Archives of Disease in Childhood最新文献

We present 19 judgments of English courts; all that we could find relating to the refusal of blood transfusion by or on behalf of children of Jehovah's Witness families.This provides detailed context to clinicians faced with this dilemma.Our review identifies demographic patterns of applications to the court: the broad separation into infants and capable teenagers; their underlying diagnosis; proximity to majority; prognosis; their independent capability to refuse life-saving treatment. The positions taken by the applicant trusts, the parents, the children themselves and the clinicians seeking permission compulsorily to transfuse also form patterns, together with the judicial response and the demonstrable evolution of judicial thinking.Without these thematic patterns, it would not be possible to provide generic guidance for patients, their families, clinicians or trust managers, as to what factors should be considered when facing the situation where a child or her family is refusing treatment that may save life or prevent irremediable harm.Our conclusions, based on the emerging patterns, including the benefits of centralising clinical judgement relating to compulsory transfusion in paediatric haematology/oncology centres; the suggestion of specific research (including to determine how the judges in these cases reached a conclusion on the individual teenager's capacity to make the choices that they advanced to the court) and avoiding the temptation to seek a rolling or enduring authority to compel transfusion.These and other patterns and conclusions provide guidance as to what should be considered if contemplating an application for judgement in these circumstances.

Objective: We evaluated the long-term association between the COVID-19 pandemic and the language development of children aged 18 months by comparing prepandemic and pandemic periods in Japan.

Study design: This repeated cross-sectional study included 39 840 children attending 18-month health check-ups conducted by the Okayama City Public Health Center (January 2017-March 2024). We compared language development indicators before (January 2017-March 2020) and during (April 2020-March 2024) the pandemic, with the latter divided into early (April 2020-March 2022) and late (April 2022-March 2024) periods. The primary outcome was the proportion of children requiring language development follow-up (children who did not meet any one of the three questions on language development). The secondary outcome was the proportion of children who could not say ≥3 meaningful words (one of the three questions). Risk ratios (RRs) and 95% CIs were estimated adjusting for confounders, with subgroup analyses by sex, childcare location (home, nursery school) and family size (≤3, ≥4).

Results: Compared with the prepandemic period, increased RRs were observed during the pandemic: 1.19 (95% CI 1.15 to 1.22) for the primary outcome and 1.16 (95% CI 1.11 to 1.22) for the secondary outcome. RRs were higher in the late than in the early period. Adverse associations were more pronounced in girls than boys, and in children cared for at home.

Conclusion: The long-term association between the pandemic and language development at 18 months suggests the need for more comprehensive support for high-risk families.

Objective: This study aimed to examine whether biomarker tests-finger-prick, skin-prick and offline fractional exhaled nitric oxide (FeNO)-are acceptable and feasible as a guide to treatment decisions, uniquely combining the perspectives of parents of preschool children with wheeze and healthcare professionals (HCPs) working in National Health Service (NHS) primary care.

Design: Qualitative interview study. Criterion sampling was used to recruit 16 parents from 16 families, and convenience sampling to recruit 16 HCPs (doctors and nurses) from 14 primary care NHS practices. Qualitative data were collected via online one-to-one interviews and focus groups (FGs), conducted on Microsoft Teams, transcribed and thematically analysed within the NVivo software package.

Results: Parents described the biomarker tests as acceptable when they were supported by evidence of effectiveness and empathetic communication from HCPs. Skin-prick testing was the most preferred test by parents as it helped them minimise allergen exposures. HCPs favoured finger-prick and FeNO tidal breathing test due to greater familiarity and feasibility in primary care. Time constraints, cost of devices and training to perform the biomarker tests were reported as barriers to implementation. Both groups agreed that testing frequency should depend on wheeze severity. Finally, a proposed future randomised controlled trial examining whether a biomarker-based approach is superior to the current symptom-based approach was regarded as acceptable and feasible.

Conclusion: Finger-prick, skin-prick and FeNO testing are conditionally acceptable and feasible in clinical practice for preschool wheeze. However, there should be evidence of their effectiveness, empathetic communication between parents and HCPs and tests' cost-effectiveness to support NHS funding.

Objective: To evaluate whether a point-of-care decision rule could safely reduce antibiotic prescriptions in children presenting with fever without source in emergency departments.

Design: Open cluster randomised clinical trial (registered on ClinicalTrials.gov).

Setting: Twenty-five European paediatric emergency departments participated from November 2018 to October 2021.

Patients: Children aged 6 days to 36 months presenting with acute fever without source.

Interventions: During the first year, all centres (or clusters) followed their usual care protocols. In the second year, centres were randomised 1:1 to either continue usual care or to adopt the decision rule based on age, clinical symptoms, urine analysis and point-of-care procalcitonin measurements. In the third year, all centres applied the decision rule.

Main outcomes and measures: The primary outcome was antibiotic exposure within 15 days. Secondary outcomes included morbidity and mortality assessed at day 15.

Results: Among 4882 children (median age: 3 months, IQR 1-14), 2440 were in the usual care group and 2442 in the decision rule group. Serious bacterial infections occurred in 766 (15.7%) children, and invasive bacterial infections in 67 (1.4%). In the intention-to-treat analysis, 927 children (38.0%) received antibiotics within 15 days in the usual care group, compared with 641 (26.2%) in the decision rule group (OR 0.57; 95% CI 0.43 to 0.75; p<0.001). Morbidity and mortality rates were similar between groups (OR 0.83; 95% CI 0.57 to 1.22; p=0.34).

Conclusions: The decision rule safely reduced unnecessary antibiotic use in young children with fever without source in emergency departments.

Trial registration number: NCT03607162.

Objective: To assess the proportion of pictures of sleeping infants or infant sleep environments that are inconsistent with safe infant sleep recommendations (SISRs) in the visual exposome of infant caretakers.

Design: A systematic review and meta-analysis.

Data sources and study selection: In November 2023, we searched PubMed, Scopus, Web of Science and Google Scholar to identify studies evaluating the level of inconsistency between SISRs and pictures in public spaces. The risk of bias of included studies was assessed with a customised version of Hoy's tool for prevalence studies. Random-effects meta-analyses were used to obtain summary estimates of the proportion of pictures inconsistent with SISRs.

Results: We screened 1380 records and included 7 peer-reviewed articles reporting studies conducted between 2008 and 2023 that analysed pictures found in parenting magazines, online and print newspapers, baby diaper packaging, commercial stock photography websites and Instagram. The overall risk of bias was low. Among the 5442 pictures depicting sleeping infants or infant sleep environments, summary estimates of the proportion of inconsistencies with SISRs were 37% for a non-supine sleeping position, 6% for a soft sleeping surface, 8% for sharing the sleeping surface, 15% for an unsafe crib, 73% for soft objects or loose bedding, 89% for no pacifier use, 17% for a covered head, and 89% for at least one SISR inconsistency.

Conclusions: Infant caretakers' visual exposome is greatly inconsistent with SISRs. Given the evidence in support that pictures affecting human behaviour, these results should serve as a call to action for stakeholders and legislators.

Objective: Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is an inherited adrenal steroid synthesis disorder included in Dutch newborn screening (NBS) since 2002. Screening involves measuring 17-hydroxyprogesterone (17-OHP) in dried blood spots (DBS) with gestational age-adjusted cut-offs. Since October 2021, a second-tier 21-deoxycortisol (21-DF) test has replaced the 17-OHP measurement in a second heel prick after inconclusive results. This study evaluates the performance of the second-tier test from 1 October 2021 to 30 September 2023.

Design: 17-OHP was measured by immunoassay in regional NBS laboratories. DBS with inconclusive and positive 17-OHP results was sent to Amsterdam UMC for 21-DF measurement by liquid chromatography tandem mass spectrometry. Genetic analysis of CYP21A2, CYP11B1, POR and HSD3B2 was performed on DBS from newborns with false-positive second-tier results.

Results: Over 2 years, 21-DF was measured in DBS of 147 newborns (=0.04%). Twenty newborns were directly referred to a paediatric endocrinologist based on positive 17-OHP results: 15 had a positive 21-DF and were diagnosed with classical CAH (genetically confirmed), while five were first-tier false-positives. Of 127 newborns with inconclusive 17-OHP results, three had a positive 21-DF and were referred but not diagnosed with CAH: second-tier false-positives. In total, 8/23 referred newborns were false-positives. Genetic analysis of six false-positive second-tier DBS showed pathogenic CYP21A2 variants in five.

Conclusions: The modified protocol improved CAH screening by preventing 127 heel pricks in 2 years and reducing unnecessary referrals (currently 2.4%, previously 7.7%). 5/6 false-positive second-tier tests were most likely due to non-classical CAH. Further optimisation of cut-offs may prevent these false-positives.