End of life care for infants, children and young people with life-limiting conditions: planning and management. NICE Guidance, Updated August 2019

 

This guideline covers the planning and management of end of life and palliative care in for infants, children and young people (aged 0–17 years) with life-limiting conditions. It aims to involve children, young people and their families in decisions about their care, and improve the support that is available to them throughout their lives.

The guideline does not cover children and young people without a life-limiting condition who die unexpectedly (for example, accidental death).

 MHRA advice on gabapentin: In July 2019 we updated a footnote to this guideline to reflect a change in the law relating to gabapentin. As of 1 April 2019, because of a risk of abuse and dependence gabapentin is controlled under the Misuse of Drugs Act 1971 as a class C substance and is scheduled under the Misuse of Drugs Regulations 2001 as schedule 3.

Link to updated guidance here

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Insights into the transfer between children’s and adults’ services for young people with selected long-term conditions – NIHR Signal

 

How young people with type 1 diabetes, autistic spectrum disorder and cerebral palsy experience the transition to adult services depends on their condition and locality. Adult and children’s services need to work together to ensure they are offering young people the sources of support and resilience they need.

This NIHR-funded study found that children with type 1 diabetes were more likely to receive help shown to aid transition. For example, around two-thirds said they had met a member of the adult team, whereas less than a quarter of those with cerebral palsy or autistic spectrum disorder had done so.

However, quality of life scores fell in all conditions after transfer, suggesting that there are improvements to be made across the board. This study identifies three key features that services need to offer, namely meeting a member of the adult team, having parental involvement and encouraging health self-efficacy. These, combined with better collaboration between services, can help ease the transition for young people.

Link to article here

Levetiracetam is a useful alternative to phenytoin in stopping prolonged epileptic seizures in children – NIHR Signal

Levetiracetam is as effective as phenytoin at stopping prolonged epileptic seizures in children. In this trial, levetiracetam stopped 70% of children convulsing compared with 64% for phenytoin within 35 to 45 minutes. Adverse events were similar. This combined with the fact levetiracetam may be easier to administer safely make it an important option.

Most epileptic seizures stop by themselves within a few minutes, but sometimes they continue for much longer. If this happens emergency treatment with IV benzodiazepines is recommended. If these fail, IV phenytoin is currently the commonest drug recommended, but is a particularly complicated drug to use and has potential interactions with other drugs.

This NIHR funded study shows that levetiracetam may be preferable to phenytoin, with comparable safety and efficacy profiles but potentially simpler administration.

Link to article here

The clinical features and therapy of community-acquired gram negative bacteremia in children less than three years old.

Pediatrics & Neonatology

Abstract

BACKGROUND:

Community-acquired Gram-Negative (GN) bacteremia caused more morbidity and mortality recently in children. The increasing drug resistance was also an important issue. However, published reference was few about children.

METHODS:

We conducted a retrospective study to collect febrile patients with blood culture from a pediatric emergency department during 2007∼2013, and exclude cases ever admitted to hospital within 14 days. These blood cultures all showed single GN organism. The demographic characteristics of enrolled patients and the antibiogram of pathogens were recorded, and then were compared statistically to find out the immediate and appropriate antibiotics.

RESULTS:

Total 143 sets of blood culture were GN bacilli and the median age of cases was 2 (IQR, 1-5) years old. Male gender was predominant. Non-fermenting Gram-negative bacilli group (NFGNB spp.), Salmonella spp. and Escherichia coli were first three common pathogens respectively. However, total 37 cases of NFGNB spp. other than Pseudomonas aeruginosa were the possible pathogens. By multiple logistic regression analysis, lower hemoglobin and higher alanine aminotransferase were significant difference between common pathogens and possible ones. Besides, the prevalent age regarding resistant strains of Escherichia coli and Pseudomonas aeruginosa were both focused on less than 1 year old. However, Salmonella spp. were prevalent in the age from 1 to 3 years old.

CONCLUSIONS:

For different age groups, Salmonella spp. and Escherchia coli were the most common pathogens of community-acquired GN bacteremia. For infants, Pseudomonas aeruginosa sepsis and resistant strain of Escherchia coli should be alert, and broader antibiotics should be considered.

Link to full text article here

Deep Learning Algorithm to Predict Need for Critical Care in Pediatric Emergency Departments.

Pediatric Emergency Care

Abstract

BACKGROUND AND OBJECTIVES:

Emergency department (ED) overcrowding is a national crisis in which pediatric patients are often prioritized at lower levels. Because the prediction of prognosis for pediatric patients is important but difficult, we developed and validated a deep learning algorithm to predict the need for critical care in pediatric EDs.

METHODS:

We conducted a retrospective observation cohort study using data from the Korean National Emergency Department Information System, which collected data in real time from 151 EDs. The study subjects were pediatric patients who visited EDs from 2014 to 2016. The data were divided by date into derivation and test data. The primary end point was critical care, and the secondary endpoint was hospitalization. We used age, sex, chief complaint, symptom onset to arrival time, arrival mode, trauma, and vital signs as predicted variables.

RESULTS:

The study subjects consisted of 2,937,078 pediatric patients of which 18,253 were critical care and 375,078 were hospitalizations. For critical care, the area under the receiver operating characteristics curve of the deep learning algorithm was 0.908 (95% confidence interval, 0.903-0.910). This result significantly outperformed that of the pediatric early warning score (0.812 [0.803-0.819]), conventional triage and acuity system (0.782 [0.773-0.790]), random forest (0.881 [0.874-0.890]), and logistic regression (0.851 [0.844-0.858]). For hospitalization, the deep-learning algorithm (0.782 [0.780-0.783]) significantly outperformed the other methods.

CONCLUSIONS:

The deep learning algorithm predicted the critical care and hospitalization of pediatric ED patients more accurately than the conventional early warning score, triage tool, and machine learning methods.

Link to article here

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EMA recommends restricting fluoroquinolone antibiotics to serious or life-threatening bacterial infections only

BMJ Best Practice, 5th July 2019

• The European Medicines Agency (EMA) has issued an alert recommending that fluoroquinolone antibiotics should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infection. [60]

• This follows a review of adverse effects associated with systemic and inhaled fluoroquinolones, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.
• The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these new restrictions. [55]
• The US Food and Drug Administration (FDA) issued a similar safety communication in 2016, restricting the use of fluoroquinolones in uncomplicated urinary tract infections. [56] In addition to these restrictions, the FDA has issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones. [57] [58]
• As a result of these restrictions fluoroquinolones are no longer recommended in this topic for children with uncomplicated urinary tract infections. Alternative antibiotics, such as a beta-lactam, are suggested instead. However, fluoroquinolone antibiotics are still recommended for children with complicated urinary tract infections.

Link to article here (Athens log in required for access to BMJ Best Practice)

A clinical scoring system to predict the need for extensive resuscitation at birth in very low birth weight infants

BMC Pediatrics 2019 19:197

Background

To analyze the risk factors for extensive cardiopulmonary resuscitation in the delivery room and develop a prediction model for outcomes in very low birth weight (VLBW) infants.

Methods

The sample was 5298 VLBW infants registered in the Korean neonatal network database from 2013 to 2015. Univariate and multivariate analyses were used to analyze the risk factors for extensive resuscitation. In addition, a multivariable model predicting extensive resuscitation in VLBW infants was developed.

Results

Univariate regression analysis of antenatal factors showed that lower gestational age, lower birth weight, birth weight less than third percentile, male sex, maternal hypertension, abnormal amniotic fluid volume, no antenatal steroid use, outborn, and chorioamnionitis were associated with extensive resuscitation at birth. Lower gestational age (25 to 27 gestational weeks, odds ratio [OR] and 95% confidence interval [CI]: 3.003 [1.977–4.562]; less than 25 gestational weeks, OR and 95% CI: 4.921 [2.926–8.276]), birth weight less than 1000 g (OR and 95% CI: 1.509 [1.013–2.246]), male sex (OR and 95% CI: 1.329 [1.002–1.761]), oligohydramnios (OR and 95% CI: 1.820 [1.286–2.575]), polyhydramnios (OR and 95% CI: 6.203 [3.185–12.081]), and no antenatal steroid use (OR and 95% CI: 2.164 [1.549–3.023]) were associated on multivariate regression analysis. The final prediction model for extensive resuscitation included gestational age, amniotic fluid, and antenatal steroid use. It presented a sensitivity of 0.795 and specificity of 0.575 in predicting extensive resuscitation at birth, corresponding to a score cut-off of 2. The area under the receiver operating characteristic curve was 0.738.

Conclusions

Lower gestational age, abnormal amniotic fluid volume, and no use of antenatal steroid in VLBW infants are important predictors of extensive resuscitation in the delivery room.

 

Link to full text article here