Views from the NHS frontline: Health Visitors

Amid drastic cuts to health visiting services, I’m struggling to help the vulnerable families I see every day | The Guardian Healthcare Network

112-2Health visitors don’t always get good press at the school gates or toddler groups. Among my fellow nursing friends, the standing joke is that I spend my day simply weighing babies. I guess as a result it’s not hard to see why in some areas the value placed on health visiting has fallen so far that the service will be cut completely.

At the moment most councils are reviewing the funding for health visiting amid drastic cuts to public health budgets. Cumbria and Staffordshire are planning on cutting health visiting posts and a number of other NHS trusts have job freezes and have discussed redundancies. NHS Digital reported this year that the number of health visitors dropped in UK by 433 posts.

While perhaps there may be some truth in the comments I so often hear, the reality of health visiting feels very different.

Read the full article here

Quality improvement in pediatrics: past, present, and future

Schwartz, S.P. & Rehder, K.J. Pediatric Research. Published online: 26 October 2016


Almost two decades ago, the landmark report “To Err is Human” compelled healthcare to address the large numbers of hospitalized patients experiencing preventable harm. Concurrently, it became clear that the rapidly rising cost of healthcare would be unsustainable in the long-term. As a result, quality improvement methodologies initially rooted in other high-reliability industries have become a primary focus of healthcare.

Multiple pediatric studies demonstrate remarkable quality and safety improvements in several domains including handoffs, catheter-associated blood stream infections, and other serious safety events. While both quality improvement and research are data-driven processes, significant differences exist between the two. Research utilizes a hypothesis driven approach to obtain new knowledge while quality improvement often incorporates a cyclic approach to translate existing knowledge into clinical practice. Recent publications have provided guidelines and methods for effectively reporting quality and safety work and improvement implementations.

This review examines not only how quality improvement in pediatrics has led to improved outcomes, but also looks to the future of quality improvement in healthcare with focus on education and collaboration to ensure best practice approaches to caring for children.

Read the abstract here

Impairment of Social Function in Young Females With Recent-Onset Anorexia Nervosa and Recovered Individuals

Bentz, M. et al. Journal of Adolescent Health. Published online: October 27, 2016
Image source: Jasmine Parker – Wellcome Images // CC BY-NC-ND 4.0

Purpose: A subgroup of individuals with anorexia nervosa (AN) displays social difficulties; however, it is not clear if individuals with comorbid autism spectrum disorders account for these difficulties.

Methods: We compared social function using the Autism Diagnostic Observation Schedule in 43 young females with first-episode AN who did not have comorbid autism spectrum disorder, 28 individuals recovered from adolescent-onset AN, and 41 healthy comparison individuals (age range 14–22 years). We measured adaptive behavior with the Vineland-II parent questionnaire, and aspects of social cognition with psychological tests, such as the Reading-the-Mind-in-the-Eyes test, Profile of Nonverbal Sensitivity short version, The Awareness of Social Inference Test, Animated Triangles, and the CANTAB Affective Go/No-go task.

Results: Participants with first-episode AN and those recovered from AN displayed difficulties in social function, which were not associated with body mass index or other state factors of the disorder in those with first-episode AN. Mood problems and anxiety were not associated with these difficulties. Parents rated participants with first-episode AN lower than recovered and control participants on the Socialization Domain of Vineland-II. Finally, only participants recovered from AN demonstrated deficits in specific domains of social cognition: perceiving nonverbal bodily gesture and vocal prosody.

Conclusions: Young females with first-episode AN and those recovered from AN displayed impairments in social function, which may represent more stable traits of the disorder. Only participants recovered from AN demonstrated deficits in social cognition.

Read the abstract here

Study recommends screening toddlers for heart disease risk

NHS Behind the Headlines | Published online: 27 October 2016

A new study looked at the feasibility of screening for familial hypercholesterolaemia (FH), an inherited condition that affects around 1 to 2 in every 250 people in the UK. It can cause abnormally high cholesterol levels. It doesn’t usually cause any noticeable symptoms, but people with FH aged between 20 and 40 are 100 times more likely to have a heart attack than other people their age.

UK researchers tested 10,095 one-year-olds to explore the feasibility of screening for FH. They tested the toddlers at the same time they had routine vaccinations at the age of one. Researchers found 28 children with FH. The parents of children with FH were then also tested. The study found not all children with an FH mutation had high cholesterol, however, and some with high cholesterol did not have a known FH mutation. This means FH mutation testing alone would not be a useful screening test, so the researchers suggest testing cholesterol levels first. The approach used in the study does have the added benefit of identifying parents with FH who didn’t realise the condition ran in their family.

Once FH is diagnosed, it is relatively straightforward to treat through making lifestyle changes and taking drugs known to reduce cholesterol, mainly statins. This research will help inform the UK’s National Screening Committee when considering whether the benefits of screening for FH outweigh the harms.

Read the full analysis here

Read the original research article here

Young children’s ability to report on past, future, and hypothetical pain states: a cognitive-developmental perspective

Jaaniste, T. et al. (2016) Pain. 157(11). pp. 2399–2409


Children are at times asked by clinicians or researchers to rate their pain associated with their past, future, or hypothetical experiences. However, little consideration is typically given to the cognitive-developmental requirements of such pain reports. Consequently, these pain assessment tasks may exceed the abilities of some children, potentially resulting in biased or random responses. This could lead to the over- or under-treatment of children’s pain.

This review provides an overview of factors, and specifically the cognitive-developmental prerequisites, that may affect a child’s ability to report on nonpresent pain states, such as past, future, or hypothetical pain experiences. Children’s ability to report on past pains may be influenced by developmental (age, cognitive ability), contextual (mood state, language used by significant others), affective and pain-related factors.

The ability to mentally construct and report on future painful experiences may be shaped by memory of past experiences, information provision and learning, contextual factors, knowledge about oneself, cognitive coping style, and cognitive development. Hypothetical pain reports are sometimes used in the development and validation of pain assessment scales, as a tool in assessing cognitive-developmental and social-developmental aspects of children’s reports of pain, and for the purposes of training children to use self-report scales. Rating pain associated with hypothetical pain scenarios requires the ability to recognize pain in another person and depends on the child’s experience with pain.

Enhanced understanding of cognitive-developmental requirements of young children’s pain reports could lead to improved understanding, assessment, and treatment of pediatric pain.

Read the abstract here

Factors important for women who breastfeed in public: a content analysis of review data from FeedFinder

Simpson, E. et al. BMJ Open.6:e011762

baby-21167_960_720Objective: To examine how the breastfeeding experience is represented by users of FeedFinder (a mobile phone application for finding, reviewing and sharing places to breastfeed in public).

Design: Content analysis using FeedFinder database.

Setting: FeedFinder, UK, September 2013–June 2015.

Methods: Reviews obtained through FeedFinder over a period of 21 months were systematically coded using a conventional content analysis approach, average review scores were calculated for the rating criteria in FeedFinder (comfort, hygiene, privacy, baby facilities) and review texts were analysed for sentiment. We used data from Foursquare to describe the type of venues visited and cross-referenced the location of venues with the Indices of Multiple Deprivation.

Results: A total of 1757 reviews were analysed. Of all the reviews obtained, 80% of those were classified as positive, 15.4% were classified as neutral and 4.3% were classified as negative. Important factors that were discussed by women include facilities, service, level of privacy available and qualities of a venue. The majority of venues were classified as cafes (26.4%), shops (24.4%) and pubs (13.4%). Data on IMD were available for 1229 venues mapped within FeedFinder, 23% were located within the most deprived quintile and 16% were located in the least deprived quintile.

Conclusions: Women create content that is positive and informative when describing their breastfeeding experience in public. Public health bodies and business owners have the potential to use the data from FeedFinder to impact on service provision. Further work is needed to explore the demographic differences that may help to tailor public health interventions aimed at increasing breastfeeding rates in the UK.

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Effect of Delayed Cord Clamping on Systemic Blood Flow: A Randomized Controlled Trial

Popat, H et al. (2016) The Journal of Pediatrics178. pp. 81–86.e2

Objective: To determine whether delayed cord clamping improves systemic blood flow compared with immediate cord clamping in very preterm infants in the first 24 hours.

Study design: Women delivering at <30 weeks’ gestation at 5 tertiary centers were randomized to receive immediate cord clamping (<10 seconds) or delayed cord clamping (≥60 seconds). Echocardiography and cardiorespiratory data were collected at 3, 9, and 24 hours after birth. The primary outcome was mean lowest superior vena cava (SVC) flow.

Results: Of 266 infants enrolled, 133 were randomized to immediate cord clamping and 133 to delayed cord clamping. The 2 groups were similar at baseline, including mean gestation (immediate cord clamping 28 weeks vs delayed cord clamping 28 weeks) and birth weight (immediate cord clamping 1003 g vs delayed cord clamping 1044 g). There was no significant difference between groups in the primary outcome of mean lowest SVC flow (immediate cord clamping 71.4 mL/kg/min [SD 28.1] vs delayed cord clamping 70.2 mL/kg/min [SD 26.9]; P = .7). For secondary outcomes, hemoglobin increased by 0.9 g/dL at 6 hours in the group with delayed cord clamping (95% CI 3.9, 14.4; P = .0005, adjusted for baseline). The group with delayed cord clamping had lower right ventricular output (−21.9 mL/kg/min, 95% CI −39.0, −4.7; P = .01). Rates of treated hypotension, ductus arteriosus size and shunt direction, and treatment of the ductus arteriosus were similar.

Conclusions: Delayed cord clamping had no effect on systemic blood flow measured as mean lowest SVC flow in the first 24 hours in infants <30 weeks’ gestation.

Read the abstract here