Is ADHD really a sleep problem?

Around 75 percent of children and adults with attention deficit hyperactivity disorder (ADHD) also have sleep problems, but until now these have been thought to be separate issues | ScienceDaily

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  • In 75% of ADHD patients, the physiological sleep phase — where people show the physiological signs associated with sleep, such as changes in the level of the sleep hormone melatonin, and changes in sleep-related movement — is delayed by 1.5 hours.
  • Core body temperature changes associated with sleep are also delayed (reflecting melatonin changes)
  • Many sleep-related disorders are associated with ADHD, including restless-leg syndrome, sleep apnea, and the circadian rhythm disturbance, the delayed sleep phase syndrome
  • ADHD people often show greater alertness in the evening, which is the opposite of what is found in the general population
  • Many sufferers benefit from taking melatonin in the evening or bright light therapy in the morning, which can help reset the circadian rhythm
  • Recent work has shown that around 70% of adult ADHD sufferers show an oversensitivity of the eyes to light, leading many to wear sunglasses for long periods during the day — which may reinforce the problems associated with a ‘circadian shift’.
  • Chronic late sleep leads to a chronic sleep debt, associated with obesity, diabetes, cardiovascular disease and cancer. This cascade of negative health consequences may in part be preventable by resetting the sleep rhythm.

Read the overview via ScienceDaily here

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Medication Errors in Pediatric Anesthesia

A Report From the Wake Up Safe Quality Improvement Initiative | Anesthesia & Analgesia

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Background: Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies.

Conclusions: Our findings characterize the most common types of medication errors in pediatric anesthesia practice and provide guidance on future preventative strategies. Many of these errors will be almost entirely preventable with the use of prefilled medication syringes to avoid accidental ampule swap, bar-coding at the point of medication administration to prevent syringe swap and to confirm the proper dose, and 2-person checking of medication infusions for accuracy.

Full reference: Lobaugh, L. et al. (2017) Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative. Anesthesia & Analgesia. Vol. 125 (Issue 3) pp. 936–942

Rehabilitation services for children after severe acquired brain injury

Survival with brain injury is an outcome of severe illness that may be becoming more common. Provision for children in this situation has received little attention | Archives of Disease in Childhood

Objectives: We sought to estimate rates of severe paediatric acquired brain injury (ABI) requiring rehabilitation and to describe current provision of services for these children in the UK.

Methods: This study conducted an analysis of Hospital Episode Statistics data between April 2003 and March 2012, supplemented by a UK provider survey completed in 2015. A probable severe ABI requiring rehabilitation (PSABIR) event was inferred from the co-occurrence of a medical condition likely to cause ABI (such as meningitis) and a prolonged inpatient stay (>=28 days).

Results: During the period studied, 4508 children aged 1–18 years in England had PSABIRs. Trauma was the most common cause (30%) followed by brain tumours (19%) and anoxia (18.3%). An excess in older males was attributable to trauma. We estimate the incidence of PSABIR to be at least 2.93 (95%CI 2.62 to 3.26) per 100 000 young people (1–18 years) pa. The provider survey confirmed marked geographic variability in the organisation of services in the UK.

Conclusions: There are at least 350 PSABIR events in children in the UK annually, a health problem of similar magnitude to that of cerebral palsy. Service provision for this population varies widely around the UK, in contrast with the nationally coordinated approach to paediatric intensive care and major trauma provision.

Full reference: Hayes, L. et al. (2017) Requirements for and current provision of rehabilitation services for children after severe acquired brain injury in the UK: a population-based study. Archives of Disease in Childhood. Vol. 102 (no. 09) pp. 813-820.

Radiation dose from common radiological investigations in children with cystic fibrosis

Cumulative radiation exposure is associated with increased risk of malignancy. This is important in cystic fibrosis (CF) as frequent imaging is required to monitor disease progression and diagnose complications | BMJ Open

Previous estimates of cumulative radiation are outdated as the imaging was performed on older equipment likely to deliver higher radiation. Our objectives were to determine the radiation dose delivered to children during common radiological investigations using modern equipment and to identify the number of such investigations performed in a cohort of children with CF to calculate their cumulative radiation exposure.

The mean EED for the common radiological investigations varied according to age. The range was 0.01–0.02 mSv for chest X-rays, 0.03–0.11 mSv for abdominal X-rays, 0.57–1.69 mSv for CT chest, 2.9–3.9 mSv for abdominal and pelvic CT, 0.20–0.21 mSv for sinus CT and 0.15–0.52 mSv for fluoroscopy-guided procedures. The mean EED was three to five times higher for helical compared with axial chest CT scans. The mean annual cumulative EED for our cohort of children with CF was 0.15 mSv/year with an estimated cumulative paediatric lifetime EED (0–18 years) of 3.5 mSv.

This study provides up-to-date estimations of the radiation exposure when using common radiological investigations. These doses and the estimates of cumulative radiation exposure in children with CF are lower than previously reported. This reflects the reduced EED associated with modern equipment and the use of age-specific scanning protocols.

Full reference: Ward, R. et al. (2017) Radiation dose from common radiological investigations and cumulative exposure in children with cystic fibrosis: an observational study from a single UK centre. BMJ Open. 7:e017548. 

Healthcare delivery in the early management of bacterial meningitis

The aim of this study was to define early presenting features of bacterial meningitis in young infants in England and to review the adequacy of individual case management as compared with relevant national guidelines and an expert panel review | BMJ Open

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Image source: Wellcome Images // CC0

Results: Of the 97 cases recruited across England and Wales, 66 (68%) were admitted from home and 31 (32%) were in hospital prior to disease onset. Almost all symptoms reported by parents appeared at the onset of the illness, with very few new symptoms appearing subsequently. Overall, 20/66 (30%) infants were assessed to have received inappropriate prehospital management. The median time from onset of first symptoms to first help was 5 hours (IQR: 2–12) and from triage to receipt of first antibiotic dose was 2.0 hours (IQR: 1.0–3.3), significantly shorter in infants with fever or seizures at presentation compared with those without (1.7 (IQR: 1.0–3.0) vs 4.2 (IQR: 1.8–6.3) hours, p=0.02). Overall, 26 (39%) infants had a poor outcome in terms of death or neurological complication; seizures at presentation was the only significant independent risk factor (OR, 7.9; 95% CI 2.3 to 207.0). For cases in hospital already, the median time from onset to first dose of antibiotics was 2.6 (IQR: 1.3–9.8) hours, and 12/31 (39%) of infants had serious neurological sequelae at hospital discharge. Hearing test was not performed in 23% and when performed delayed by ≥4 weeks in 41%.

Conclusions: In young infants, the non-specific features associated with bacterial meningitis appear to show no progression from onset to admission, whereas there were small but significant differences in the proportion of infants with more specific symptoms at hospital admission compared with at the onset of the illness, highlighting the difficulties in early recognition by parents and healthcare professionals alike. A substantial proportion of infants received inappropriate prehospital and posthospital management. We propose a targeted campaign for education and harmonisation of practice with evidence-based management algorithms.

Full reference: Okike, I.O. et al. (2017) Assessment of healthcare delivery in the early management of bacterial meningitis in UK young infants: an observational study. BMJ Open. 7:e015700.

Fever in under 5s: assessment and initial management

New NICE guidance

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This guideline was updated in August 2017. It covers the assessment and early management of fever with no obvious cause in children aged under 5. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness among young children who present with fever in primary and secondary care.

Read full Clinical guideline [CG160] here

The role of trait mindfulness in quality of life and asthma control among adolescents with asthma

The current study focused on the role of trait mindfulness in asthma-related quality of life (QoL) and asthma control in adolescent asthma patients | Journal of Psychosomatic Research

In this cross-sectional study, questionnaire data of 94 adolescents with asthma that were prescribed daily asthma medication were included. Two Structural Equation Models (SEMs), a direct model and an indirect model, were tested.

We found that trait mindfulness was directly related to asthma-related QoL, but not to asthma control. The relationship between trait mindfulness and asthma-related QoL was explained by asthma-specific, but not by general stress. Furthermore, an indirect relation from mindfulness to asthma control via asthma-specific stress was found.

Cross-sectional evidence for a relation between mindfulness and asthma-related QoL is found. These findings may point to the possibility that an intervention aimed at increasing mindfulness could be a promising tool to improve asthma-related QoL in adolescents via a decrease in asthma-specific stress.

Full reference: Cillessen, L. et al. (2017) The role of trait mindfulness in quality of life and asthma control among adolescents with asthma. Journal of Psychosomatic Research. Vol. 99 (August) pp. 143–148.