adverse effects were insufficient, and no numerical data were available from the included studies.

Overall the quality of included studies was low to very low across all outcomes. We downgraded GRADE outcomes because of concerns about allocation concealment and blinding, reporting bias, small sample sizes with few events, and wide confidence intervals.

Authors’ conclusions

Large, well‐designed trials would be required to evaluate more precisely and reliably the effects of oropharyngeal colostrum on important outcomes for preterm infants.

Link to review here

Homeopathic medicinal products for preventing and treating acute respiratory tract infections in children: Cochrane review

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Image: Freephotos.cc

Abstract

Background

Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although these infections are self‐limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most have minimal benefit and may lead to adverse effects. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for effectiveness is established.

Objectives

To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat acute respiratory tract infections in children.

 

Main results

We included eight RCTs of 1562 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for upper respiratory tract infections (URTIs). Four treatment studies examined the effect on URTI recovery, and four studies investigated the effect on preventing URTIs after one to three months of treatment, followed up for the remainder of the year. Two treatment and two prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non‐individualised treatments. All studies involved highly diluted homeopathic medicinal products.

We found several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention‐to‐treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many had additional domains with unclear risk of bias. Three studies received funding from homeopathy manufacturers; one support from a non‐government organisation; two government support; one was cosponsored by a university; and one did not report funding support.

Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta‐analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products; trials at uncertain and high risk of bias reported beneficial effects.

We found low‐quality evidence that non‐individualised homeopathic medicinal products confer little preventive effect on ARTIs (OR 1.14, 95% CI 0.83 to 1.57). We found low‐quality evidence from two individualised prevention studies that homeopathy has little impact on the need for antibiotic usage (N = 369) (OR 0.79, 95% CI 0.35 to 1.76). We also assessed adverse events, hospitalisation rates and length of stay, days off school (or work for parents), and quality of life, but were not able to pool data from any of these secondary outcomes.

There is insufficient evidence from two pooled individualised treatment studies (N = 155) to determine the effect of homeopathy on short‐term cure (OR 1.31 favouring placebo, 95% CI 0.09 to 19.54; very low‐quality evidence) and long‐term cure rates (OR 0.99, 95% CI 0.10 to 9.67; very low‐quality evidence). Adverse events were reported inconsistently; however, serious events were not reported. One study found an increase in the occurrence of non‐severe adverse events in the treatment group.

Authors’ conclusions

Pooling of two prevention and two treatment studies did not show any benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, so conclusions about safety could not be drawn.

Link to review page here