‘I fell off and landed badly’: Children’s experiences of forearm fracture and injury prevention.

Sims-Gould, J. et al. Journal of child health care. Vol. 20, no. 1, p. 98-108, 1741-2889 (March 2016)

Forearm fractures are one of the most common injuries sustained by children. Our descriptive study addressed, from the perspective of a child, the following research objectives: (1) to describe their fracture experience and (2) to describe how fractures might be prevented.

Photovoice is a unique research strategy by which people create and discuss photographs. This technique has been used to elicit the perspectives of those whose voices are often ‘not heard’ in research, like children.

Participants were recruited from a larger three-year prospective trial and included 10 boys (12.3 ± 1.6 years) and 7 girls (11.3 ± 1.6 years). We asked participants to take pictures to explain where their injury occurred (place), what they were doing at the time (context) and how the fracture had happened (mechanism). We also used semi-structured interview techniques.

The following key themes emerged from our interviews: (1) the built environment as a key factor that ’caused’ their fracture, (2) the fracture experienced as a journey not an event and (3) strategies to prevent fractures.

A simple clinical step to potentially reduce subsequent fractures will be for clinicians to have a brief conversation with their young patients and to listen to the child’s personal preventive strategies.

Role of Vitamin D in Hospitalized Children With Lower Tract Acute Respiratory Infections.

Cebey-López, M. et al. Journal of pediatric gastroenterology and nutrition, vol. 62, no. 3, p. 479-485, 1536-4801 (March 2016)

Vitamin D is known to have modulatory actions in the immune system. Its influence on the severity of lower tract acute respiratory infections (LT-ARIs) is unclear. The aim of the present study was to evaluate the role of vitamin D on LT-ARI in paediatric patients. Children admitted to hospital with LT-ARI were prospectively recruited through the GENDRES network (March 2009-May 2013).

The 25-hydroxyvitamin D (25-OHD) levels were measured by immunoassay. The severity of the illness was evaluated according to clinical scales, length of hospital stay, ventilatory requirements, and pediatric intensive care unit admission. A total of 347 patients with a median (interquartile range) age of 8.4 (2.6-21.1) months were included. The mean (SD) 25-OHD levels in our series were 27.1 (11.3) ng/mL. In this study, a cutoff value of ≥30 ng/mL was considered optimal vitamin status.

Patients with 25-OHD levels <20 ng/mL were at a higher risk of showing severe signs of respiratory difficulties (OR 5.065, 95% confidence interval 1.998-12.842; P = 0.001) than patients with normal values, and had a 117% higher risk of oxygen necessity and 217% higher risk of ventilatory requirement than those patients with normal values. An inverse correlation was found between 25-OHD levels and the severity in the evaluated scales. 25-OHD levels did not influence PICU admission rate or length of hospital stay. 25-OHD levels of children admitted because of a LT-ARI are <30 ng/mL. Lower levels of 25-OHD were found to be correlated with severity of the disease.

The possible role of abnormal 25-OHD levels as a facilitator or consequence of the infection needs further evaluation.

Read the abstract here

Zinc as an adjunct to antibiotics for the treatment of severe pneumonia in children <5 years: a meta-analysis of randomised-controlled trials.

Tie, H-T. The British journal of nutrition, vol. 115, no. 5, p. 807-816, 1475-2662 (March 2016)

N0019779 Primary atpical pneumonia
Image source: Medical Art Service, I. Christensen – Wellcome Images

The effect of Zn, as an adjunct to antibiotics, on the treatment of severe pneumonia in young children is still under debate; therefore, we performed a meta-analysis to evaluate the therapeutic role of Zn for severe pneumonia in children younger than 5 years.

PubMed, Cochrane library and Embase databases were systematically searched from inception until October 2015 for randomised-controlled trials (RCT) that assessed the effect of Zn as an adjunct to antibiotics for severe pneumonia. Random-effects model was used for calculating the pooled estimates, and intention-to-treat principle was also applied. Nine RCT involving 2926 children were included.

Overall, the pooled results showed that adjunct treatment with Zn failed to reduce the time to recovery from severe pneumonia (hazard ratios (HR)=1·04; 95 % CI 0·90, 1·19; I 2=39 %; P=0·58), hospital length of stay (HR=1·04; 95 % CI 0·83, 1·33; I 2=57 %; P=0·74), treatment failure (relative risk (RR)=0·95; 95 % CI 0·79, 1·14; I 2=20 %; P=0·58) or change of antibiotics (RR=1·07; 95 % CI 0·79, 1·45; I 2=44 %; P=0·67).

In addition, continuous outcomes were consistent while meta-analysed with standard mean difference, and all outcomes remained stable in intention-to-treat analysis.

No significant differences were observed in the two groups between death rate, adverse events or recovery times of severe pneumonia indicators. Our results suggested that adjunct treatment with Zn failed to benefit young children in the treatment of severe pneumonia. Considering the clinical heterogeneity, baseline characteristics of children, definition of severe pneumonia and Zn supplement way should be taken into consideration in future research.

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Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

Rossi, V. et al. Pediatric Surgery International. March 2016, Volume 32, Issue 3, pp 277-283

Background: Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

Aims: To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

Methods: We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients’ Visick score assessed parents’ perspective.

Results: Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents’ perspectives were excellent or good in 85 %.

Conclusions: A significant positive impact of redo Nissen intervention on the patient’s outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

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Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments

Kessler, D. et al. The Journal of Emergency Medicine. Volume 50, Issue 3, March 2016, Pages 403–415.e3

Background: Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of $4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described.

Objectives: We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance.

Methods: This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance.

Results: We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43–84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01–1.88).

Conclusions: Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.

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A systematic review of alternative splinting versus complete plaster casts for the management of childhood buckle fractures of the wrist.

Hill, C. E. et al. Journal of pediatric orthopedics. Part B, vol. 25, no. 2, p. 183-190, 1473-5865 (March 2016)

N0017004 Fracture, distal radius and ulna
Image source: Wellcome Images

Image shows fracture, distal radius and ulna

Abstract:  Paediatric wrist-buckle fractures are common distal radius fractures with inherent stability. Traditional management with complete plaster-cast immobilization necessitates follow-up visits, time off school/work and hospital treatment costs. Treatment with alternative splinting, negating the need for follow-up visits and saving time and money, has been proposed. However, concerns with regard to complications, primarily pain, have been raised; hence, the topic remains controversial.

A systematic review was performed with eight randomized-controlled trials analysed. Alternative splinting was superior to casting in terms of function, cost and convenience, but with no significantly worse pain or fracture complication level. The evidence endorses the use alternative splinting over casting in paediatric wrist-buckle fractures.

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“Vaginal seeding” of infants born by caesarean section

Cunningham, A. et al. BMJ 2016;352:i227

How should health professionals engage with this increasingly popular but unproved practice?

The microbiota is the community of microbes that colonises our bodies, outnumbering our own cells 10 to 1. This complex microbial community varies from one part of the body to another, and from one person to another. Characteristic differences in the microbiota are associated with various diseases. As a result interest has surged in the potential for manipulating the microbiota to promote health and treat disease.

The term “vaginal seeding” describes the use of a gauze swab to transfer maternal vaginal fluid, and hence vaginal microbiota, on to an infant born by caesarean section. The composition of the early microbiota of infants is heavily influenced by mode of delivery. In infants born by caesarean section the microbiota resembles that of maternal skin, whereas in vaginally born infants it resembles that of the maternal vagina.

These early differences in the microbiota have been suggested to determine susceptibility to an increasing number of common non-communicable diseases. In theory, vaginal seeding might restore the microbiota of infants born by caesarean section to a more “natural” state and decrease the risk of disease. The potential benefits of vaginal seeding have recently been reported in the press and, as a result, demand has increased among women attending our hospitals. Demand has outstripped both professional awareness and professional guidance on this practice.

Read the full editorial here