Paediatrics

Current management of children and young people with heterozygous familial hypercholesterolaemia – HEART UK statement of care (2019)

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Type of publication:
Journal article

Author(s):
Ramaswami U.; Humphries S.E.; Priestley-Barnham L.; Green P.; Wald D.S.; *Capps N.; Anderson M.; Dale P.; Morris A.A.

Citation:
Atherosclerosis; Nov 2019; vol. 290 ; p. 1-8 [epub ahead of print]

Abstract:
This consensus statement on the management of children and young people with heterozygous familial hypercholesterolaemia (FH) addresses management of paediatric FH in the UK, identified by cascade testing when a parent is diagnosed with FH and for those diagnosed following incidental lipid tests. Lifestyle and dietary advice appropriate for children with FH; suggested low density lipoprotein cholesterol (LDL-C) targets and the most appropriate lipid-lowering therapies to achieve these are discussed in this statement of care. Based on the population prevalence of FH as ~1/250 and the UK paediatric population, there are approximately 50,000 FH children under 18 years. Currently only about 550 of these children and young people have been identified and are under paediatric care.

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Cancelled! Cancelled! An audit on cancellation of paediatric surgical cases on the day of surgery in a district general hospital (2019)

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Type of publication:
Conference abstract

Author(s):
Singh M.; *Annadurai S.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 90

Abstract:
Surgical case cancellation has significant impacts on operating theatre efficiency and the UK loses a substantial amount of money on these cases [1]. A recent prospective study over a 1-week period in an NHS hospital suggested a adult surgical case cancellation rate between 10% and 14% and the majority of these cases were due to non-clinical reasons [2]. It is distressing for the patient and affects outcomes. We undertook an audit regarding cancellation of paediatric surgical cases on the day of surgery at a district general hospital (DGH) to look for various reasons for the cancellations and to evaluate the services. Methods We collected prospective data from the hospital’s database regarding cancelled paediatric surgical procedures over a 6-month period from February 2018 to July 2018 in our DGH. Results We found that a total of 70 paediatric surgical cases were cancelled on the day of surgery out of total of 653 paediatric surgical cases, which is an approximately 10% cancellation rate over the 6-month period with a range of cancellations from 7% in May and June to 18% in February. We observed that 76% of the cancellations were of elective cases. We subdivided the reasons for cancellations into organisational, patient, surgical and anaesthetic factors. Among the organisational factors, 23% of cancellations were due to ‘unavailable beds’. We observed that 11% of cancellations occurred because patients ‘did not attend’, 7% of patients were reported as ‘sick’ and 3% of patients did not follow preoperative fasting instructions. Surgeons cancelled 15% of cases for the reason ‘procedure no longer required’, whereas anaesthetist ‘sickness’ was the reason for cancellation in 9% of cases. Discussion Cancellations prolong the waiting list and worsens patient experiences and clinical outcomes. In our audit, we found that the main reasons for cancellations were non-clinical. To improve the surgical reasons for cancellation, we suggest timely rereview of the need for surgery. Although staff allocation is looked at regularly, some cases were cancelled due to the unavailability of staff, which can be improved on. We discussed the idea of seasonal planning of cases. We plan to re-audit with the aim of investigating cancellation rates in elective cases over a 1-year period to also review the cancellation rate during the winter months.

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Parent Experiences with Paediatric Allergy Pathways in the West Midlands: A Qualitative study. (2019)

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Type of publication:
Journal article

Author(s):
Diwakar, Lavanya; Cummins, Carole; Hackett, Scott; *Rees, Martyn; Charles, Lynette; Kerrigan, Caroline; Creed, Helen; Roberts, Tracy

Citation:
Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology; Jan 2019 Volume49, Issue3, Pages 357-365

Abstract:
BACKGROUND The prevalence, severity and complexity of allergic diseases has been increasing steadily in the UK over the last few decades. Primary care physicians are often not adequately trained in allergy management whilst specialist services for allergy are scarce and heterogeneous. Services, therefore, have been unable to meet the rising demand. This is particularly true for paediatric allergy services in the UK. OBJECTIVE To understand parent experiences with paediatric allergy pathways in the West Midlands (WM) region of the UK. METHODS Parents of children aged between 0-16 years from the WM region were recruited opportunistically until thematic saturation was achieved. 18 semi-structured interviews were carried out and transcribed verbatim. Data were analysed on NVivo software using the framework method. Themes were identified from the transcripts as well as from existing literature. RESULTS Parents highlighted numerous issues related to allergy services in the region including difficulties with being taken seriously by their physicians, problems with accessing healthcare and issues with information and the need for additional supportive care for allergies. CONCLUSIONS AND CLINICAL RELEVANCE Primary care for children with allergies in the West Midlands is disparate. Parents experience difficulties in accessing primary and secondary care services and also obtaining timely and appropriate information regarding their child’s allergies. Most parents were happy to be reviewed by either specialist nurses or by consultants in the hospital. Improving accessibility and availability of reliable information as well as provision of additional services (such as psychologists and dietetics) were highlighted by parents as being important to allergy services in the region. These findings can help inform future planning and commissioning of allergy services

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Perplexing presentations in paediatric gastroenterology (2018)

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Type of publication:
Journal article

Author(s):
Pigott, Anna Jane; Saran, Shashwat; *Monaghan, Sean

Citation:
Paediatrics & Child Health; Nov 2018; vol. 28 (no. 11); p. 515-519

Abstract:
Abstract The nature of gastroenterological conditions often lead the clinician to rely on the history offered by the parents or carers to make a diagnosis and create a management plan. It is no coincidence that some of the most frequent presentations of fabricated or induced illness (FII) are with apparent gastroenterological complaints. This review details elements in the presenting history of vomiting, constipation, diarrhoea, blood in stool, faltering growth and abdominal pain that potentially make FII a more likely diagnosis, and proposes a management approach to a suspected presentation of FII.

The paediatrician and the management of common gynaecological conditions (2018)

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Type of publication:
Journal article

Author(s):
*Ritchie, Joanne K; Latthe, Pallavi; Jyothish, Deepthi; Blair, Joanne C

Citation:
Archives of disease in childhood; Jul 2018, 103(7), p. 703-706

Abstract:
Paediatric gynaecology is an emerging discipline. Since 2000, there has been an advanced training programme in paediatric gynaecology available for obstetric and gynaecology trainees; additionally, a set of clinical standards1 for the care of paediatric and adolescent patients has been developed by The British Society of Paediatric and Adolescent Gynaecology (BritSPAG). BritSPAG is a multidisciplinary group of professionals including gynaecologists, paediatricians, paediatric urologists and endocrinologists.Girls with gynaecological conditions are often seen in general paediatric services; it is important that those assessing them are confident in identifying patients who require more specialist care. Despite this, gynaecology does not appear in the Royal College of Paediatrics and Child Health curriculum. This article aims to increase the knowledge base and confidence of paediatricians in dealing with common paediatric and adolescent gynaecological conditions.

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An auditon paediatric syncope: Do paediatricians identify the red flags for cardiac syncope? (2016)

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Type of publication:
Conference abstract

Author(s):
*Mikrou P.; *Kannivelu A.

Citation:
European Journal of Pediatrics; 2016; vol. 175 (no. 11); p. 1480-1481

Abstract:
Background and aims Syncope is a common presentation in Paediatrics. Although cardiac syncope is rare, identifying the red flags that could signify an underlying cardiac cause (see chart 1) is an essential skill for all Paediatricians. Methods We conducted a retrospective audit of children with presentation of syncope/presyncope in our local District General Hospital. We based our standards on the Department of Health and Arrhythmia Alliance Primary Care pathway, NICE and European Society of Cardiology guidance on Transient Loss of Consciousness in young people and adults. Results A total of 33 patients were analysed, in two different subgroups: Paediatric Assessment Unit (PAU) group (n=23) and Outpatient group (n=10). In the PAU subgroup, only 70% of patients had a 12-lead ECG (44% had a manual QTC calculated). Family history of sudden death was not documented in 48% of cases. In the outpatient subgroup a significantly higher number of investigations were performed (100% had 12-lead ECGs, 70% Holter monitors and 30% echocardiograms). There was felt to be a selection bias (clinic being run by a Paediatrician with Cardiology expertise). Conclusions A standard operating procedure pathway was formulated to guide clinicians in the Emergency Department and PAU for the management of children presenting with syncope. Key points are that all children presenting with syncope should have a 12-lead ECG and ‘red flags’ explored in history (e.g. family history of sudden unexplained death, exercise induced symptoms, palpitations). We hope that the pathway implementation will lead to improved patient care outcomes.

Parent experiences of paediatric allergy pathways in the West Midlands Region of the United Kingdom – A qualitative study (2016)

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Type of publication:
Conference abstract

Author(s):
*Diwakar L., Cummins C., Williams L., Sansom H., Kerrigan C., *Rees M., Hackett S., Lilford R., Roberts T.

Citation:
Allergy: European Journal of Allergy and Clinical Immunology, August 2016, vol./is. 71/(577)

Abstract:
Background: Almost all allergy care in the UK is provided by the publicly funded National Health Service (NHS). Services are deficient in most parts of the country at both primary and secondary level, with few regions having appropriate access to trained allergy clinical teams. The problem is especially acute for paediatric allergy services. Method: We are carrying out a qualitative study using in-depth, semi-structured interviews of parents purposively selected from two separate NHS Paediatric allergy clinics. All interviews are being audio-taped and transcribed anonymously. Analysis is by framework approach facilitated by NVivo software. Themes are being identified and alternate theories for findings will be sought using peer panels and literature searches. Interviews will be carried out until data saturation is achieved. Results: Preliminary analysis of 6 completed interviews has revealed a few emerging themes. Access to Primary Care services was variable with some parents expressing frustration at delays in obtaining appointments. Some of the mothers felt aggrieved that their ‘gut reactions’ regarding the well being of their child were often disregarded by Primary Care Physicians (PCPs). This was perceived strongly as 0being dismissed0 and made the mothers feel frustrated and often helpless with regards to taking care of their children. “I’d come out sometimes and I’d be so frustrated because I felt like, ‘You weren’t listening’. They just wouldn’t listen to me. It was as if – you know, ‘You’re just an overreacting mom’.” (P6) Even when the PCPs did not provide effective treatments, mothers were quite accepting of the treatment when they felt that their views were respected and ‘listened to’ ” that’s not eczema cream, so I thought that’s not what I was expecting … but I can’t really-you know -fault them for trying the different creams.”(P7) Referral practices from Primary to Secondary Care also varied significantly with some parents facing frustrating delays with referral. Most of our interviewees found specialist clinics satisfactory, although some expressed discontentment over the usefulness of the consultation and followup processes. Conclusion: Parents experience considerable variation with regards to access, knowledge and attitude of PCPs in the WM region for children with allergies. Experiences with secondary care were largely favourable. In general, parents greatly valued being listened to and taken seriously by their clinicians.

Anesthetic agents in patients with very long-chain acyl-coenzyme A dehydrogenase deficiency: a literature review (2014)

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Type of publication:
Journal article

Author(s):
*Redshaw C, *Stewart C

Citation:
Pediatric Anesthesia, 11 2014, vol./is. 24/11(1115-9), 1155-5645;1460-9592 (2014 Nov)

Abstract:
Very long-chain acyl-coenzyme A dehydrongenase deficiency (VLCADD) is a rare disorder of fatty acid metabolism that renders sufferers susceptible to hypoglycemia, liver failure, cardiomyopathy, and rhabdomyolysis. The literature about the management of these patients is hugely conflicting, suggesting that both propofol and volatile anesthesia should be avoided. We have reviewed the literature and have concluded that the source papers do not support the statements that volatile anesthetic agents are unsafe. The reports on rhabdomyolysis secondary to anesthesia appear to be due to inadequate supply of carbohydrate not volatile agents. Catabolism must be avoided with minimal fasting, glucose infusions based on age and weight, and attenuation of emotional and physical stress. General anesthesia appears to be protective of stress-induced catabolism and may offer benefits in children and anxious patients over regional anesthesia. Propofol has not been demonstrated to be harmful in VLCADD but is presented in an emulsion containing very long-chain fatty acids which can cause organ lipidosis and itself can inhibit mitochondrial fatty acid metabolism. It is therefore not recommended. Suxamethonium-induced myalgia may mimic symptoms of rhabdomyolysis and cause raised CK therefore should be avoided. Opioids, NSAIDS, regional anesthesia, and local anesthetic techniques have all been used without complication.

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