We support the call for action by Wolfe et al. to address UK's high
child mortality rates relative to some other European countries (e.g.
Sweden) and we agree that preventive public health strategies are crucial
for reducing child mortality in the UK. To put these aspirations into
practice policy makers need to know which populations to target. In
particular, whether the priority should be to focus on the health of women...
We support the call for action by Wolfe et al. to address UK's high
child mortality rates relative to some other European countries (e.g.
Sweden) and we agree that preventive public health strategies are crucial
for reducing child mortality in the UK. To put these aspirations into
practice policy makers need to know which populations to target. In
particular, whether the priority should be to focus on the health of women
and girls, especially during pregnancy, or on the care of children and
families after birth. We do not suggest either or, but our basic
comparison of England & Wales and Sweden, using publicly available
tabulated data, adds information about where the priorities might lie.
We compared mortality rates per 1000 live births by birth weight and
age-at-death categories in England & Wales and Sweden for singleton
pregnancies in 2006. We restrict these analyses to infants, because most
deaths occur in the first year of life.
First, when we applied the Swedish infant mortality rate to the
number of live births in England and Wales, and compared the result with
the actual number of deaths that occurred in 2006, we obtained a
difference of 1238 excess deaths. This result is consistent with the
numbers cited in the paper (2000 excess deaths under the age of 14). We
then applied Swedish birth weight specific infant mortality rates to the
number of live births in England and Wales in each birth weight category
and calculated the differences with the observed number of deaths. When we
summed excess deaths over all categories, we obtained only 559 excess
deaths. This substantial drop implies that the majority of excess deaths
in 2006 were driven by the differences in the distribution of birth
weights between England & Wales and Sweden. Field et al. (2009) show
consistent results for gestational age - a higher proportion of children
in the UK are born preterm compared to other European countries and this
accounts for a substantial amount of the mortality difference. These
results suggest that preventive strategies should focus on reducing
prenatal risk factors and improving maternal health before and during
pregnancy.
Amongst the remaining excess deaths our research has identified two
groups most at risk. The greatest disparities were observed for extremely
low birth weight babies (<1000g) dying in the first week of life, with
440 excess deaths. Differences in resuscitation policies, practices for
the recording of live births and/or obstetric practices could explain
disparities in the early deaths among these babies. Babies with normal
birth weights (2500-3499g) had the second highest number of excess deaths
(219), with the majority occurring in the post-neonatal period. Further
investigation into causes of death and the impact of socio-economic
factors is required to fully understand the mechanisms driving mortality
in this group. Numbers of excess deaths in these two groups sum to more
than 559 as some birth weight groups had lower rates in England &
Wales than in Sweden.
These calculations are based on tabulations, but illustrate that if
we take into account differences in characteristics of babies at birth,
then the outlook for England and Wales is better than previously assumed.
Comparability of the datasets to explore country differences related to
reporting of live- and stillbirths, birth weight, and gestational age
distributions, and timing of death registrations could be maximised by the
use of individual-level data for such cross-country comparisons. Such
analyses would enable better understanding of where the disparities
originate from and more specifically what preventive strategies in the UK
may have the greatest impact.
Field D, Draper ES, Fenton A, et al. Rates of very preterm birth in
Europe and neonatal mortality rates. Arch Dis Child Fetal Neonatal Ed
2009;94:F253-6.
Modi and McIntosh [1] discuss over-regulation of clinical trials and
the small number of large neonatal multicentre trials carried out in the
UK in 2006.
As there is no single and exhaustive repository of data about UK
trials, it is difficult to determine exactly the level of trial activity
at that time. We can provide data which include 2006 from a survey of
level 2 and 3 neonatal units which identified ran...
Modi and McIntosh [1] discuss over-regulation of clinical trials and
the small number of large neonatal multicentre trials carried out in the
UK in 2006.
As there is no single and exhaustive repository of data about UK
trials, it is difficult to determine exactly the level of trial activity
at that time. We can provide data which include 2006 from a survey of
level 2 and 3 neonatal units which identified randomised trials conducted
in the UK in 2002-06. As part of the BRACELET (Bereavement and Randomised
Controlled Trials) Study questionnaires were sent to 220 neonatal units;
191(86.8%) responded, of which 149 were eligible (82 Level 2, 67 Level 3).
Seventy-six units enrolled 3137 neonates in one or more of 36 identified
trials in 2002-06 (10 international, 14 UK multicentre, 12 single centre);
85% (N=2657) were enrolled into multicentre trials [2]. Our parallel
paediatric survey showed a much smaller proportion (55% N=116) enrolled
into multicentre trials in this setting.
We categorised interventions as drugs and foods (including blood
products, anaesthesia, oxygen, food supplements) (n=19); physical
therapies (including cooling, heating, mechanical ventilation, surgery)
(n=15); other (including monitoring, parenting support (n=2)).
We are unable to disaggregate individual years within 2002-06 so
cannot show trends but it is clear that, in addition to INIS, NIRTURE and
PROGRAMS, there were other albeit smaller trials assessing medicinal and
other interventions in the UK.
These figures provide a recruitment baseline for neonatal trials
around the time of the regulatory and structural changes to the UK
research environment considered by Modi and McIntosh. Future studies may
be able to determine empirically whether the number of research-active
units and participants recruited increases, decreases or remains stable in
the aftermath.
[1]Neena Modi, Neil McIntosh. The effect of the neonatal Continuous
Negative Extrathoracic Pressure (CNEP) trial enquiries on research in the
UK. Arch Dis Child published 25 January 2011, 10.1136/adc.2010.188243
[2] Snowdon C, Harvey SE, Brocklehurst P, Tasker RC, Ward Platt MP, Allen
E, Elbourne D. BRACELET Study: surveys of mortality in UK neonatal and
paediatric intensive care trials. Trials 2010,11:65 (26 May 2010).
We read Ladhani and Ramsay's editorial with great interest. Whilst we
agree on the need for the delivery of a completed course of Hepatitis B
vaccinations in infants of high-risk mothers where the fourth vaccination
is administration by their first birthday, in order to improve uptake of
vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in an...
We read Ladhani and Ramsay's editorial with great interest. Whilst we
agree on the need for the delivery of a completed course of Hepatitis B
vaccinations in infants of high-risk mothers where the fourth vaccination
is administration by their first birthday, in order to improve uptake of
vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in antenatal services
may give birth in a labour unit outside of their local area due to bed
pressures and newborns may not receive their first vaccination. This
should, however, be limited by the use of patient-held maternity records.
The initial Hepatitis B vaccination is often administered by
maternity or neonatal paediatric staff under a hospital doctor
prescription. Subsequent vaccines are currently offered by a variety of
healthcare professionals such as general practitioners (GP) or community
paediatricians. Yates et al[1] showed a high level of participation at the
first vaccination but large numbers of infants did not have follow-up
vaccines. Reasons for this may include poor transfer of information and
clinical records between providers. Also, the administration of infant
Hepatitis B vaccinations does not result in item of service payments for
GPs and as such GP may be less likely to offer follow up vaccinations.
Similarly, acquisition of vaccines, blood test sampling, sample handling
practices and pathology systems may vary among GP practices, thus posing
additional barriers to the completion of vaccination schedules and
serological testing.
In the North London Borough of Enfield, a number of children under
the age of 2 years old move in and out of area making follow-up more
challenging. However, in 2004 in this borough, 80% of all high-risk
neonates of Hepatitis B positive mothers registered at Chase Farm Hospital
during antenatal testing received the full vaccination course and
serology[2]. This success has been attributed to the use of a named
clinical lead conducting an integrated immunisation clinic with a clinic
nurse. The team would recall and follow up patients to offer immunisation
and serological testing while considering migration, language and access
barriers. In a resource-limited health system such immunisation clinics
may not be feasible. Universal vaccination of children with Hepatitis B
vaccines is not practical or more effective than a targeted approach[3].
Therefore, we would recommend that follow-up Hepatitis B vaccinations and
serology are performed by incentivised GPs as a new 'item of service'
payment.
1. Yates TA, Paranthaman K, Yu L-M, et al. UK vaccination schedule:
persistence of immunity to hepatitis B in children vaccinated after
perinatal exposure. Arch Dis Child 2013;98:429-33.
2. Giroudon I. Immunization Coverage in Infants at Risk of Perinatal
Transmission of Hepatitis B: A London Study (LANSSG). HPA London Regional
Epidemiology Unit. 2008.
3. Balogum MA, Parry JV, Mutton K, et al. Hepatitis B virus transmission
in pre-adolescent schoolchildren in four multi-ethnic areas of England.
Epidemiol Infect 2013; 141(5):916-25
Wolfe et al heighten my anxiety about solution- focussed
epidemiological research with their recommendations for improving child
survival in the UK (1). The correlation of lower socio- economic
inequality with better child health outcomes in Sweden is clear enough but
correlation does not equal causation, as we never tire of hearing. The
assertion that "child survival in Britain would be improved through
macroeconomic po...
Wolfe et al heighten my anxiety about solution- focussed
epidemiological research with their recommendations for improving child
survival in the UK (1). The correlation of lower socio- economic
inequality with better child health outcomes in Sweden is clear enough but
correlation does not equal causation, as we never tire of hearing. The
assertion that "child survival in Britain would be improved through
macroeconomic policies to redistribute wealth and narrow the income gap
between rich and poor people" is barely plausible and not demonstrable.
The relevant papers in October's ADC demand a solution to fundamental
puzzles of pathophysiology- What causes intra-uterine growth restriction
and premature birth; and what part is played by their social determinants?
The association of preterm birth with poverty is modest (2). The
suggestion that a comparison of your income with your wealthy compatriots
can cause death goes too far.
One reason that Sweden has lower infant mortality rates is that they
have very few births to teenage women. This in turn is due to high
abortion ratios for teenagers, rather than having particularly low rates
of teenage pregnancy (3). Of course we can't rationally propose more
abortion as a solution to infant mortality when it is associated with
increased rates of premature birth in subsequent pregnancies (4).
Teenage maternity is a biological norm, and is not universally
associated with preterm birth. We must consider why preterm birth is
commoner in young mothers in the UK and many other countries. Pre-
conception stressful life events are associated with a four-fold increase
in preterm birth for teenage mothers in the USA (5). Pre-conception stress
provides us with a plausible pathophysiological model for causes of
prematurity and a potential focus for research. Its causes reach far
beyond family income and a protective effect against childhood stress of
certain family structures might explain their association with infant
survival and reduced risk of preterm birth(6).
Meanwhile, Sweden may be storing up its child mortality risk. Falling
educational attainment and rising rates of reported stress in young Swedes
should cause our Scandinavian colleagues some sleepless nights(3).
1 Wolfe I; ADC 2015
2 De Franco E; BMC Public Health 2008
3 Hjern A; Scand J Public Health 2012
4 Hardy G; J Obs Gynaecol Canada 2013
5 Witt W; AJPH 2014
6 Zeitlin JA; Paediatr Perinat Epidemiol 2002
The child death review procedures in place in England (1) are ideally
placed to address the issues that Kenny and Martin raise in their paper on
drowning and sudden cardiac death (2). Although rare - there were 43
drowning deaths of 0-19 year olds in England in 2009 (3), such deaths may
hide important medical conditions, notably cardiac rhythm disorders.
Following every unexpected child death, a rapid response...
The child death review procedures in place in England (1) are ideally
placed to address the issues that Kenny and Martin raise in their paper on
drowning and sudden cardiac death (2). Although rare - there were 43
drowning deaths of 0-19 year olds in England in 2009 (3), such deaths may
hide important medical conditions, notably cardiac rhythm disorders.
Following every unexpected child death, a rapid response by health
professionals working with the police and other agencies enables
appropriate information to be gathered and analysed to clarify the causes
and contributory factors, to support the family, and to identify lessons
to be learnt for prevention. This will include a thorough review of the
circumstances of death, and a detailed medical and family history. This
process should help to highlight factors that may otherwise have been
hidden. This is important, not just for the grieving parents, but also to
identify potential genetic or other risks to the family, and public health
concerns for the wider community. Information gained through the rapid
response, together with a rigorous autopsy, is essential for the coroner,
who can only reach a verdict on the basis of the information provided.
By reviewing every child's death in their area, the multi-agency
child death overview panels provide a further opportunity to consider that
information and to identify issues, patterns and discrepancies that may
help prevent future child deaths. Although it has not yet been achieved,
regional or national collation of data from these panels would achieve the
kind of overview of these deaths that Kenny and Martin call for.
References
1. Sidebotham P, Pearson G. Responding to and learning from childhood
deaths. BMJ 2009;338: 531
2. Kenny D, Martin R. Drowning and sudden cardiac death. Archives of
Disease in Childhood 2011; 96: 5-8
3. Office for National Statistics. DR_09 Mortality statistics: deaths
registered in 2009. London: ONS, 2010
Conflict of Interest:
I am involved in research and training in relation to child death review. I have no competing financial interests.
We have read with interest the paper by Sayal et al. concerning a
cohort of 11-year-old children prenatally exposed to alcohol and the major
conclusion that light drinking in pregnancy does not appear to be
associated with clinically important adverse effects for mental health and
academic outcomes at the age of 11 years.
This broad epidemiological study has several problems related to the...
We have read with interest the paper by Sayal et al. concerning a
cohort of 11-year-old children prenatally exposed to alcohol and the major
conclusion that light drinking in pregnancy does not appear to be
associated with clinically important adverse effects for mental health and
academic outcomes at the age of 11 years.
This broad epidemiological study has several problems related to the
analysis of data and to the risk assumption. First of all, it has been
demonstrated that questionnaires about the blame-attributing question of
alcohol consumption during pregnancy are not reliable, because women do
not tell the truth or because they are not aware about real alcohol
consumption. (1) As a consequence, the division of the groups of women
into various drinking levels cannot be considered reliable, which in turn,
makes it impossible to draw conclusions from the outcomes of tests on the
children. (1,2) Thus human observational studies must be based on
objective measurements of prenatal alcohol exposure, that is, based on
alcohol biomarkers in alternative matrices. (1,2)
There is clear evidence from animal studies and from human clinical
observation that prenatal exposure to alcohol has deleterious effects,
even in low doses, specifically on neurodevelopmental aspects. Clearer
answers on the effects of alcohol on humans are to be expected from
several currently on-going follow-up studies of newborns whose exposure
was measured based on meconium alcohol biomarkers. (3,4)
However, the most important problem of this paper is the non
acceptable risk assumption. It is not responsible to state that
"occasional light drinking does not appear to be associated with adverse
mental health or academic consequences at the age of 11 years". There HAVE
TO be sure that there is no risk at all; if not, it is mandatory to
recommend not to drink during pregnancy. Conversely to the authors'
conclusion, the most "advanced" advice for women is not to drink alcohol
during pregnancy. As everybody knows, lack of evidence is not the same as
evidence of absence, and in this case, no evidence of harm does not mean
evidence of no harm. (5)
Garcia-Algar O1,2, Diane Black2, Consuelo Guerri2,3, Simona
Pichini2,4
1 URIE, Institut Hospital del Mar d'Investigacions M?diques (IMIM),
Barcelona, Spain
2 European FASD Alliance, The Nederlands
3 Department of Therapeutic Research and Medicines Evaluation, Istituto
Superiore di Sanit?, Rome, Italy
4 Centro de Investigaci?n Pr?ncipe Felipe, Valencia, Spain
References
1. Manich A, Velasco M, Joya X, Garc?a-Lara NR, Pichini S, Vall O,
Garc?a-Algar O. [Validity of a maternal alcohol consumption questionnaire
in detecting prenatal exposure]. An Pediatr (Barc) 2012;76:324-328.
2. Pichini S, Marchei E, Vagnarelli F, Tarani L, Raimondi F, Maffucci R,
et al. Assessment of prenatal exposure to ethanol by meconium analysis:
results of an Italian multicenter study. Alcohol Clin Exp Res 2012;36:417-
424.
3. Garcia-Algar O, Kulaga V, Gareri J, Koren G, Vall O, Zuccaro P,
Pacifici R, Pichini S. Alarming prevalence of fetal alcohol exposure in a
Mediterranean city. Ther Drug Monit 2008;30:249-254.
4. Valenzuela CF, Morton RA, Diaz MR, Topper L. Does moderate drinking
harm the fetal brain? Insights from animal models. Trends Neurosci
2012;35:284-92.
5. Garcia-Algar O, Black D, Guerri C, Pichini S. The effect of different
alcohol drinking patterns in early to mid-pregnancy. BJOG 2012;119:1670-1.
We read with great interest the recent Archimedes discussion
entitled "Can faecal calprotectin be used as an effective diagnostic aid
for necrotizing enterocolitis in neonates" by Houston and Morgan. In their
commentary the authors correctly state that most of the studies used an
ELISA method and that many local laboratories currently only run fecal
calprotectin testing in once or twice weekly, which would not support it...
We read with great interest the recent Archimedes discussion
entitled "Can faecal calprotectin be used as an effective diagnostic aid
for necrotizing enterocolitis in neonates" by Houston and Morgan. In their
commentary the authors correctly state that most of the studies used an
ELISA method and that many local laboratories currently only run fecal
calprotectin testing in once or twice weekly, which would not support its
use as a diagnostic tool in clinical practice. What they didn't mention is
that part of the reason for this delay is that ELISA is a method which
requires accumulation of multiple samples (96 wells) to run, and thus most
clinical laboratories will wait until the requisite number of samples have
accumulated. As the authors stated, these limitations have to date
relegated fecal calprotectin, as measured by ELISA, to the realm of
interesting research findings, not very useful as a diagnostic tool. In
order for fecal calprotectin to be used as a clinical tool for the
assessment of neonates with abdominal symptoms, a single sample test would
need to be available to local laboratories and the results rapidly
transmitted to treating clinicians. With this in mind, we would like to
call the authors' attenction to our recent report [2] of a significant
correlation between necrotizing enterocolitis and fecal calprotectin
levels as measured by a rapid assay technique. This new approach, in
contrast to ELISA, can serve as point of care testing and hence now render
fecal calprotectin as useful clinical tool.
Alona Bin-Nun
Cathy Hammerman
1. Houston JF, Morgan JE. Question 2: Can faecal calprotectin be used
as an effective diagnostic aid for necrotising enterocolitis in neonates?
Arch Dis Child. 2015;100:1003-6
2. Bin-Nun A, Booms C, Sabag N, Mevorach R, Algur N, Hammerman C. Rapid
fecal calprotectin (FC) analysis: point of care testing for diagnosing
early necrotizing enterocolitis. Am J Perinatol. 2015;32:337-42.
We read with interest the recent paper by Doull et al [1] which
explores the optimal model for delivery of paediatric cystic fibrosis (CF)
care. The authors compared three models of paediatric CF care within
their established CF network: full centre care; local clinic based care
with annual review by the CF centre; and hybrid care, where a child is
usually reviewed at least three times a year by the specialist centre....
We read with interest the recent paper by Doull et al [1] which
explores the optimal model for delivery of paediatric cystic fibrosis (CF)
care. The authors compared three models of paediatric CF care within
their established CF network: full centre care; local clinic based care
with annual review by the CF centre; and hybrid care, where a child is
usually reviewed at least three times a year by the specialist centre.
Three outcomes were considered: nutritional status, pulmonary function and
prevalence of chronic Pseudomonas aeruginosa infection. The only
significant finding was that mean FEV1 was lower amongst children
receiving local clinic based care than full centre care (74.5% predicted
vs 89.2%: p = 0.001) and the authors extrapolate from this that model of
care may affect long term clinical outcomes for children with CF.
The data presented are interesting and highly relevant to all
involved in CF care in South and Mid Wales. However, the study has
several shortcomings which limit generalisation of its findings to other
paediatric CF populations. It is crucial that these are highlighted to
the varied audience of the paper to avoid unnecessary and misguided loss
of confidence in local services elsewhere in the UK.
The number of patients cared for by each local clinic in South and
Mid Wales appears to be small. We are told that the majority of patients
receive local care from ten paediatric units and, later in the paper, that
three of these units deliver hybrid care. The 102 patients receiving
local clinic care must, therefore, be served by 7 centres, equating to an
average caseload of just 15 patients per centre. Ensuring maintenance of
skills for all clinical groups involved with these patients is likely to
be challenging and this may have contributed to the results of the study.
Details about staffing of the South & Mid Wales local clinics are
sparse. Is there a lead consultant paediatrician for CF in each unit? A
cohesive multidisciplinary approach to CF management is vital (as
reflected in the UK CF Trust standards of care [2]) yet Doull's paper
provides very little information about the availability of key team
members in local clinics. The difference in prevalence of nasogastric
feeding between patients attending the specialist centre (7.8%) and the
local clinics (2.9%) is notable and open to various interpretations. How
accessible are physiotherapists? Are they specialist trained? Do they
have capacity to carry out home/school visits? These factors could have a
direct and significant effect on pulmonary function.
No information is provided about the practicalities of pulmonary
function testing. Do the local clinics use the same equipment as the
specialist centre? Are the same calibration procedures in use? If these
variables are not standardised it is inappropriate to make direct
comparisons of pulmonary function data. The standard deviation for %
predicted FEV1 is greatest amongst local clinic patients, indicating a
wider spread of data within this group. Were there any palliative care
patients, for example, in this cohort who may have skewed the data?
Rate of decline in lung function in CF patients is influenced by
socioeconomic status [3]. Unfortunately we are given no information about
levels of social deprivation the population studied and this compounds the
aforementioned problems with interpretation of the data presented.
CF care provision by "local clinics" varies tremendously and it would
be unwise to extrapolate clinical data from one region of the UK and apply
it to another. In January 2011 we launched a new "local clinic" in Wishaw
General Hospital, Lanarkshire, signifying the culmination of years of
strategic planning and preparation in line with the Scottish Government's
National Delivery Plan for Specialist Children's Services. The majority
of our 48 patients have been repatriated from the specialist centre in the
Royal Hospital for Sick Children (RHSC), Yorkhill, Glasgow (20 miles away;
road links good). Social deprivation is prevalent, with north and south
Lanarkshire both being within the five most deprived local authority areas
in Scotland [4]. Our own local multidisciplinary team comprises two
consultant paediatricians with a special interest in respiratory
paediatrics (one of whom is fully subspecialty trained), an associate
specialist with a special interest in respiratory paediatrics, a dedicated
CF specialist nurse, two specialist paediatric respiratory
physiotherapists, a senior paediatric dietitian and a CF pharmacist. We
operate within the West of Scotland managed clinical network (MCN) for
paediatric CF and virtually all care (including pulmonary function
testing, frequency of clinic review, annual review procedures and
transition arrangements) is standardised across the region. We are
currently developing clinical guidelines which will be shared by all four
units in the network. Children attend our fully segregated CF clinics
eight weekly as standard (more frequently in infancy) and are reviewed
annually by the specialist RHSC team at joint clinics held in our
hospital. This said, communication channels are wide open and challenging
patients can be discussed with/reviewed by the specialist team in between
times if clinical need dictates. Ours is the third largest paediatric CF
unit in Scotland. We operate within a robust MCN and we are confident
that we can deliver equitable CF care. Our patients' clinical outcomes
will be monitored closely and we aim to report our experience and data in
years to come.
Finally, it should be borne in mind that local CF care affords many
benefits to children and their families. Strong links with community
organisations such as primary care, social work and education, combined
with shorter travel distances and less disruption to family life, will all
have a positive effect on long term outcomes for children with CF.
References
1. Doull I, Evans H, South and Mid Wales Paediatric Cystic Fibrosis
Network. Full, shared and hybrid paediatric care for cystic fibrosis in
South and Mid Wales. Arch Dis Child 2011 10.1136/adc.2010.199380
2. CF Trust. Standards for the clinical care of children and adults
with cystic fibrosis in the UK. May 2001
3. Taylor-Robinson D, Whitehead M, Diggle P, et al. Socioeconomic
status and rate of decline of lung function in the UK cystic fibrosis
population (abstract). Pediatric Pulmonology 2010;45(S33):449
4. Scottish Index of Multiple Deprivation (SIMD) data 2009.
http://www.scotland.gov.uk/Topics/Statistics/Browse/Social-
Welfare/TrendSIMD Accessed 24th February 2011.
Dear Ed
Gill [1] and Powell [2] state there is little data on delivery of
unscheduled care. We would like to share
our learning.
To improve paediatric training in primary care one of us (SC) has
worked with Advanced Life Support
Group (ALSG) led by SW and piloted a, "Poorly Child Pathway Course." This
one day course deals
with the most common acute childhood presentations and uses a traffic
light system (gree...
Dear Ed
Gill [1] and Powell [2] state there is little data on delivery of
unscheduled care. We would like to share
our learning.
To improve paediatric training in primary care one of us (SC) has
worked with Advanced Life Support
Group (ALSG) led by SW and piloted a, "Poorly Child Pathway Course." This
one day course deals
with the most common acute childhood presentations and uses a traffic
light system (green, amber,
red) to classify patients. It aims to improve the management of children
presenting to Urgent Care and
Out of Hours and communication between primary and secondary care.
23 candidates were taught by 8 faculty. Candidate and Faculty
feedback is ongoing, early results
show: 80% agreed that a one day course worked well; confidence improved
from 2.7/4 to
3.8/4. Primary Care facilities do not have the facility to review patients
so hospitals see all amber
patients
The second intervention was to pilot a, "Front of House," (FoH) model
of care where children
were seen and assessed by either a consultant paediatrician, paediatric
middle grade or Advanced
Nurse Practitioner Students (APNPs) prior to admission. There are two 24
hour paediatric
units within CDDFT separated by 22 miles, University Hospital North Durham
(UHND) and Darlington
Memorial Hospital (DMH). The pilot ran at DMH over a 3 week period between
5th to 23rd November,
2013 on Mondays to Fridays 9:00 to 21:00. There was insufficient staff to
run this model at weekends.
During November there were 391 admissions under 18 years of age
compared to 406
in November 2012. The data is not scientific. Considering successive 8%
annual increases in
admissions it suggests a decrease in admissions.
We plan to perform a 6 month, "trial," at UHND using the system 7
days a week with consultants
triaging calls.
References
1. Gill PJ, Goldacre MJ, Mant D et al. Increase in Emergency
Admissions to Hospital for Children aged under 15 in Emgland, 199-2010:
National Database Analysis. Arch. Dis Child 2013; 98: 328-334
2. Powell C Do we need to change the way we deliver unscheduled care?
Arch. Dis Child 2013; 98: 319-320
With sincere thanks to the faculty of the pilot Poorly Child Pathway
Course:
Prof. Peter Driscoll (IDP)
Dr. Martin Samuels (Stoke-on-Trent)
Paul Lattimer (CDDFT)
Dr Leigh Simmonds (CDDFT)
Dr John Holmes (CDDFT)
Dr Barbara Phillips (IDP)
Dr David Ratcliffe (Manchster)
and to our APNPs:
Lisa German-Phillips
Amanda Dunn
Susie Watson
Shona Sangster
Meg Davies
Cheryl Peart
We highlight the recent case of a term female neonate aged 9 days who
was referred by her community midwife on account of features of mild
respiratory distress symptoms. Initially sepsis was suspected and
treatment with antibiotics was initiated. Tachypnoea persisted though
there were no other abnormal physical signs; laboratory studies were
normal. An echocardiogram, performed to exclude a primary cardiac cause
showed...
We highlight the recent case of a term female neonate aged 9 days who
was referred by her community midwife on account of features of mild
respiratory distress symptoms. Initially sepsis was suspected and
treatment with antibiotics was initiated. Tachypnoea persisted though
there were no other abnormal physical signs; laboratory studies were
normal. An echocardiogram, performed to exclude a primary cardiac cause
showed pulmonary hypertension, with right to left flow through a small
atrial septal defect. There was no echo evidence of heart failure and the
pulmonary hypertension could not be explained by heart abnormalities.
Cranial ultrasound was performed and showed a large midline vascular
abnormality posterior to brainstem, with turbulent Doppler flow,
suggestive of vein of Galen malformation. There was no cranial bruit.
Urgent transfer to a specialist centre was arranged for endovascular
embolization therapy. The case emphasises the importance of correct
identification of the cause of respiratory distress in young infants, even
if symptoms are initially mild; also to explain the finding of pulmonary
hypertension which may have an underlying pathological basis which is not
primarily cardiac or respiratory.
We support the call for action by Wolfe et al. to address UK's high child mortality rates relative to some other European countries (e.g. Sweden) and we agree that preventive public health strategies are crucial for reducing child mortality in the UK. To put these aspirations into practice policy makers need to know which populations to target. In particular, whether the priority should be to focus on the health of women...
Modi and McIntosh [1] discuss over-regulation of clinical trials and the small number of large neonatal multicentre trials carried out in the UK in 2006.
As there is no single and exhaustive repository of data about UK trials, it is difficult to determine exactly the level of trial activity at that time. We can provide data which include 2006 from a survey of level 2 and 3 neonatal units which identified ran...
We read Ladhani and Ramsay's editorial with great interest. Whilst we agree on the need for the delivery of a completed course of Hepatitis B vaccinations in infants of high-risk mothers where the fourth vaccination is administration by their first birthday, in order to improve uptake of vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in an...
Wolfe et al heighten my anxiety about solution- focussed epidemiological research with their recommendations for improving child survival in the UK (1). The correlation of lower socio- economic inequality with better child health outcomes in Sweden is clear enough but correlation does not equal causation, as we never tire of hearing. The assertion that "child survival in Britain would be improved through macroeconomic po...
The child death review procedures in place in England (1) are ideally placed to address the issues that Kenny and Martin raise in their paper on drowning and sudden cardiac death (2). Although rare - there were 43 drowning deaths of 0-19 year olds in England in 2009 (3), such deaths may hide important medical conditions, notably cardiac rhythm disorders.
Following every unexpected child death, a rapid response...
Dear Editor,
We have read with interest the paper by Sayal et al. concerning a cohort of 11-year-old children prenatally exposed to alcohol and the major conclusion that light drinking in pregnancy does not appear to be associated with clinically important adverse effects for mental health and academic outcomes at the age of 11 years.
This broad epidemiological study has several problems related to the...
We read with great interest the recent Archimedes discussion entitled "Can faecal calprotectin be used as an effective diagnostic aid for necrotizing enterocolitis in neonates" by Houston and Morgan. In their commentary the authors correctly state that most of the studies used an ELISA method and that many local laboratories currently only run fecal calprotectin testing in once or twice weekly, which would not support it...
We read with interest the recent paper by Doull et al [1] which explores the optimal model for delivery of paediatric cystic fibrosis (CF) care. The authors compared three models of paediatric CF care within their established CF network: full centre care; local clinic based care with annual review by the CF centre; and hybrid care, where a child is usually reviewed at least three times a year by the specialist centre....
Dear Ed Gill [1] and Powell [2] state there is little data on delivery of unscheduled care. We would like to share our learning.
To improve paediatric training in primary care one of us (SC) has worked with Advanced Life Support Group (ALSG) led by SW and piloted a, "Poorly Child Pathway Course." This one day course deals with the most common acute childhood presentations and uses a traffic light system (gree...
We highlight the recent case of a term female neonate aged 9 days who was referred by her community midwife on account of features of mild respiratory distress symptoms. Initially sepsis was suspected and treatment with antibiotics was initiated. Tachypnoea persisted though there were no other abnormal physical signs; laboratory studies were normal. An echocardiogram, performed to exclude a primary cardiac cause showed...
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