Early care of the preterm infant – current evidence

Morris, I & Adappa, R. Paediatrics and Child Health. Available online: 26 March 2016

The quality of care delivered in the immediate aftermath of delivery is crucial in determining short and long term outcomes for babies, especially in those born at less than 28 weeks gestation. From parental counselling and team preparation prior to delivery, to delivery suite management and early care on the neonatal unit, each element plays an important role. Good team working, excellent communication, and a focussed and logical approach are essential. This article gives an overview of the key considerations to be incorporated in to this period, and reviews the latest evidence base behind recommendations including thermoregulatory support, delayed cord clamping, oxygen supplementation, PEEP versus intubation, and the role of surfactant.

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New action to cut stillbirths

NHS England publishes new guidance that aims to reduce stillbirths in England.

The new guidance – called Saving Babies’ Lives Care Bundle – is part of a drive to halve the rate of stillbirths from 4.7 per thousand to 2.3 per thousand by 2030, potentially avoiding the tragedy of stillbirth for more than 1500 families every year.
While the majority of women receive high quality care, there is around a 25 per cent variation in stillbirth rates across England.

The guidance addresses this variation by bringing together four key elements of care based on best available evidence and practice in order to help reduce stillbirth rates.

Children in intensive care recover faster with little to no nutrition


Critically ill children are artificially fed soon after their arrival in intensive care. This common practice is based on the assumption that it will help them recover more quickly. An international study coordinated at KU Leuven, Belgium, has now disproven this theory. The study shows that receiving little to no nutrition during the first week in intensive care makes children recover faster.

Critically ill children in intensive care are unable to eat independently. The current standard of care for such children is based mostly on the assumption that they need to eat to regain their strength. Therefore, the method that is applied worldwide is to artificially feed these children during the first days of their stay in intensive care. This artificial nutrition is meant to strengthen their muscles, prevent complications, and speed up their recovery. The artificial nutrition is infused directly into the bloodstream.

An international team of researchers from University Hospitals Leuven (Belgium), Sophia Children’s Hospital Rotterdam (The Netherlands), and Stollery Children’s Hospital Edmonton (Canada) has now challenged the validity of this common practice. They conducted a randomized controlled trial that involved 1,440 critically ill children. The researchers examined whether fasting or receiving very small amounts of feeding during the first week in the pediatric intensive care unit was better for the children than full feeding through an IV.

Read the full commentary here

Read the original research here

Diagnosis and management of food allergy in children

Luyt, D. et al. Paediatrics and Child Health. Available online: 17 March 2016.

Image source: Wellcome Library, London // CC BY-NC-ND 4.0

Food allergy (FA) in children is common, affecting about 6% of children in the UK, and is thought to be increasing in prevalence.

Presentation varies widely with age, causative food, type of FA (IgE-mediated or non-IgE mediated) and severity. Assessment of suspected FA includes a detailed clinical history and dietary history and appropriate confirmatory allergy testing.

The traditional management of complete dietary exclusion of the causative and related foods is evolving to one of limiting exclusion and early reintroduction. Novel treatments under investigation are mechanisms to prevent FA and oral desensitisation in selected cases in an attempt to cure FA.

This article aims to give advice to the generalist about how to assess and initiate appropriate investigation a child presenting with possible food allergy.

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Biomechanical characteristics of head injuries from falls in children younger than 48 months

Hughes, J. et al. Arch Dis Child 2016;101:310-315

Background: A fall-height threshold is important when evaluating the likelihood of structural head injury or abusive head trauma. This study investigates witnessed falls to correlate the fall characteristics with the extent of injury.

Method: Case–control study of children aged ≤48 months who attended one hospital following a fall from <3 m (10 ft), comparing cases who sustained a skull fracture or intracranial injury (ICI) with controls, who had minor head injuries. Characteristics included: the mechanism of injury, surface of impact, site of impact to the head and fall height.

Results Forty-seven children had a skull fracture or ICI, while 416 children had minor head injuries. The mean fall height for minor head injuries was significantly lower than that causing skull fracture/ICI (p<0.001). No skull fracture/ICI was recorded in children who fell <0.6 m (2 ft), based on the height of the head centre of gravity. Skull fractures/ICI were more likely in children aged ≤12 months (p<0.001) from impacts to the temporal/parietal or occipital region (p<0.001), impacts onto wood (p=0.004) and falls from a carer’s arms, particularly when on stairs (p<0.001). No significant difference was reported between the mean fall heights of children who had a simple skull fracture (n=17) versus those who had a complex fracture or ICI (n=30).

Conclusions: An infant is more likely to sustain a skull fracture/ICI from a fall above a 0.6 m (2 ft) threshold, based on the height of the head centre of gravity, or with a parietal/temporal or occipital impact. These variables should be recorded when evaluating the likelihood of skull fracture/ICI.

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Systematic review of the toxicity of short-course oral corticosteroids in children

Aljebab, F. et al. Arch Dis Child 2016;101:365-370

Background: Short-course oral corticosteroids are commonly used in children but are known to be associated with adverse drug reactions (ADRs). This review aimed to identify the most common and serious ADRs and to determine their relative risk levels.

Methods: A literature search of EMBASE, MEDLINE, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions to identify studies in which oral corticosteroids were administered to patients aged 28 days to 18 years of age for up to and including 14 days of treatment. Each database was searched from their earliest dates to December 2013. All studies providing clear information on ADRs were included.

Results: Thirty-eight studies including 22 randomised controlled trials (RCTs) met the inclusion criteria. The studies involved a total of 3200 children in whom 850 ADRs were reported. The three most frequent ADRs were vomiting, behavioural changes and sleep disturbance, with respective incidence rates of 5.4%, 4.7% and 4.3% of patients assessed for these ADRs. Infection was one of the most serious ADRs; one child died after contracting varicella zoster. When measured, 144 of 369 patients showed increased blood pressure; 21 of 75 patients showed weight gain; and biochemical hypothalamic–pituitary–adrenal axis suppression was detected in 43 of 53 patients.

Conclusions: Vomiting, behavioural changes and sleep disturbance were the most frequent ADRs seen when short-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR.

Read the abstract here