Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch‐up growth is the main focus and the recommended energy and protein requirements are much higher. In‐hospital rehabilitation of children with SAM is not always desirable or practical ‐ especially in rural settings ‐ and home‐based care can offer a better solution. Ready‐to‐use therapeutic food (RUTF) is a widely used option for home‐based rehabilitation, but the findings of our previous review were inconclusive.
Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With ‘quality of evidence’ we mean how confident we are that the particular finding represents the true effect. For example, ‘very low‐quality’ means we are very uncertain about the finding, ‘low‐quality evidence’ means the future research is very likely to change the finding, ‘moderate‐quality evidence’ means that future studies may change this finding, and ‘high‐quality evidence’ means that it is unlikely that future studies will change the finding.
Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence).
When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used.
Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.
Implications for practice
Standard ready‐to‐use therapeutic food (RUTF) probably improves recovery and may increase the rate of weight gain compared to alternative dietary approaches, but its effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet. However, its effects on mortality and the rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. The current limitations in the evidence base do not allow us to draw definitive conclusions regarding the applicability of these findings to children with severe acute malnutrition (SAM) with or without comorbidity and at different ages and levels of severity.
Early microbial colonization is a relevant aspect in human health. Altered microbial colonization patterns have been linked to an increased risk of non-communicable diseases (NCDs). Advances in understanding host-microbe interactions highlight the pivotal role of maternal microbiota on infant health programming. This birth cohort is aimed to characterize the maternal microbes transferred to neonates during the first 1000 days of life, as well as to identify the potential host and environmental factors, such as gestational age, mode of delivery, maternal/infant diet, and exposure to antibiotics, which affect early microbial colonization.
MAMI is a prospective mother-infant birth cohort in the Spanish-Mediterranean area. Mothers were enrolled at the end of pregnancy and families were follow-up during the first years of life. Maternal-infant biological samples were collected at several time points from birth to 24 months of life. Clinical and anthropometric characteristics and dietary information is available. Specific qPCR and 16S rRNA gene sequencing as well as short chain fatty acid (SCFAs) profile would be obtained. Multivariable models will be used to identy associations between microbiota and clinical and anthropometric data controlling for confounders.
MAMI would contribute to a better understanding of the interaction between diet, microbiota and host response in early life health programming, enabling new applications in the field of personalized nutrition and medicine.
The ideal asanguineous intravenous fluid for volume resuscitation in children is controversially debated and clinical practice guidelines are scarce. Administration of large amounts of normal saline has been associated with complications including hyperchloremic acidosis, dysnatremia, neurologic damage, and fatality. Aim
We examined the current practice of intravenous fluid and blood product administration in acutely ill and injured children among pediatric acute care physicians in Switzerland. Methods
For this descriptive, cross-sectional study, pediatric emergency departments, pediatric and neonatal intensive care units were surveyed by means of an online questionnaire. Results
Sixty of 66 departments and 47 of 87 participants returned the survey. Normal saline (NS) was most commonly administered (n = 42/46, 91.3%) and twice as many times as balanced electrolyte solutions (n = 20/46, 43.5%). The mean fluid volumes ranged from 7.9 to 19.1 mL/kg. Hypertonic saline/NS were selected most often for shock with severe head injury. Half of participants administered colloids (48.9%). Packed red blood cells (97.7%) and fresh frozen plasma (88.4%) were most frequently given blood products. Conclusion
There is a distinct practice variation in intravenous fluid and blood product administration in children in Switzerland. Although NS is most frequently given, we observed a trend toward the use of balanced electrolyte solutions. Prospective studies are warranted to compare NS with balanced electrolyte solution (BES) in the pediatric acute care setting. We suggest that pediatric fluid administration guidelines and mass transfusion protocols are implemented to standardize this frequent intervention and minimize complications.
To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice.
In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised.
In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy.
In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe.
Concussion in children and adolescents is a prevalent problem with implications for subsequent physical, cognitive, behavioral, and psychological functioning, as well as quality of life. While these consequences warrant attention, most concussed children recover well. This study aimed to determine what pre-injury, demographic, and injury-related factors are associated with optimal outcome (“wellness”) after pediatric concussion.
A total of 311 children 6-18 years of age with concussion participated in a longitudinal, prospective cohort study. Pre-morbid conditions and acute injury variables, including post-concussive symptoms (PCS) and cognitive screening (Standardized Assessment of Concussion, SAC), were collected in the emergency department, and a neuropsychological assessment was performed at 4 and 12 weeks post-injury. Wellness, defined by the absence of PCS and cognitive inefficiency and the presence of good quality of life, was the main outcome. Stepwise logistic regression was performed using 19 predictor variables.
41.5% and 52.2% of participants were classified as being well at 4 and 12 weeks post-injury, respectively. The final model indicated that children who were younger, who sustained sports/recreational injuries (vs. other types), who did not have a history of developmental problems, and who had better acute working memory (SAC concentration score) were significantly more likely to be well.
Determining the variables associated with wellness after pediatric concussion has the potential to clarify which children are likely to show optimal recovery. Future work focusing on wellness and concussion should include appropriate control groups and document more extensively pre-injury and injury-related factors that could additionally contribute to wellness.
Independent Child Trafficking Advocates (ICTAs) are an
independent source of advice for trafficked children and
somebody who can speak up on their behalf. What do ICTAs do?
• Support children to understand how social care,
immigration and criminal justice systems work
• Enable children’s voices to be heard.
• Provide advocacy, guidance and signposting to
• Ensure children are referred into the National Referral
• Support in keeping children safe and work toward the
prevention of re-trafficking
• Raise awareness and support professionals in their
work with trafficked children
The provision of ICTAs is covered by Section 48 of the Modern
Slavery Act 2015. An early adopter phase has been live since
January 2017 and the service has now gone live in the East
Midlands. ICTA provision in Nottinghamshire
A new model of ICTA provision provided through Barnardo’s is
being trialled in the East Midlands which continues to provide
intensive one-to-one support for children separated from
country and family. The model also introduces an expert ICTA
regional practice co-ordinator whose role will be to support
professionals working with internally trafficked, including UK
All overseas children identified as potentially
trafficked must be referred into Barnardo’s ICTA
Service for 1:1 support and the referral can be
made by any agency. UK children can be referred in
for specialist advice and support, including on the
This is in addition to the requirement to make a
referral to the National Referral Mechanism (NRM),
which is a framework for identifying victims of
human trafficking or modern slavery, outlined in
the local inter-agency procedures.
Archives of Disease in Childhood Published Online First: 08 May 2019
This commentary is part of a series on practical research ethics and focuses on ‘coproduction’. Increasingly, research funders are asking for coproduced research. Here, we clarify this concept and the opportunities and practical challenges it can bring to paediatric research. Our commentary complements Preston et al’s1 article on how to involve children and young people in research.
What is coproduction?
Coproduction is sometimes thought of as innovative, but it has been around for a good while—even longer if you look for the concept rather than the term itself. Practically, it means researchers and patients prioritising and/or designing research together from the start.
Coproduction theory argues that knowledge arises from lived experiences, as well as meticulous scientific work, which in turn is influenced and constructed by peoples’ lives and interactions: ‘the ways in which we know and represent the world are inseparable from the ways in which we choose to live in it’ (p. 2).2 In the health context, knowledge is created in the interaction between science and the social world outside the laboratory, the hospital and the university.
This understanding of knowledge informs the practice of coproduction, which we focus on here. Central to this is research as a shared enterprise.
A good example is the groundbreaking research funded by the French Muscular Dystrophy Association (AFM-Téléthon: http://www.afm-telethon.com/). AFM-Téléthon was established in 1958 by parents of children with muscular dystrophy and has remained a patient-led organisation and a leading funder of research into the cure and care of neuromuscular conditions. In this organisation, patients and parents hold several roles. They are political agents working to improve the treatment of muscular dystrophy. They are active collaborators shaping the research. They volunteer as participants in research studies. For example, when little was known about this condition, parents played an instrumental role in evidencing the impact of muscular dystrophy by filming their children over time. Parents and adult patients hold strategic positions within the organisation, directing what research is prioritised. Researchers are in charge of ensuring the scientific quality of the research, while patients and parents help shape the research so that it is relevant to their experiences, and their knowledge gained through those experiences.3
AFM-Téléthon is a story of teamwork by people with a shared interest (patients, parents, clinicians and researchers) and research outputs that could not have existed without this teamwork.3 This is coproduction.