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PubMed2003

Risks of mortality in children admitted to the paediatric intensive care unit after haematopoietic stem cell transplantation.

The risk of mortality in children admitted to the paediatric intensive care unit (PICU) after haematopoietic stem cell transplantation is felt to be very high. Life-threatening complications leading to PICU admission are due to organ toxicity caused by conditioning regimes and graft-versus-host disease (GVHD), systemic infections and other organ dysfunctions. Data collected between October 1998 and December 2001 of paediatric patients undergoing haematopoietic stem cell transplantation and thereafter admitted to the PICU were retrospectively analysed in order to reveal the possible causes and risk factors related to death while in the PICU. Twenty-six PICU admissions were recorded. We found a mortality rate of 57.7% and a 6-month survival rate of 23.1%. Univariate analysis identified an oncological paediatric risk of mortality (O-PRISM) score above 10 points, sustained renal failure and a failed negative fluid balance as significant predictors to non-survival.

Adolescent↗

PubMed2003

Extracorporeal photochemotherapy for paediatric patients with graft-versus-host disease after haematopoietic stem cell transplantation.

This study aimed to ascertain whether extracorporeal photochemotherapy (ECP) is an effective treatment for paediatric patients with refractory graft-versus-host disease (GVHD). From January 1992 to December 2000, 77 children (median age 8.6 years) with either acute (n = 33) or chronic (n = 44) GVHD, resistant to conventional immunosuppressive therapy, were treated with ECP in four Italian paediatric hospitals. After ECP, acute GVHD involving skin, liver and gut responded completely in 76%, 60% and 75% of patients respectively. The 5-year overall survival was 69% for responding patients vs 12% for non-responders (P = 0.001). Among the 44 children with chronic GVHD, 15 (44%) showed a complete response and 10 (29%) a significant improvement after ECP. The 5-year overall survival was 96% for responders vs 58% for non-responders (P = 0.04). Our results suggest that ECP is an effective treatment that may be useful in paediatric patients with either acute or chronic GVHD who have failed to respond to standard immunosuppressive therapy.

Acute Disease↗

PubMed1998

The British Paediatric Surveillance Unit--a pioneering method for investigating the less common disorders of childhood. Report of a seminar held in June 1995.

The British Paediatric Surveillance Unit (BPSU) of the Royal College of Paediatrics and Child Health is an 'active' case reporting scheme set up in 1986 to facilitate the investigation of uncommon childhood conditions of public health and clinical importance in the UK and Ireland. Its methodology involves the monthly mailing of a card containing a menu of up to 12 reportable conditions to all clinically active paediatricians in the British Isles. Respondents either indicate any cases seen in the past month or make a nil return. The BPSU forwards details of respondents reporting cases to the investigators, who when obtain information from the clinician. The menu changes from time to time and studies undergo a rigorous selection process. In 1995, the BPSU held an international seminar to review lessons learned during its first decade which would improve and develop surveillance of paediatric disorders. Over the 9 years to mid-1995 a total of 34 studies took place (25 completed, nine still in progress) with a high respondent response rate (e.g. 90% in 1994). Underascertainment had been addressed by seeking, in parallel, other sources of cases, e.g. death registrations, laboratory reports, other relevant clinical specialists, and by use of capture-recapture techniques. Other specialties and countries have since followed the BPSU example providing opportunity for multispeciality and international studies. The latter were valuable, but required careful planning to standardize case definitions and laboratory techniques, otherwise geographical differences in the incidence of study disorders were difficult to interpret. The BPSU has facilitated studies which increased knowledge about a range of disorders and informed national policy decisions. It also increased diagnostic awareness and showed itself able to respond to public health emergencies. Its emulation in further countries will have similar benefits.

Adolescent↗

PubMed2003

A 6-year follow-up study of chronic constipation and soiling in a specialist paediatric service.

OBJECTIVE: Constipation and soiling is a relatively common condition in childhood and its course is often chronic. This study investigated long-term outcome of children with chronic constipation and soiling by following up a cohort of children 6 years after their presentation to a specialist paediatric gastroenterology clinic with chronic constipation and soiling. DESIGN: Retrospective postal survey. SETTING/SAMPLE: All children referred in 1991 to a specialist paediatric gastroenterology clinic accepting both secondary and tertiary referrals. MEASURES: A semi-structured postal questionnaire was sent to all families, and the Strengths and Difficulties Questionnaire (SDQ) was sent to a random sample. RESULTS: The response rate (of those who could be traced) was 89%. Of these, over a third (36%) still had a problem with constipation and soiling and 17% were using regular laxatives. Three people still having problems with constipation and soiling in the sample were aged over 18 years. No significant difference was found with regard to age, sex or age at referral between the group that improved and the group that did not. Both groups felt they had suffered a high degree of distress because of the problem, with parents highlighting their powerlessness to help their child and the child identifying the embarrassment caused by the problem. CONCLUSIONS: A significant number of children presenting to a specialist paediatric clinic continue to have problems for several years. Further research is needed to identify these cases and to identify which factors promote resolution of the problem.

Adolescent↗

PubMed1998

Serum leptin and insulin in paediatric end-stage liver disease and following successful orthotopic liver transplantation.

OBJECTIVE: Leptin, the product of the ob gene, is a postulated feedback regulator of adiposity with appetite suppressant and catabolic effects. Catabolic states are associated with decreased body fat mass as a result of both nutritional and metabolic perturbation. Low serum leptin has been described previously in a number of catabolic states. It has been unclear whether the observed changes in leptin are a cause or consequence of changes in adiposity. Paediatric end-stage liver disease (ESLD) is characterized by decreased body fat mass and poor linear growth. Successful treatment by orthotopic liver transplantation (OLT) is accompanied by increase in fat mass. We investigated the hypothesis that serum leptin would be low in paediatric ESLD and that increase in body fat mass post-OLT would result in increased serum leptin. DESIGN: Serum leptin and insulin were measured by radioimmunoassay in children with ESLD before and after successful OLT and in age-matched controls. PATIENTS: Twenty-four children with ESLD attending the outpatient department of King's College Hospital, London and 10 age-matched controls. MEASUREMENTS: Anthropometric measurements were performed according to standard techniques and standard deviation (SDS) derived from population standards. Serum leptin and insulin were measured by radioimmunoassay. RESULTS: Serum leptin pre-OLT, leptin (4.06 micrograms/l, [3.45, 5.68] median, with 25th and 75th interquartile ranges) was significantly lower than controls (6.62 micrograms/l, [4.33, 8.05], P = 0.02). Following OLT, serum leptin fell to levels which were significantly lower than pre-OLT values (3.32 micrograms/l, [2.30, 3.99], P = 0.01). There was no significant difference between boys and girls either pre-OLT (boys; 3.64 micrograms/l, [2.45, 5.57], girls; 4.14 micrograms/l, [3.18, 5.65]) or post-OLT (boys; 3.32 micrograms/l, [2.93, 3.62], girls; 3.69 micrograms/l, [2.23, 4.63]. Neither the age at OLT nor the age at the time of blood sampling was correlated with serum leptin pre-OLT or post-OLT. Pre-OLT the children were significantly malnourished with low measures of body fat mass (mid-arm circumference (MAC) SDS -1.90 [-4.67, -1.07]; triceps skinfold thickness (TSF) SDS -1.53, [-2.23, -0.23]; body mass index (BMI) 16.2, [15.5, 16.9]). Three months post-OLT, there were significant improvements in MAC SDS (-0.77, [-1.08, -0.20], P = 0.02) and TSF SDS (-0.41, [-1.95, -0.38], P = 0.003), but no significant change in BMI (15.9 [15.3, 16.7], P = 0.41. Pre-OLT, log serum leptin did not correlate with BMI, MAC SDS or TSF SDS. In contrast, post-OLT, there was a positive correlation between log serum leptin and BMI (r = 0.59, P = 0.003), MAC SDS (r = 0.49, P = 0.01) and TSF SDS (r = 0.41, P = 0.05). BMI also correlated with log serum leptin in the control children (r = 0.64, P = 0.04). CONCLUSIONS: Serum leptin is low in children with end-stage liver disease but does not show the expected correlation with measures of body fat mass. Surprisingly, following orthotopic liver transplantation serum leptin falls significantly despite significant increases in measures of body fat mass (triceps skinfold thickness standard deviation scores, mid-arm circumference standard deviation scores). Orthotopic liver transplantation restores the expected correlation of serum leptin with measures of body fat mass within the treatment group. The elevation of serum leptin above predicted levels in paediatric end-stage liver disease offers a mechanism for the anorexia and cachexia characteristic of this disease.

Anthropometry↗

PubMed2003

Role of fine needle aspiration cytology in evaluation of paediatric lymphadenopathy.

Fine needle aspiration cytology (FNAC) in children has been slow to gain acceptance as compared with its use in adults. The aim of this retrospective study is to determine the utility of FNAC in diagnosing paediatric lymphadenopathy. Six hundred and ninety-two paediatric lymph nodes were aspirated during the period from January 1996 to June 2001. Aspirated material in 32 cases (4.6%) was deemed inadequate for cytological diagnosis. In the remaining cases, 62.2% were reactive lymphadenopathy, 25.2% tuberculous lymphadenitis, 6.3% acute suppurative lymphadenitis, nine cases revealed malignancy (seven lymphoma, two metastatic deposits) and one case had Langerhan's cell histiocytosis. No significant complications were encountered in any of the cases. FNAC emerged as a safe and reliable diagnostic procedure in paediatric age group obviating the need for excision biopsy.

Adolescent↗

PubMed2001

Melanosis of the appendix: common in the paediatric age group.

AIMS: To investigate the incidence of melanosis of the vermiform appendix in a paediatric population, and look for correlations with season, apoptotic rate and inflammation as possible causes. METHODS AND RESULTS: We examined 300 appendices removed for abdominal pain and incidentally during other procedures over the period January 1996 to March 1999. Melanosis was present in 46% of adequate specimens with an even distribution between sexes and age groups. The two older age groups had a relatively higher incidence of severe involvement compared with the younger age group, although the difference was not statistically significant. We attempted to correlate the presence of melanosis with the season of the year and the peak incidences of paediatric gastrointestinal disease but could find no relationship. No statistically significant correlation was found between apoptotic rate and the presence of melanosis. CONCLUSIONS: The findings suggest melanosis of the appendix is relatively common. It is probably due to apoptosis associated with increased epithelial cell turnover due to many differing causes including infection, with purgative ingestion probably involved in only a minority of paediatric cases.

Adolescent↗

PubMed1998

Whither paediatric dentistry?

The objective of the British Society of Paediatric Dentistry is to promote the oral health of children. This objective is discussed from four different aspects. First, it is necessary to quantify the dental needs of children and to appreciate how these needs have changed over the last 20 years. Using information from national dental surveys, changes between 1973 and 1993 in the prevalence of dental caries, periodontal disease, accidental damage to anterior teeth and occlusal problems, are summarized. Secondly, the development in consultant posts and the specialty of paediatric dentistry are discussed. The impact of research gradings given to Dental Schools in Britain is the third aspect to be considered and its possible effect on research topics directly relevant to improving the oral health of children. Lastly the effect of public perceptions on our specialty must be considered. Although paediatric dentists may not hit the headlines, the public must be convinced that good oral health is the birthright of every child and that we are dedicated to preventing and treating oral disease in children.

Adolescent↗

PubMed2003

Vital pulpotomy in the primary dentition: attitudes and practices of Specialists in Paediatric Dentistry practising in the United Kingdom.

OBJECTIVES: This study was designed to examine the attitudes and practices of Specialists in Paediatric Dentistry practising in the United Kingdom in relation to vital pulpotomy in the primary dentition. DESIGN: Data were collected by postal questionnaire. SAMPLE AND METHODS: All dentists whose names were entered on the General Dental Council's Specialist List in Paediatric Dentistry, and who were resident and practising in the United Kingdom, were asked to complete a questionnaire consisting of nine questions. RESULTS: Questionnaires were returned by 184 (86.8%) of the eligible Specialists in Paediatric Dentistry. These yielded a sample group of 179 Specialists practising the primary vital pulpotomy technique. The most commonly used medicament was formocresol, with a 1 : 5 dilution being used by 66.5% of the sample. More than half (54.2%) of the Specialists practising the technique expressed concern regarding their preferred medicament. Without exception, their concerns related to the potential adverse effects of formocresol and formaldehyde. Seventy-five respondents (41.9% of the sample) were considering changing their technique. One hundred and thirty-seven Specialists stated that they routinely took preoperative radiographs, while postoperative radiographs were routinely taken by 107 Specialists (76.5% and 59.8% of the sample, respectively). Rubber dam isolation was used by 62.6% of the sample. CONCLUSIONS: The majority of Specialists are adhering to the UK national clinical guideline for pulp treatment of the primary dentition. However, significant numbers are considering changing their chosen technique. There is a lack of consensus on the use of pre- and postoperative radiographs; specific guidance with respect to their use is required.

Attitude of Health Personnel↗

PubMed2001

The paediatric diabetes specialist nurse and diabetes education in childhood.

AIMS OF THE STUDY: The aim of this study was to identify the job title, work setting, qualifications and training of the paediatric diabetes specialist nurse (PDSN) as well as to examine the composition of the multidisciplinary diabetes team. It also aimed to determine who is involved in diabetes education and to explore the teaching methods, approaches, tools and materials that the PDSN uses in the educational process. DESIGN AND METHODS: A survey design was used. Questionnaires, which combined quantitative and qualitative approaches, were sent to 80 participants from eight opportunistically selected regions of the United Kingdom (UK). Access to names and addresses was gained through the directory of diabetes specialist nurses (DSNs). The selection criteria were nurses working full-time with children with diabetes or having children with diabetes on their caseloads. The overall response rate was 66 (82.5%). FINDINGS: The study findings showed that the majority of the respondents were based in both hospital and community, held paediatric qualifications and had undertaken further training to prepare as diabetes specialists. Respondents used a wide range of teaching methods and materials in the educational process. A substantial number of individuals and voluntary organizations were also involved in diabetes education. CONCLUSIONS: The findings of this study support the belief that the PDSN, as a member of the multidisciplinary paediatric diabetes team, has a key role in the education of children with diabetes and their parents/carers. However, the importance of the team approach as a whole should not be underestimated.

Attitude of Health Personnel↗

PubMed2003

Barriers to paediatric nurses' research utilization.

BACKGROUND: A number of studies have investigated barriers to research utilization among nurses in various countries, and standardized scales have been validated to study this. Reported barriers have been categorized as individual, organizational and environmental, with organizational characteristics generally accounting for more variance. However, information about research utilization among paediatric nurses is lacking. AIM: The objective of the research reported here was to investigate barriers to research utilization and relationships between those barriers and participation in research, self-reported research utilization and education among paediatric nurses. DESIGN: A survey of all nurses in a paediatric teaching hospital; 176 nurses (33.3%) responded. Two standardized measures were used, the Barriers Scale and the Edmonton Research Orientation Scale. RESULTS: Lack of time to read research was the most frequently cited barrier to using research and administrators not allowing implementation was the least frequently cited. Characteristics of the communication and of the setting were more likely to be cited as barriers to research use than were characteristics of the nurse. Nurses who reported higher levels of actual research use were slightly less likely to see characteristics within themselves as barriers. Those who had taken a course about reading or using research were more likely to see the organization as a barrier. Barriers to research use were not associated with self-reported understanding of research. CONCLUSIONS: These results are congruent with previous findings that implementing research in practice is a complex process. They indicate that individual nurses' knowledge about research may not be as important as the process by which organizations implement research. However, the Barriers Scale measures general perceptions about barriers to research utilization and not nurses' specific experiences with barriers to implementing particular research.

Adult↗

PubMed1999

Parents-as-teachers: design and establishment of a training programme for paediatric residents.

OBJECTIVES: To improve the training of paediatric residents in general and to provide more meaningful insights into family functioning. DESIGN: The programme is one facet of a 1-month developmental disabilities rotation for paediatric PL2 residents. It incorporates elements of family-centred care whereby physicians learn through home and community site visits about the importance of developing partnerships with parents and service providers in order to give better care to children with chronic conditions. SETTING: Gillette Specialty Health Care Center, St Paul, Minnesota. SUBJECTS: Paediatric PL2 residents and a parent group. RESULTS: Of 18 residents, 11 completed written and 18 completed oral feedback evaluations. There were infrequent but consistent complaints relating to logistics; more positive comments were made about the programme and individuals involved. CONCLUSIONS: In the minds of all participants, the Parents-as-Teachers (PAT) programme has been highly successful, as documented by short-term objective and subjective parent and resident feedback. The PAT experience represents a unique opportunity for parents and physicians-in-training to improve their mutual understanding. While not analysed in this report, the inclusion of a complementary programme involving on-site teaching in various community agencies also appears to be of value.

Education, Continuing↗

PubMed1999

Medical informatics education in paediatric residency training.

OBJECTIVES: The objective of this study was to determine whether Medical Informatics education among house staff is included in the current residency curriculum, and to present ways in which this type of education may be improved. DESIGN: During autumn 1996 a mailed survey was distributed to chief residents of American paediatric residency programmes. Questions included the resident's use of computers, the influence of Informatics-trained faculty members on programme education and plans for curriculum expansion. SETTING: Division of General Paediatrics, University of Alabama, United States. SUBJECTS: Paediatric chief residents. RESULTS: Eighty programmes (63%) returned a survey. An average of 97% of residents use the computer for looking up patient laboratory results, while 70% use it for Medline searches. Less than half of all residents use the Internet or computer-based learning programmes. Thirty-seven per cent of programmes provided formal lectures on computer topics, and 22% of programmes provided hands-on Internet training. There was no association between the presence if Informatics faculty and current programmes; however, programmes with Informatics faculty were more likely to have future curriculum plans (P=0.04). Some of the programmes' future plans are described. CONCLUSIONS: We felt that an overall description of what is currently being done with computers would be helpful as a baseline for other programmes considering new curricula changes. Residents use the computer often to check patient laboratory results but not as much for self-education. Many programmes are expanding their Informatics curriculum. Faculty without formal Informatics training can take part in basic computer education for residents. A self-study approach by the residents has been received positively.

Computer-Assisted Instruction↗

PubMed2004

Influence of a multidisciplinary paediatric allergy clinic on parental knowledge and rate of subsequent allergic reactions.

BACKGROUND: Studies have demonstrated that families of children with food allergy have significant deficiencies in their knowledge of how to avoid allergen exposure and how to manage allergic reactions. This study aims to assess the impact of a multidisciplinary paediatric allergy clinic consultation on parental knowledge of food allergy and to determine the rate of subsequent allergic reactions. METHODS: Sixty-two subjects (<17 years) referred with food allergy were prospectively enrolled. Parental knowledge was assessed by questionnaire and EpiPen trainer. Families saw a paediatric allergist, clinical nurse specialist and dietician. Knowledge was reassessed after 3 months and rate of allergic reactions after 1 year. RESULTS: After one visit to the paediatric allergy clinic, there was a significant improvement in parental knowledge of allergen avoidance (26.9%, P < 0.001), managing allergic reactions (185.4%, P < 0.0001) and EpiPen usage (83.3%, P < 0.001). Additionally, there was a significant reduction in allergic reactions (P < 0.001). Children with egg, milk or multiple food allergies were more likely to suffer subsequent reactions. CONCLUSIONS: A single visit to a multidisciplinary allergy clinic considerably improves families' abilities to manage allergic reactions to foods with an accompanying reduction in allergic reactions. Young children with egg, milk or multiple food allergies were at greatest risk of further reactions.

Adolescent↗

PubMed2001

Paediatric transfusion.

Paediatric transfusion encompasses a wide range of clinical circumstances including the consideration of maternal antibodies, the changing nature of the transfusion recipient with respect to growth and development, and the management of inherited conditions which if optimally treated in early life may have problems which are delayed or less severe in adult life. Whilst the transfusion of adults and children has much in common, a child cannot be considered as a scaled down adult; there are many important differences. Developmental changes are most marked in the neonate and, together with the fact that their antibodies are maternally derived, this population provide some of the most striking challenges. The increased use of intra uterine transfusion adds an extra dimension here. A particular paediatric concern is the long-term consequences of transfusion. It is to be hoped that paediatric transfusion recipients will live long enough that any potential problems will manifest themselves, thus the aim must be to minimize transfusion risks.

Blood Cells↗

PubMed2003

Paediatric radiotherapy in Australia and New Zealand: an anachronism in 2003?

This report reviews the activities of the Paediatric Special Interest Group of the Royal Australian and New Zealand College of Radiologists in terms of its involvement with the Australian and New Zealand Children's Cancer Study Group and its research and educational activities. Examples of when and how radiotherapy is currently used in the management of paediatric malignancies are provided. Some thoughts for the future of both paediatric radiotherapy and our subspecialty are also presented.

Australia↗

PubMed1999

Meeting the needs of medical students training in paediatrics and child health.

The way education is delivered is changing, and the type of clinical experience in paediatrics available to medical students is changing. Accordingly, the academic departments of Paediatrics and Child Health in Australia and New Zealand are revising both the content and methods of delivery of training in Paediatrics and Child Health. The educational change paradigm and the nature of the changes in training proposed are summarized.

Australia↗

PubMed1999

Alcohol use by parents who present their child to a paediatric emergency department.

OBJECTIVES: Parental alcohol misuse exposes children to risk, but is poorly identified in paediatric settings. We aimed to (i) measure the alcohol use in parents of a sample of children attending emergency and (ii) assess the quality of documentation of this alcohol use by paediatric residents. METHOD: Parents of children presenting to the Emergency Department of a children's hospital were interviewed regarding their alcohol use, and each completed an AUDIT CORE questionnaire. The child's case notes were reviewed for documentation of parental alcohol use. RESULTS: One hundred and ninety-three parents were interviewed. Although per capita alcohol use for both sexes, and hazardous drinking for females were found to be significantly less than general population figures, rates of hazardous drinking were high for fathers. Yet only 1% of case notes reviewed contained any documentation of parental alcohol use. CONCLUSION: This small study suggests that although average alcohol intake amongst parents presenting their children to a paediatric emergency department may be lower than for the general population, there is a significant prevalence of undetected hazardous drinking amongst parents.

Adult↗