Showing papers in "Archives of Disease in Childhood in 2018"

Cognitive trajectories from infancy to early adulthood following birth before 26 weeks of gestation: a prospective, population-based cohort study.

Abstract: Objective To determine the trajectory of cognitive test scores from infancy to adulthood in individuals born extremely preterm compared with term-born individuals. Design A prospective, population-based cohort study. Setting 276 maternity units in the UK and Ireland. Patients 315 surviving infants born less than 26 completed weeks of gestation recruited at birth in 1995 and 160 term-born classroom controls recruited at age 6. Main outcome measures Bayley Scales of Infant Development-Second Edition (age 2.5); Kaufman Assessment Battery for Children (ages 6/11); Wechsler Abbreviated Scale of Intelligence-Second Edition (age 19). Results The mean cognitive scores of extremely preterm individuals over the period were on average 25.2 points below their term-born peers (95% CI −27.8 to −22.6) and remained significantly lower at every assessment. Cognitive trajectories in term-born boys and girls did not differ significantly, but the scores of extremely preterm boys were on average 8.8 points below those of extremely preterm girls (95% CI −13.6 to −4.0). Higher maternal education elevated scores in both groups by 3.2 points (95% CI 0.8 to 5.7). Within the extremely preterm group, moderate/severe neonatal brain injury (mean difference: −10.9, 95% CI −15.5 to −6.3) and gestational age less than 25 weeks (mean difference: −4.4, 95% CI −8.4 to −0.4) also had an adverse impact on cognitive function. Conclusions There is no evidence that impaired cognitive function in extremely preterm individuals materially recovers or deteriorates from infancy through to 19 years. Cognitive test scores in infancy and early childhood reflect early adult outcomes.

G292(P) Estimates of the burden of group b streptococcal disease worldwide for pregnant women, stillbirths and children

Abstract: Background We aimed to estimate, for the first time, the global burden of Group B Streptococcus (GBS), with regards to invasive disease in infants, as well as in pregnant and postpartum women, and fetal infection/stillbirth. Intrapartum antibiotic prophylaxis (IAP) is currently used for prevention of early onset infant disease in high-income contexts, but is difficult to implement globally, and may contribute to antimicrobial resistance. Maternal GBS vaccines are in development. Methods For 2015 live births, we used data from systematic reviews and meta-analyses (presented in separate papers in this GBS supplement) and a compartmental model to estimate: exposure to maternal GBS colonisation, cases of infant invasive GBS disease, deaths, and disabilities. We applied incidence or prevalence data to estimate cases of maternal and fetal infection/stillbirth, and infants with invasive GBS disease presenting with neonatal encephalopathy (NE). We applied risk ratios to estimate numbers of preterm births attributable to GBS. Uncertainty was also estimated. Worldwide in 2015, we estimated 2 05 000 (uncertainty range [UR], 101000–327000) infants with early-onset disease and 1 14 000 (UR, 44000–326000) with late-onset disease, of whom a minimum of 7000 (UR, 0–19000) presented with neonatal encephalopathy. There were 90 000 (UR, 36000–169000) deaths in infants Conclusions Our conservative estimates suggest that GBS is a leading contributor to adverse maternal and newborn outcomes, with at least 4 09 000 (UR, 144000–573000) maternal/fetal/infant cases and 1 47 000 (UR, 47000–273000) stillbirths and infant deaths annually. An effective GBS vaccine could reduce disease in the mother, the fetus, and the infant. Acknowledgement Additional authors include H Blencowe (1), S Cousens (1), CJ Baker, L Bartlett, C Cutland, MGGravett, PT Heath, M Ip, K Le Doare, SA Madhi, CE Rubens, SK Saha, SJ Schrag, A Sobanjo-ter Meulen, J Vekemans

Melatonin for the management of sleep problems in children with neurodevelopmental disorders: a systematic review and meta-analysis.

Abstract: Importance Children with neurodevelopmental disorders have a higher prevalence of sleep disturbances. Currently there is variation in the use of melatonin; hence, an up-to-date systematic review is indicated to summarise the current available evidence. Objective To determine the efficacy and safety of melatonin as therapy for sleep problems in children with neurodevelopmental disorders. Data sources and study selections PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were searched from inception up to January 2018. Two reviewers performed data assessment and extraction. We assessed randomised controlled trials that compared melatonin with placebo or other intervention for the management of sleep disorders in children ( Data extraction and synthesis We identified 3262 citations and included 13 studies in this meta-analysis. Main outcomes Main outcomes included total sleep time, sleep onset latency, frequency of nocturnal awakenings and adverse events. Results Thirteen randomised controlled trials (n=682) met the inclusion criteria. A meta-analysis of nine studies (n=541) showed that melatonin significantly improved total sleep time compared with placebo (mean difference (MD)=48.26 min, 95% CI 36.78 to 59.73, I 2 =31%). In 11 studies (n=581), sleep onset latency improved significantly with melatonin use (MD=−28.97, 95% CI −39.78 to −18.17). No difference was noted in the frequency of nocturnal awakenings (MD=−0.49, 95% CI −1.71 to 0.73). No medication-related serious adverse event was reported. Conclusion Melatonin appeared safe and effective in improving sleep in the studied children. The overall quality of the evidence is limited due to heterogeneity and inconsistency. Further research is needed.

Assessment and support of children and adolescents with gender dysphoria

Abstract: There has been a large increase in the number of children and adolescents who question conventional gender expectations and seek recognition and acceptance of their gender diversity, wishing to develop a body that is congruent with their gender feelings.1 Professionals may be unsure how best to provide supportive care, how to access the national Gender Identity Development Service (GIDS) for children and adolescents, or how to deal with a transgender young person presenting with another clinical problem unrelated to their gender transition. Faced with very distressed young people, they may feel under pressure to initiate physical intervention without consultation with psychosocial colleagues. It is important that all professionals are aware of the care pathway for transgender children that may be of relevance in a range of paediatric settings. The purpose of this practice review is to present an up-to-date perspective on the care of transgender children and adolescents to guide management and to enable the provision of a practical, evidence-based approach to their support. Gender atypical behaviour is common among young children and can be part of general development. It is difficult to determine the exact incidence and prevalence of more intense and long-standing gender dysphoria (GD) in the UK and elsewhere as the total number of children and young people referred to the GIDS has risen exponentially since 20112 (figure 1). A striking feature of this increase is the large proportion of birth-registered females from 2011 onwards. This increase and the change in sex ratio is also seen in other countries.1 The reasons are not fully explicable and a number of questions arise. Is this increase due mostly to the greater tolerance of gender-diverse expression in westernised society? Is male status still regarded as preferable? Are all referrals to a specialist service appropriate and do all these young …

Toxicity of long-term use of proton pump inhibitors in children

Abstract: Proton pump inhibitor (PPI) use is becoming increasingly common. Although the toxicity profiles of PPIs are not well understood particularly in children, PPIs have been associated with increased risks of gastrointestinal and respiratory tract infection, vitamin B12 deficiency, hypomagnesaemia, bone fractures, and rebound hyperacidity after discontinuation. Prescribers should take into account that PPI uses pose toxicity risks, which remain to be fully characterised in infants and children.

Pharmacokinetic studies in children: recommendations for practice and research.

Abstract: Optimising the dosing of medicines for neonates and children remains a challenge. The importance of pharmacokinetic (PK) and pharmacodynamic (PD) research is recognised both in medicines regulation and paediatric clinical pharmacology, yet there remain barriers to undertaking high-quality PK and PD studies. While these studies are essential in understanding the dose-concentration-effect relationship and should underpin dosing recommendations, this review examines how challenges affecting the design and conduct of paediatric pharmacological studies can be overcome using targeted pharmacometric strategies. Model-based approaches confer benefits at all stages of the drug life-cycle, from identifying the first dose to be used in children, to clinical trial design, and optimising the dosing regimens of older, off-patent medications. To benefit patients, strategies to ensure that new PK, PD and trial data are incorporated into evidence-based dosing recommendations are needed. This review summarises practical strategies to address current challenges, particularly the use of model-based (pharmacometric) approaches in study design and analysis. Recommendations for practice and directions for future paediatric pharmacological research are given, based on current literature and our joint international experience. Success of PK research in children requires a robust infrastructure, with sustainable funding mechanisms at its core, supported by political and regulatory initiatives, and international collaborations. There is a unique opportunity to advance paediatric medicines research at an unprecedented pace, bringing the age of evidence-based paediatric pharmacotherapy into sight.

Fine particulate pollution and asthma exacerbations

Abstract: Objective As the results from epidemiological studies about the impact of outdoor air pollution on asthma in children are heterogeneous, our objective was to investigate the association between asthma exacerbation in children and exposure to air pollutants. Methods A database of 1 264 585 paediatric visits during the 2010–2015 period to the emergency rooms from 20 emergency departments (EDs) of ‘Assistance Publique Hopitaux de Paris (APHP)’, the largest hospital group in Europe, was used. A total of 47 107 visits were classified as asthma exacerbations. Concentration of air pollutants (nitrogen dioxide, ozone, fine particulate matter (PM) with an aerodynamic diameter smaller than 10 µm (PM 10 ) and 2.5 µm (PM 2.5 )), as well as meteorological data, evolution of respiratory syncytial virus infection and pollen exposition, were collected on an hourly or daily basis for the same period using institutional databases. To assess the association between air pollution and asthma, mixed-effects quasi-Poisson regression modelling was performed. Results The only compound independently associated with ED visits for asthma was PM 2.5 (P −4 ). The association between asthma exacerbation and PM 2.5 was not linear, and a sigmoid function described the relationshipsatisfactorily. PM 2.5 concentration, which gives half the maximum effect, was estimated at 13.5 µg/m 3 . Conclusions We found an association between daily asthma exacerbation in paediatric visits to the ED and fine particulate air pollutants.

Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda

Abstract: Objective Mortality rates from birth asphyxia in low-income countries remain high. Face mask ventilation (FMV) performed by midwives is the usual method of resuscitating neonates in such settings but may not always be effective. The i-gel is a cuffless laryngeal mask airway (LMA) that could enhance neonatal resuscitation performance. We aimed to compare LMA and face mask (FM) during neonatal resuscitation in a low-resource setting. Setting Mulago National Referral Hospital, Kampala, Uganda. Design This prospective randomised clinical trial was conducted at the labour ward operating theatre. After a brief training on LMA and FM use, infants with a birth weight >2000 g and requiring positive pressure ventilation at birth were randomised to resuscitation by LMA or FM. Resuscitations were video recorded. Main outcome measures Time to spontaneous breathing. Results Forty-nine (24 in the LMA and 25 in the FM arm) out of 50 enrolled patients were analysed. Baseline characteristics were comparable between the two arms. Time to spontaneous breathing was shorter in LMA arm than in FM arm (mean 153 s (SD±59) vs 216 s (SD±92)). All resuscitations were effective in LMA arm, whereas 11 patients receiving FM were converted to LMA because response to FMV was unsatisfactory. There were no adverse effects. Conclusion A cuffless LMA was more effective than FM in reducing time to spontaneous breathing. LMA seems to be safe and effective in clinical practice after a short training programme. Its potential benefits on long-term outcomes need to be assessed in a larger trial. Clinical trial registry This trial was registered in https://clinicaltrials.gov, with registration number NCT02042118.

Children with life-limiting conditions in paediatric intensive care units: a national cohort, data linkage study

Abstract: Objective To determine how many children are admitted to paediatric intensive care unit (PICU) with life-limiting conditions (LLCs) and their outcomes. Design National cohort, data-linkage study. Setting PICUs in England. Patients Children admitted to a UK PICU (1 January 2004 and 31 March 2015) were identified in the Paediatric Intensive Care Audit Network dataset. Linkage to hospital episodes statistics enabled identification of children with a LLC using an International Classification of Diseases (ICD10) code list. Main outcome measures Random-effects logistic regression was undertaken to assess risk of death in PICU. Flexible parametric survival modelling was used to assess survival in the year after discharge. Results Overall, 57.6% (n=89 127) of PICU admissions and 72.90% (n=4821) of deaths in PICU were for an individual with a LLC. The crude mortality rate in PICU was 5.4% for those with a LLC and 2.7% of those without a LLC. In the fully adjusted model, children with a LLC were 75% more likely than those without a LLC to die in PICU (OR 1.75 (95% CI 1.64 to 1.87)). Although overall survival to 1 year postdischarge was 96%, children with a LLC were 2.5 times more likely to die in that year than children without a LLC (OR 2.59 (95% CI 2.47 to 2.71)). Conclusions Children with a LLC accounted for a large proportion of the PICU population. There is an opportunity to integrate specialist paediatric palliative care services with paediatric critical care to enable choice around place of care for these children and families.

Family Integrated Care: changing the culture in the neonatal unit

Abstract: Family Integrated Care (FIC) is a new model of neonatal care which supports parents to be primary caregivers, as partners with the clinical team.1 The inspiration for FIC comes from lower resource settings where families provide care through necessity rather than choice.2 3 This approach has been adapted for modern neonatal intensive care by pioneering FIC teams in Canada, Scandinavia and the UK. Trials in preterm infants have demonstrated improved rate of weight gain, reduced parental stress and shorter length of stay.4 5 By supporting and combining the benefits of breast feeding, kangaroo mother care (KMC) and parental presence, FIC may have even greater long-term benefits for infants and their families.6 FIC builds on the foundations of Family-Centred Care, a well-established approach with accepted standards supported by Unicef and the neonatal charity Bliss.7 8 FIC takes parental involvement to a new level placing families at the centre of care and empowering them as primary caregivers (table 1). View this table: Table 1 Comparison of FCC and FIC at RHC, Glasgow Though the concept of FIC is intuitive and the potential benefits compelling, delivering this model of care may be challenging. We took on this challenge in our neonatal unit, the largest unit in Scotland with approximately 1000 admissions per year and over 200 staff. Our patients include extremely preterm infants as well as those requiring specialist medical and surgical care including extracorporeal membrane oxygenation (ECMO). Implementing FIC in a unit of this size and diversity has its own specific challenges, but has been hugely rewarding. In this article, we share our approach and lessons learnt, and describe the transformative effect on families and staff. FIC means not just physically involving families, but equally importantly changing the culture and relationships with staff.9 10 Staff engagement is potentially the greatest challenge. FIC requires a …

Live attenuated influenza vaccine (LAIV): recent effectiveness results from the USA and implications for LAIV programmes elsewhere

Abstract: The USA has a long-standing paediatric influenza vaccination programme, including use of live attenuated influenza vaccine (LAIV). Following US evidence of apparent lack of vaccine effectiveness (VE) of LAIV in 2015/2016, particularly against A(H1N1)pdm09, the USA suspended the use of LAIV in the 2016/2017 season. The UK introduced LAIV for children in 2013/2014 and Finland in 2015/2016. Both countries have since been closely monitoring programme performance. In 2015/2016, the UK and Finland, unlike the USA, found evidence of significant VE of LAIV against laboratory-confirmed influenza. Several studies, however, reported relatively lower VE of LAIV against A(H1N1)pdm09 infection compared with inactivated influenza vaccine, although not for A(H3N2) or B. The reasons for these apparent differences remain under investigation. Both the UK and Finland continue to recommend the use of LAIV in children for the 2017/2018 season and are intensifying further monitoring of their childhood programmes against a range of end-points.

Abusive head trauma and the triad: a critique on behalf of RCPCH of 'Traumatic shaking: the role of the triad in medical investigations of suspected traumatic shaking'.

Abstract: The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) has recently published what they purported to be a systematic review of the literature on 'isolated traumatic shaking' in infants, concluding that 'there is limited evidence that the so-called triad (encephalopathy, subdural haemorrhage, retinal haemorrhage) and therefore its components can be associated with traumatic shaking'. This flawed report, from a national body, demands a robust response. The conclusions of the original report have the potential to undermine medico-legal practice. We have conducted a critique of the methodology used in the SBU review and have found it to be flawed, to the extent that children's lives may be put at risk. Thus, we call on this review to be withdrawn or to be subjected to international scrutiny.

Approaching quality improvement at scale: a learning health system approach in Kenya.

Abstract: In 2002, we identified major shortcomings in the management of sick newborns and children at the first referral or district hospital level in Kenya.1 Failure in the dissemination of knowledge and skills (and thus of translation of evidence informed policy) was a fundamental problem. To address this challenge between 2005 and 2012 we developed, implemented and studied: 1. the national evidence-based clinical practice guidelines in the form of protocol booklets that can be disseminated at scale (and have recently described how this process matured over more than a decade)2 3; 2. the Emergency Triage Assessment and Treatment plus Admission Care course4 (that has been updated over time); 3. the standardised medical record forms including checklists of key symptoms and signs that are key elements of the protocols and help define the nature and severity of common illnesses5 (also updated over time). The effect of implementing these tools as part of a multifaceted strategy including outreach, audit and feedback to improve guideline adherence was tested between 2006 and 2009 and proven effective in a cluster randomised trial.6 In recent years, we have been able to document wider adoption of the protocols, training and record forms (including uptake outside Kenya) with some evidence of improvements in the quality of district hospital care, measured as adherence to guidelines, beyond centres directly engaged in research.7–10 In the last 4 years (2013–2017) we have adopted a new strategy, building on these earlier experiences, to continue efforts to improve hospital care for children in Kenya with a focus on adoption of agreed practice guidelines and uptake of basic technologies. At the heart of this new strategy is a Clinical Information Network (CIN). Here we outline the rationale for and philosophy of the CIN and how we suggest it helps Kenya as a low-income country (LIC) meet …

Diagnostic delay in Canadian children with inflammatory bowel disease is more common in Crohn’s disease and associated with decreased height

Abstract: Objectives To determine time to diagnosis in a paediatric inflammatory bowel disease (IBD) cohort and the relative contribution of the component intervals, and to identify factors associated with diagnostic delay. Design Prospective cohort study Setting Single-centre study including children with incident IBD at the Hospital for Sick Children diagnosed between December 2013 and December 2015. Interventions Time to diagnosis and its subintervals were determined and patient, disease and institutional factors were tested for associations. Results Among 111 children, the median overall time to diagnosis was 4.5 (IQR 2.1–8.8) months. Time to diagnosis was longer in Crohn’s disease (CD) than ulcerative colitis (UC) (median 6.8 (IQR 2.9–12.5) vs 2.4 (IQR 1.3–5.3) months) and patients with isolated small bowel disease. Twenty per cent of patients were diagnosed≥1 year after symptom onset (86% CD, 14% UC, p=0.003). Time from symptom onset to gastroenterology referral was the greatest contributor to overall time to diagnosis (median 2.9 (IQR 1.6–8.2) months). Height impairment was independently associated with diagnostic delay (OR 0.59, p=0.02, for height-for-age z-score (HAZ), signifying almost 70% increased odds of delay for every 1 SD decrease in HAZ). This height discrepancy persisted 1 year after diagnosis. Bloody diarrhoea was protective against delay (OR 0.28, p=0.02). The subinterval from referral to diagnosis was shorter in patients with laboratory abnormalities, particularly hypoalbuminaemia. Conclusions Diagnostic delay was more common in CD and associated with height impairment that persisted 1 year after presentation. The greatest contributor to time to diagnosis was time from symptom onset to referral.

Prevention of rickets and osteomalacia in the UK: political action overdue.

Abstract: The consequences of vitamin D and dietary calcium deficiency have become a huge public health concern in the UK. The burden of disease from these deficiencies includes rickets, and hypocalcaemic seizures, dilated cardiomyopathy and mostly occult myopathy and osteomalacia. The increasing burden of the disease is intrinsically linked to ethnicity and the population demographic changes in the UK. Three facts have led to the resurfacing of the English disease: (1) the UK has no ultraviolet sunlight for at least 6 months of the year, (2) dark skin produces far less vitamin D than white skin per unit ultraviolet light exposure, and (3) non-European Union immigration over the last century. To date, the UK government demonstrates incomplete understanding of these three facts, and its failure to adjust its prevention programmes to changing demographics is endangering the health and life of UK residents with dark skin, of whom infants are the most vulnerable. Establishing accountability through the implementation of monitored antenatal and infantile supplementation programmes and mandatory food fortification is overdue.

Patterns of pain over time among children with juvenile idiopathic arthritis.

Abstract: Objectives Pain is a very common symptom of juvenile idiopathic arthritis (JIA). Disease activity alone cannot explain symptoms of pain in all children, suggesting other factors may be relevant. The objectives of this study were to describe the different patterns of pain experienced over time in children with JIA and to identify predictors of which children are likely to experience ongoing pain. Methods This study used longitudinal-data from patients (aged 1–16 years) with new-onset JIA. Baseline and up to 5-year follow-up pain data from the Childhood Arthritis Prospective Study (CAPS) were used. A two-step approach was adopted. First, pain trajectories were modelled using a discrete mixture model. Second, multinomial logistic regression was used to determine the association between variables and trajectories. Results Data from 851 individuals were included (4 years, median follow-up). A three-group trajectory model was identified: consistently low pain (n=453), improved pain (n=254) and consistently high pain (n=144). Children with improved pain or consistently high pain differed on average at baseline from consistently low pain. Older age at onset, poor function/disability and longer disease duration at baseline were associated with consistently high pain compared with consistently low pain. Early increases in pain and poor function/disability were also associated with consistently high pain compared with consistently low pain. Conclusions This study has identified routinely collected clinical factors, which may indicate those individuals with JIA at risk of poor pain outcomes earlier in disease. Identifying those at highest risk of poor pain outcomes at disease onset may enable targeted pain management strategies to be implemented early in disease thus reducing the risk of poor pain outcomes.

Treatment and management of children with haemolytic uraemic syndrome.

Abstract: Haemolytic uraemic syndrome (HUS), comprising microangiopathic haemolytic anaemia, thrombocytopaenia and acute kidney injury, remains the leading cause of paediatric intrinsic acute kidney injury, with peak incidence in children aged under 5 years. HUS most commonly occurs following infection with Shiga toxin-producing Escherichia coli (STEC-HUS). Additionally, HUS can occur as a result of inherited or acquired dysregulation of the alternative complement cascade (atypical HUS or aHUS) and in the setting of invasive pneumococcal infection. The field of HUS has been transformed by the discovery of the central role of complement in aHUS and the dawn of therapeutic complement inhibition. Herein, we address these three major forms of HUS in children, review the latest evidence for their treatment and discuss the management of STEC infection from presentation with bloody diarrhoea, through to development of fulminant HUS.

Liver transplantation in children: state of the art and future perspectives

Abstract: In this review, we provide a state of the art of liver transplantation in children, as the procedure is now carried out for more than 30 years and most of our paediatric colleagues are managing these patients jointly with liver transplant centres. Our goal for this article is to enhance the understanding of the liver transplant process that a child and his family goes through while explaining the surgical advances and the associated complications that could happen in the immediate or long-term follow-up. We have deliberately introduced the theme that 'liver transplant is a disease' and 'not a cure', to emphasise the need for adherence with immunosuppression, a healthy lifestyle and lifelong medical follow-up.

Question 1: Is it safe to use ivermectin in children less than five years of age and weighing less than 15 kg?

Abstract: You are working in a remote clinic in Northern Australia and see an 18-month-old girl (weight 10 kg) who presents with a pruritic rash on her extremities. She has a history of persistent scabies despite multiple treatments with topical permethrin 5%. You diagnose her with scabies and although you are aware that oral ivermectin is used for scabies in children over 5 years and weighing more than 15 kg, you consider whether it would be safe to use ivermectin for the treatment of scabies in this child. In a child less than 5 years of age and less than 15 kg (patient), is oral ivermectin (intervention) a safe treatment option (outcome)? In May 2017, the Ovid interface was used to search English-language articles in MEDLINE (1946 to current) and EMBASE (1974 to present). The following search terms were used: ivermectin AND off-label use OR ivermectin* AND newborn* or neonat* or infan* or pre-school* or preschool* or child* or pediatric* or paediatric*. The search identified a total of 610 articles which were reviewed by a single author (AW). Of these, 30 studies were identified which described the use of ivermectin in children less than 5 years old and, where weight was specified, less than 15 kg.1–30 One study had sufficient demographic and safety data in the original manuscript to fulfil the inclusion criteria.1 For the remaining 29 articles, we attempted to contact the corresponding authors to request further demographic and safety data to confirm inclusion criteria and received 13 responses. In total, nine studies were included in this review (table 1). No additional studies were identified following the review of the references from all articles. View this table: Table 1 Summary of evidence Ivermectin has been successfully used as part of large mass drug administration programmes for treatment of onchocerciasis31 32 and lymphatic filariasis.33 It is registered for use …

Perinatal outcomes following Helping Babies Breathe training and regular peer–peer skills practice among village midwives in Sudan

Abstract: Background Over 80% of deliveries in Sudan occur in rural areas, attended by village midwives (VMWs). Objective To determine the impact of Helping Babies Breathe training and regular peer–peer skills practice (HBBT +RPPSP ) on VMW resuscitation practices and outcomes. Methods In a prospective community-based intervention study, 71/82 VMWs, reporting to six East Nile rural medical centres, with previous experience in community health research, consented to HBBT +RPPSP . Outcomes included changes in the resuscitation practices, fresh stillbirths (FSB) and early neonatal deaths Results There were 1350 and 3040 deliveries before and after HBBT +RPPSP , respectively, with no significant differences between the two cohorts regarding maternal age, education or area of birth. Drying of the newborn increased almost tenfold (8.4%, n=113 to 74.9%, n=1011) while suctioning of the mouth/nose decreased fivefold (80.3%, n=2442 to 14.4%, n=437) following HBBT +RPPSP . Pre-HBBT +RPPSP 9/18 (50%) newborns who had mouth-to-mouth ventilation died, compared with 13/119 (11%) who received bag-mask ventilation post-HBBT +RPPSP . Excluding 11 macerated fetuses, there were 55 perinatal deaths: 14 FSB/18 ENND (6 months pre-HBBT +RPPSP ) and 10 FSB/13 ENND (18 months post-HBBT +RPPSP ). FSB rates decreased from 10.5 to 3.3 per 1000 births ((χ 2 )=8.6209, p=0.003), while ENND rates decreased from 13.5 to 4.3 per 1000 live births ((χ 2 )=10.9369, p=0.001) pre-HBBT +RPPSP and post-HBBT +RPPSP , respectively. Conclusion In a selected group of VMWs, HBBT +RPPSP was associated with improvements in newborn resuscitation and perinatal outcomes. HBBT +RPPSP could have immense benefits if propagated nationally to all 17 000 VMWs in Sudan.

Managing problematic severe asthma: beyond the guidelines

Abstract: This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients' asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.

Health professionals’ and coroners’ views on less invasive perinatal and paediatric autopsy: a qualitative study

Abstract: Objective To assess health professionals’ and coroners’ attitudes towards non-minimally and minimally invasive autopsy in the perinatal and paediatric setting. Methods A qualitative study using semistructured interviews. Data were analysed thematically. Results Twenty-five health professionals (including perinatal/paediatric pathologists and anatomical pathology technologists, obstetricians, fetal medicine consultants and bereavement midwives, intensive care consultants and family liaison nurses, a consultant neonatologist and a paediatric radiologist) and four coroners participated. Participants viewed less invasive methods of autopsy as a positive development in prenatal and paediatric care that could increase autopsy rates. Several procedural and psychological benefits were highlighted including improved diagnostic accuracy in some circumstances, potential for faster turnaround times, parental familiarity with imaging and laparoscopic approaches, and benefits to parents and faith groups who object to invasive approaches. Concerns around the limitations of the technology such not reaching the same levels of certainty as full autopsy, unsuitability of imaging in certain circumstances, the potential for missing a diagnosis (or misdiagnosis) and de-skilling the workforce were identified. Finally, a number of implementation issues were raised including skills and training requirements for pathologists and radiologists, access to scanning equipment, required computational infrastructure, need for a multidisciplinary approach to interpret results, cost implications, equity of access and acceptance from health professionals and hospital managers. Conclusion Health professionals and coroners viewed less invasive autopsy as a positive development in perinatal and paediatric care. However, to inform implementation a detailed health economic analysis and further exploration of parental views, particularly in different religious groups, are required.

Research priority setting in childhood chronic disease: a systematic review

Abstract: Objective To evaluate research priority setting approaches in childhood chronic diseases and to describe the priorities of stakeholders including patients, caregivers/families and health professionals. Design We conducted a systematic review of MEDLINE, Embase, PsycINFO and CINAHL from inception to 16 October 2016. Studies that elicited stakeholder priorities for paediatric chronic disease research were eligible for inclusion. Data on the prioritisation process were extracted using an appraisal checklist. Generated priorities were collated into common topic areas. Results We identified 83 studies (n=15 722). Twenty (24%) studies involved parents/caregivers and four (5%) children. The top three health areas were cancer (11%), neurology (8%) and endocrine/metabolism (8%). Priority topic areas were treatment (78%), disease trajectory (48%), quality of life/psychosocial impact (48%), disease onset/prevention (43%), knowledge/self-management (33%), prevalence (30%), diagnostic methods (28%), access to healthcare (25%) and transition to adulthood (12%). The methods included workshops, Delphi techniques, surveys and focus groups/interviews. Specific methods for collecting and prioritising research topics were described in only 60% of studies. Most reviewed studies were conducted in high-income nations. Conclusions Research priority setting activities in paediatric chronic disease cover many discipline areas and have elicited a broad range of topics. However, child/caregiver involvement is uncommon, and the methods often lack clarity. A systematic and explicit process that involves patients and families in partnership may help to inform a more patient and family-relevant research agenda in paediatric chronic disease.

Do cash transfer programmes yield better health in the first year of life? A systematic review linking low-income/middle-income and high-income contexts.

Abstract: Introduction Decades of research unequivocally demonstrates that no matter the society, socioeconomic resources are perhaps the most fundamental determinants of health throughout the life course, including during its very earliest stages. As a result, societies have implemented ‘cash transfer’ programmes, whichprovide income supplementation to reduce socioeconomic disadvantage among the poorest families with young children. Despite this being a common approach of societies around the world, research on effects of these programmes in low-income/middle-income countries, and those in high-income countries has been conducted as if they are entirely distinct phenomena. In this paper, we systematically review the international literature on the association between cash transfer programmes and health outcomes during the first year of life. Methods We conducted a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Using a variety of relevant keywords, we searched MEDLINE, EMBASE, CINAHL, Cochrane Reviews, EconLit and Social Sciences Citations Index. Results Our review yielded 14 relevant studies. These studies suggested cash transfer programmes that were not attached to conditions tended to yield positive effects on outcomes such as birth weight and infant mortality. Programmes that were conditional on use of health services also carried positive effects, while those that carried labour-force participation conditionalities tended to yield no positive effects. Discussion Given several dynamics involved in determining whether children are healthy or not, which are common worldwide, viewing the literature from a global perspective produces novel insights regarding the tendency of policies and programmes to reduce or, to exacerbate, the effects of socioeconomic disadvantage on child health.

Respiratory manifestations of gastro-oesophageal reflux in children

Abstract: Gastro-oesophageal reflux disease (GORD) is a complex problem in children. Suspected respiratory manifestations of GORD, such as asthma, chronic cough and laryngitis, are commonly encountered in the paediatric practice, but continue to be entities with more questions than answers. The accuracy of diagnostic tests (ie, pH or pH-impedance monitoring, laryngoscopy, endoscopy) for patients with suspected extraoesophageal manifestations of GORD is suboptimal and therefore whether there is a causal relationship between these conditions remains largely undetermined. An empiric trial of proton pump inhibitors can help individual children with undiagnosed respiratory symptoms and suspicion of GORD, but the response to therapy is unpredictable, and in any case what may be being observed is spontaneous improvement. Furthermore, the safety of these agents has been called into question. Poor response to antireflux therapy is an important trigger to search for non-gastro-oesophageal reflux causes for patients' symptoms. Evidence for the assessment of children with suspected extraoesophageal manifestations of GORD is scanty and longitudinal studies with long-term follow-up are urgently required.

The majority of irregular menstrual cycles in adolescence are ovulatory: results of a prospective study

Abstract: Purpose While ovulation is most likely to occur in adolescent girls with regular menstrual cycles, there are limited data on the incidence of ovulation in girls with irregular menstrual cycles in early postmenarcheal years. The aim of the study was to evaluate the presence of ovulation in healthy postmenarcheal girls with irregular menstrual cycles. Methods, design and subjects Prospective cohort study over 12 weeks including 40 healthy postmenarcheal girls recruited from the population-based cohort of adolescents from Western Australian Pregnancy Cohort (Raine) Study with irregular menstrual cycles defined by either menstrual cycles 35 days in duration or cycle length that varied from month to month by >4 days according to menstrual diaries. Main outcome measure Ovulation defined by urinary pregnanediol-3α–glucuronide/creatinine measurements higher than three times above minimum value obtained from 12 samples (1 per week). Results Forty girls (37 Caucasians) with irregular menstrual cycles aged 15.1 (median (IQR) 14.9–15.4) years who were 2.3 (1.9–3.3) years postmenarche were assessed. Urinary pregnanediol-3α–glucuronide/creatinine values identified that 33 girls (82.5%) ovulated during the 3 months of observation and 7 girls had anovulatory cycles. Menstrual diaries collected for a median (IQR) of 159 (137.5–188.2) days showed median minimal and maximum menstrual cycle duration of 24 (11.5–29) and 38.5 (35–48) days, respectively. Conclusions A large proportion of healthy adolescent girls with irregular menstrual cycles are still ovulating despite irregular and infrequent menses.

Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia.

Abstract: Aim This longitudinal study investigated protective factors for social-emotional well-being in refugee children in Australia. Methods Newly arrived refugee children aged 4–15 years were recruited between 2009 and 2013 and assessments were conducted at two points, at years 2 and 3 postarrival. Social-emotional well-being was assessed using the Strengths and Difficulties Questionnaire (SDQ). Protective factors were assessed by structured interview and the Social Readjustment Rating Scale (SRRS); scores Results Forty-three eligible refugee children were recruited. The SDQ was completed by parents in 90% and protective factor data in 80% at years 2 and 3 of follow-up. Protective factors for normal SDQ scores were: originating from Africa (p=0.01), father present on arrival (p=0.019) and family SRRS scores Conclusions Cumulative protective factors, some of which are potentially modifiable, can predict social-emotional well-being in newly arrived refugee children. Children with four or more protective factors are at low risk of poor social-emotional well-being.

Portal hypertension and its management in children.

Abstract: Portal hypertension (PHT), defined as raised intravascular pressure in the portal system, is a complication of chronic liver disease or liver vascular occlusion. Advances in our ability to diagnose and monitor the condition but also predict the risk of gastrointestinal bleeding have enabled us to optimise the management of children with PHT either at a surveillance or at a postbleeding stage. A consensus among paediatric centres in the classification of varices can be beneficial in streamlining future paediatric studies. New invasive (endoscopic and surgical procedures) and non-invasive (pharmacotherapy) techniques are currently used enabling clinicians to reduce mortality and morbidity in children with PHT.

Predicting respiratory hospital admissions in young people with cerebral palsy.

Abstract: Objective To determine the early predictors of respiratory hospital admissions in young people with cerebral palsy (CP). Design A 3-year prospective cohort study using linked data. Patients Children and young people with CP, aged 1 to 26 years. Main outcome measures Self-reported and carer-reported respiratory symptoms were linked to respiratory hospital admissions (as defined by the International Statistical Classification of Diseases and Related Health Problems 10th Revision codes) during the following 3 years. Results 482 participants (including 289 males) were recruited. They were aged 1 to 26 years (mean 10 years, 10 months; SD 5 years, 11 months) at the commencement of the study, and represented all Gross Motor Function Classification Scale (GMFCS) levels. During the 3-year period, 55 (11.4%) participants had a total of 186 respiratory hospital admissions, and spent a total of 1475 days in hospital. Statistically significant risk factors for subsequent respiratory hospital admissions over 3 years in univariate analyses were GMFCS level V, at least one respiratory hospital admission in the year preceding the survey, oropharyngeal dysphagia, seizures, frequent respiratory symptoms, gastro-oesophageal reflux disease, at least two courses of antibiotics in the year preceding the survey, mealtime respiratory symptoms and nightly snoring. Conclusions Most risk factors for respiratory hospital admissions are potentially modifiable. Early identification of oropharyngeal dysphagia and the management of seizures may help prevent serious respiratory illness. One respiratory hospital admission should trigger further evaluation and management to prevent subsequent respiratory illness.

Clinical and cost-effectiveness of the Lightning Process in addition to specialist medical care for paediatric chronic fatigue syndrome: randomised controlled trial.

Abstract: Objective Investigate the effectiveness and cost-effectiveness of the Lightning Process (LP) in addition to specialist medical care (SMC) compared with SMC alone, for children with chronic fatigue syndrome (CFS)/myalgic encephalitis (ME). Design Pragmatic randomised controlled open trial. Participants were randomly assigned to SMC or SMC+LP. Randomisation was minimised by age and gender. Setting Specialist paediatric CFS/ME service. Patients 12–18 year olds with mild/moderate CFS/ME. Main outcome measures The primary outcome was the the 36-Item Short-Form Health Survey Physical Function Subscale (SF-36-PFS) at 6 months. Secondary outcomes included pain, anxiety, depression, school attendance and cost-effectiveness from a health service perspective at 3, 6 and 12 months. Results We recruited 100 participants, of whom 51 were randomised to SMC+LP. Data from 81 participants were analysed at 6 months. Physical function (SF-36-PFS) was better in those allocated SMC+LP (adjusted difference in means 12.5(95% CI 4.5 to 20.5), p=0.003) and this improved further at 12 months (15.1 (5.8 to 24.4), p=0.002). At 6 months, fatigue and anxiety were reduced, and at 12 months, fatigue, anxiety, depression and school attendance had improved in the SMC+LP arm. Results were similar following multiple imputation. SMC+LP was probably more cost-effective in the multiple imputation dataset (difference in means in net monetary benefit at 12 months £1474(95% CI £111 to £2836), p=0.034) but not for complete cases. Conclusion The LP is effective and is probably cost-effective when provided in addition to SMC for mild/moderately affected adolescents with CFS/ME. Trial registration number ISRCTN81456207.