Tag Archives: BMJ

Towards developing an ethical framework for decision making in long-term ventilation in children – BMJ

Published 5th June 2018

The use of long-term ventilation (LTV) in children is growing in the UK and worldwide. This reflects the improvement in technology to provide LTV, the growing number of indications in which it can be successfully delivered and the acceptability of LTV to families and children. In this article, we discuss the various considerations to be made when deciding to initiate or continue LTV, describe the process that should be followed, as decided by a consensus of experienced physicians, and outline the options available for resolution of conflict around LTV decision making. We recognise the uncertainty and hope provided by novel and evolving therapies for potential disease modification. This raises the question of whether LTV should be offered to allow time for a therapy to be trialled, or whether the therapy is so unlikely to be effective, LTV would simply prolong suffering. We put this consensus view forward as an ethical framework for decision making in children requiring LTV.

 Link to article page here

Pneumococcal haemolytic uraemic syndrome in the postvaccine era – BMJ Archives of disease in childhood


Objective Pneumococcal infection is a leading cause of haemolytic uraemic syndrome (HUS) and is potentially vaccine preventable. Published data suggest high mortality and poor renal outcomes. The introduction of the 7-valent pneumococcal conjugate vaccine (PCV) has seen the emergence of disease caused by non-vaccine strains, particularly 19A. We sought to describe serotype prevalence and outcomes, particularly after the introduction of the 13-valent PCV.

Design and setting We performed a retrospective chart review, using hospital medical records to identify cases of HUS in a tertiary paediatric hospital in Australia over a 20-year period (January 1997–December 2016). Associated pneumococcal infection was identified, and serotype data were categorised according to vaccine era: prevaccine (January 1997–December 2004), PCV7 (January 2005–June 2011) and PCV13 (July 2011–December 2016).

Results We identified 66 cases of HUS. Pneumococcal infection was proven in 11 cases, representing 4% (1/26) of cases prior to the introduction of PCV7, 20% (3/15) in the PCV7 era and 28% (7/25) in the PCV13 era. Subtype 19A was the most prevalent pneumococcal serotype (6/11). All four patients who received PCV7 were infected with a non-vaccine serotype. Four of the five patients who received PCV13 were classed as vaccine failures. Median follow-up was 14 (range 1–108) months. Chronic kidney disease was the most common complication (4/7). We observed no mortality, neurological sequelae or progression to end-stage kidney disease.

Conclusions Serotype 19A is most commonly associated with pneumococcal HUS, despite the introduction of the 13-valent vaccine. Chronic kidney disease is a significant complication of pneumococcal HUS.

Link to article here

The case for child health – BMJ Archives of Disease in Childhood

There is unlikely to be anyone in the world who would not be supportive of good health for children. Yet, child health is struggling. A year ago, the UK Royal College of Paediatrics and Child Health (RCPCH) published ‘State of Child Health’.  We found nearly one in five children in the UK to be living in poverty and troubling disparity between the health of children in the UK and many similar nations in Europe. A year on and the RCPCH has issued a series of scorecards, showing what change there has been in the nations of the UK. Individual nations, chiefly Scotland and Wales, have made commendable progress. However, what emerges is a picture of piecemeal policy, not the astute, visionary, integrated strategy so sorely needed. Current UK metrics remain stark; child mortality is higher than in many comparable countries; about a third of 10-year-old children are overweight or obese; a quarter of 5-year-olds have tooth decay; self-harm among girls aged 13–16 has risen by two-thirds in the last 3 years; compared with 2015–2016, there has been a decrease in 2016–2017 in coverage of four of the six routine vaccinations at age 1 and 2 years, and coverage for Measles, Mumps and Rubella decreased for the third year in a row, following previous annual increases over 9 years. Child poverty is at its highest since 2010 and compared with the overall population, children are more likely to be living in a low-income household.

Poor child health has very serious wider implications. Over 80% of obese children will remain obese as they grow older, and this will lead to them losing about 15–20 healthy-life years as adults. Teenagers, even if only at the upper end of normal body weight, have a substantially increased risk of premature death in adulthood. Air pollution experienced in fetal life, infancy and early childhood scars lungs for life, increasing the likelihood of chronic respiratory conditions in old age. Adverse childhood experiences increase the risk of health-harming behaviours and non-communicable diseases in later life. These are classic examples of societies fouling their own nests, by failing to see the destructive consequences for everyone of not safeguarding child health. The moral case for better child health is self-evident, as is that vested in self-interest, but these aside, there is a powerful economic case too. Governments need populations that are healthy, economically active and not crippled by chronic illness in old age. This means placing health foremost, especially during early development when life-long trajectories of well-being are set.

Link to report page here

BMJ Article: Clinical characteristics of children evaluated for suspected pulmonary embolism with D-dimer testing



Background We sought to determine clinical variables in children tested for suspected pulmonary embolism (PE) that predict PE+ outcome for the development of paediatric PE prediction rule.

Methods Data were collected by query of a laboratory database for D-dimer from January 2004 to December 2014 for a large multicentre hospital system and the radiology database for pulmonary vascular imaging in children aged 5–17. Using explicit, predefined methods, trained abstractors, determined if D-dimer was sent in the evaluation of PE and then recorded predictor data which was tested for association with PE+ outcome using univariate techniques.

Results D-dimer was ordered in 526 children for clinical suspicion of PE. Thirty-four of 526 were PE+ (6.4%, 95% CI 4.3% to 8.7%). The radiology database identified 17 additional patients with PE (n=51 PE+ total). Children evaluated for PE were primarily in the ED setting (80%), teenagers (88%) and 2:1 female:male. Children with PE had higher mean heart and higher respiratory rate and a lower pulse oximetry and haemoglobin concentration. On univariate analysis, five conditions were more frequent in PE+ compared with no PE: surgery, central line, limb immobility, prior PE or deep vein thrombosis and cancer.

Conclusions The rate of PE diagnosis in children with D-dimer was 6.4%, similar to that seen in adults; most children with PE are over 13 years and had clinical predictors known to increase probability of PE in symptomatic adults. Future studies should use these criteria to develop a clinical decision rule for PE in children.

Link to full article here