BMJ Paediatrics Open最新文献

Introduction: Delayed cord clamping (DCC) is an evidence-based intervention that reduces mortality, anaemia and disability in infants born <37 weeks' gestation who do not require immediate resuscitation. However, it is neither reliably recorded nor routinely implemented in Australia. The Wait a Minute or More (WAMM) study aims to reduce this gap between the evidence and practice by integrating timely sharing of cord clamping data with Evidence-based Practice for Improving Quality methods to increase the proportion of preterm infants receiving DCC for 60 s or longer (DCC60).

Methods: The WAMM study is a pragmatic stepped wedge cluster randomised trial (SW-CRT), informed by the Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Up to 20 Australian maternity hospitals will participate in this pragmatic SW-CRT to evaluate if in (Population) infants <37 weeks' gestation who do not need resuscitation, does (Intervention) the WAMM intervention (sharing of anonymised data on DCC60, together with a locally adapted quality improvement (QI) programme), compared with (Control) sharing of anonymised data on DCC60 alone, increase (primary Outcome) the proportion of infants receiving DCC60? At the end of 72 weeks, all sites will complete an 8-week period without the WAMM intervention to evaluate if implementation of DCC is sustained. Alongside the SW-CRT, an embedded process evaluation will assess the fidelity, acceptability, mechanisms of action and contextual barriers and enablers of the WAMM intervention.

Discussion: Using the stepped wedged design and guided by an explicit implementation framework (i-PARIHS), WAMM will provide information on the effectiveness and transferability of a locally adapted QI method to improve DCC60. If proven effective, ultimately scaling up the WAMM intervention globally will greatly improve childhood anaemia, death, disability and long-term costs.

Trial registration number: ACTRN12624000035527.

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe mucocutaneous reactions in children, often triggered by medications such as antibiotics, anticonvulsants and non-steroidal anti-inflammatory drugs (NSAIDs). Treatment guidelines in paediatric populations remain unclear, particularly in South Asia, where data are scarce. This study aims to describe the clinical profile, triggers, management and outcomes of paediatric SJS/TEN cases from a tertiary care centre in Pakistan.

Methods: A retrospective cross-sectional study was conducted at Aga Khan University Hospital, Karachi, Pakistan. Medical records of children aged 1 month to 15 years diagnosed with SJS or TEN between June 2008 and December 2020 were reviewed. Data on demographics, drug exposure, clinical features, treatment modalities and outcomes were extracted and analysed using Stata V.14.

Results: Among 124 identified cases, 98 children (79.0%) had TEN with >30% body surface area involvement. Mucosal involvement was seen in 85 (68.5%) cases. Prior drug exposure was documented in 98 (79.0%) patients, with antibiotics (52.0%) and NSAIDs (48.0%) being the most common triggers. Supportive care was the mainstay of treatment. Age was associated with poorer outcomes.

Conclusion: Paediatric drug-induced SJS/TEN remains a critical concern, particularly due to commonly prescribed antibiotics and NSAIDs. High mortality in TEN cases and predominant use of supportive therapy highlight the need for clear paediatric treatment protocols. Local data on the role of early immunomodulatory therapy are limited, indicating a need for further research on optimal early interventions to improve outcomes.

Background: Cochlear implantation (CI) is a critical intervention for restoring auditory function in individuals with severe to profound hearing impairment; however, the relationship between CIs and social development in hearing-impaired children has not been fully elucidated. This study examined disparities in child-parent relationship, teacher-student relationship and peer relationship between hearing-impaired children with CIs and their typically hearing (TH) peers in China, focusing on the dimensions of social relationships in social development.

Methods: Samples were selected from one primary special school and two primary mainstream schools in Xi'an, Shaanxi Province, China, in August 2024. According to the inclusion criteria, 35 CI recipients and 209 TH children in grades 3-5 were enrolled in the experimental and control groups, respectively. Self-reported data were used. Propensity score matching was employed to control demographic covariates, and the Hodges-Lehmann aligned rank test was used for the postmatching analysis.

Results: This study revealed that CI recipients reported higher teacher-student closeness (ATE=2.55, d=0.61, p<0.05) yet experienced more teacher-student conflict (ATE=5.25, d=1.78, p<0.001). CI recipients exhibited significantly elevated peer-related loneliness (ATE=18.03, d=1.62, p<0.001). The two groups have no significant differences in child-parent closeness, teacher-student dependency and teacher-student satisfaction.

Discussion: These multifaceted outcomes highlight that while hearing-impaired children with CIs achieved positive relationships with peers and adults comparable to their normal-hearing peers in specific domains, the auditory restoration provided by CIs does not automatically ensure social ease. This underscores the need for targeted language rehabilitation and inclusive educational environments to enhance their socioemotional well-being.

Background: Wilms tumour is the most common paediatric renal malignancy. The RNA demethylase alkylation repair homologue protein 5 (ALKBH5), known for its role in reversing N6-methyladenosine modification, has been increasingly implicated in tumourigenesis. Its specific role in Wilms tumour, however, remains largely unexplored. We conducted a case-control study to investigate the association between ALKBH5 gene polymorphisms and susceptibility to Wilms tumour.

Methods: Our study included 416 patients and 936 cancer-free controls from East China. We genotyped two ALKBH5 single-nucleotide polymorphisms: rs1378602 G>A and rs8400 G>A.

Results: We found that the rs8400 AA genotype was significantly associated with an increased risk of Wilms tumour compared with GG/GA carriers (adjusted OR=1.39, 95% CI 1.04 to 1.85, p=0.025). Furthermore, individuals carrying two risk genotypes faced a significantly higher risk than those with zero or one risk genotype (adjusted OR=1.43, 95% CI 1.07 to 1.92, p=0.017). Stratified analysis revealed that this elevated risk was particularly pronounced in specific subgroups: children older than 18 months, females and those diagnosed with clinical stages I and II.

Conclusion: Our findings suggest that the ALKBH5 rs8400 G>A polymorphism is associated with increased susceptibility to Wilms tumour in the Eastern Chinese paediatric population.

Background: Paediatricians are particularly vulnerable to burnout due to the emotional intensity of providing healthcare to children, along with heavy workloads and administrative burdens. This study aims to evaluate burnout among paediatricians across different seniority levels and explores its relationship with job satisfaction, quality of life and anxiety.

Methods: This cross-sectional, self-report survey was designed by an interdisciplinary team. Data on sociodemographics, burnout (Maslach Burnout Inventory), job satisfaction (Minnesota Job Satisfaction Questionnaire), quality of life (Short Form-12 Health Survey) and anxiety (Beck Anxiety Inventory) were collected and analysed.

Results: 125 paediatricians participated, including residents (54.4 %), fellows (22.4 %) and academics (23.2 %). Burnout was identified in 26.4% of participants, with emotional exhaustion (EE) (12%) and depersonalisation (15%) most elevated. Clinically verified psychiatric diagnoses (depression or anxiety) within the last year were reported by 31% of participants and were significantly associated with higher EE. Severe anxiety was found in 15%, most frequently among fellows (53%), and was inversely correlated with job satisfaction. Job satisfaction also showed a moderate negative correlation with EE and a positive correlation with personal accomplishment. Although 95% had voluntarily chosen paediatrics, only 58% would choose it again and 72% would not recommend it to their child.

Conclusions: Despite the limitations of a cross-sectional, self-reported design-which may involve risks of selection and reporting bias-this study provides important insights into burnout and its psychosocial correlates in paediatrics. Our findings highlight the need to strengthen institutional support systems, particularly for residents and fellows, to safeguard physician well-being and promote sustainable paediatric careers.

Background: This study explores child welfare investigations for medical neglect in Canada, focusing on household, family and child characteristics and drivers of substantiated victimisation.

Methods: Data from the Canadian Incidence Study of Reported Child Abuse and Neglect 2019 (CIS-2019), the most recent source of Canadian data on child maltreatment-related investigations, were used. A multistaged sampling design was used in the CIS-2019 to select a representative sample of child welfare agencies, and data were collected from investigating child welfare workers at selected agencies over a 3-month sampling period. Complex survey design weights were used to derive an annual estimate of maltreatment-related investigations conducted in the country (299 171 investigations involving children aged 0-15 years). The current study specifically examined the characteristics of the estimated 2934 investigations for medical neglect in the CIS-2019 (1% of all investigations). Bivariate analyses compared medical neglect investigations with investigations involving other forms of neglect, and a binary logistic regression identified characteristics associated with substantiation of medical neglect.

Results: Compared with other neglect investigations, medical neglect investigations were more likely to involve children less than 1 year old, caregivers under 21 years old and over 30 years old, households whose primary source of income was full-time work, primary caregivers with mental health concerns, and children with at least one functioning concern. Medical neglect investigations in which the primary caregiver had noted alcohol abuse (OR=4.693, p<0.001), drug/solvent abuse (OR=2.485, p<0.001) or mental health concerns (OR=2.231, p<0.001) were more likely to be substantiated.

Conclusions: Medical neglect is a child welfare concern with potentially dire consequences. We demonstrate that substantiated cases of medical neglect in Canada arise within the context of complex caregiver and child factors. Early collaboration, preventative efforts and supportive relationships between families and their healthcare teams could enhance adherence to medical recommendations and mitigate harm to the child.

Objective: To evaluate whether a protocol-based patent ductus arteriosus (PDA) screening pathway using targeted neonatal echocardiography (TnECHO) is associated with improved outcomes in extremely preterm infants.

Design: Single-centre pre versus post cohort study comparing a non-standardised care epoch with a prespecified PDA screening and management pathway.

Setting: Tertiary neonatal intensive care unit, Riyadh, Saudi Arabia.

Patients: Inborn infants <29 weeks' gestation cared for before and after implementation of the PDA pathway (non-standardised care n=122; protocol-based care n=122).

Interventions: Introduction of a structured PDA screening protocol incorporating TnECHO within 72 hours of birth and physiology-guided management.

Main outcome measures: Bronchopulmonary dysplasia (BPD), major intraventricular haemorrhage (IVH) and death before discharge. Multivariable logistic regression adjusted for sex, mode of delivery, plurality, antenatal corticosteroid exposure and gestational age.

Results: The protocol-based care epoch was associated with lower adjusted odds of BPD (aOR 0.43, 95% CI 0.25 to 0.75; p=0.003) and major IVH (aOR 0.27, 0.12 to 0.61; p=0.002). Mortality did not differ significantly (aOR 0.60, 0.30 to 1.22; p=0.158). PDA diagnosis increased with early structured screening (61% to 76%), but treatment rates remained stable, reflecting a physiology-guided approach. Treated infants in the protocol-based epoch demonstrated more clearly defined haemodynamic significance on echocardiography. Infants in the protocol-based epoch also required fewer days of invasive ventilation (median 23 to 10 days), and no surgical ligation procedures occurred.

Conclusions: A protocol-based PDA screening pathway using early TnECHO was associated with lower adjusted odds of BPD and major IVH, reduced invasive ventilation days and no increase in PDA treatment, without a change in mortality. Because pre versus post observational designs remain susceptible to residual confounding and secular practice changes, findings should be interpreted as associations rather than causal effects. Prospective multicentre evaluations using standardised echocardiographic criteria are needed to assess pathway impact and inform PDA screening strategies.

Background: The utility of a PCR-based respiratory virus panel (RVP) in limiting antibiotic overuse in paediatric febrile and respiratory illnesses in low- and middle-income countries remains unclear.

Methods: This retrospective study included inpatients who underwent RVP testing within 48 hours of admission between January 2021 and December 2022. The primary outcome was the impact of the respiratory viral panel result on total duration of antibiotics. The secondary outcome was discontinuation of antibiotics following test results and duration of antibiotics in specific subgroups. A zero-inflated negative binomial (ZINB) regression identified predictors of outcome.

Results: Of the 210 cases, 152 (72.3%) tested positive for ≥1 virus. 42% of patients had their antibiotics discontinued after getting a positive result. Overall, we noted a minimal effect of a positive RVP result in reducing antibiotic utilisation. However, in influenza patients, we observed a significant decrease in median antibiotic days compared with those with negative RVP (3 days (IQR 0-5.5) vs 6 days (IQR 2.25-8); p=0.011). Patients with acute febrile illness with viral aetiology received fewer days of antibiotics compared with those with negative RVP (2.5 days (IQR 0-5) vs 5 days (IQR 2-7); p=0.035). ZINB regression analysis showed that pneumonia patients (OR=1.27; p=0.03) and those with paediatric intensive care unit stay (1.2; 0.02) had higher odds of prolonged antibiotic use despite RVP positivity.

Conclusion: In our setting, RVP reduced antibiotic use in specific subgroups like influenza-positive patients and those with acute febrile illness and could be potentially used as an antibiotic stewardship tool in these settings.

Objective: To evaluate clinical and biochemical predictors of metabolic bone disease in preterm infants and determine the diagnostic performance of serum biomarkers for radiographic osteopenia.

Design: Retrospective cohort study.

Setting: Level III tertiary neonatal intensive care unit, King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Patients: 484 infants born at <28 weeks' gestation or birth weight <1000 g enrolled in a structured Bone Health Programme (2017-2024); infants who died before 4 weeks or had skeletal dysplasia/genetic bone disease were excluded.

Main outcome measures: Radiographic osteopenia on standardised anteroposterior babygrams. Biomarkers included parathyroid hormone (PTH), alkaline phosphatase (ALP), phosphate and 25-OH vitamin D. A paediatric radiologist, blinded to biochemistry, classified images using predefined criteria. Predictive accuracy was assessed with receiver operating characteristic (ROC) analysis; non-parametric tests were used for group comparisons.

Results: Biochemical abnormalities were common: hypophosphataemia <1.8 mmol/L in 38% and <1.6 mmol/L in 25%; elevated PTH >10 pmol/L in 77% and >18 pmol/L in 43%; ALP >500 IU/L in 21%; vitamin D <50 nmol/L in 41%. Radiographic osteopenia occurred in 35/484 (7.2%), including 9 fractures (1.9% of the cohort; 25.7% of osteopenia). Compared with infants without osteopenia, affected infants had higher peak PTH (33.2 vs 19.6 pmol/L, p<0.001), screening PTH (21.4 vs 14.2 pmol/L, p=0.002) and peak ALP (558 vs 427 IU/L, p=0.006). On ROC analysis, peak PTH showed the best discrimination for radiographic osteopenia (area under the curve, AUC 0.821, 95% CI 0.754 to 0.889; optimal cut-off >28.7 pmol/L), followed by screening PTH (AUC 0.761, 95% CI 0.676 to 0.845; cut-off >17.6 pmol/L) and peak ALP (AUC 0.657, 95% CI 0.563 to 0.750; cut-off >525 IU/L).

Conclusions: In this large single-centre cohort, peak PTH was the most accurate biochemical marker for radiographic osteopenia, outperforming ALP and phosphate. Incorporating PTH into routine screening, alongside ALP and phosphate, may improve early identification and targeted mineral optimisation, potentially reducing fractures and streamlining follow-up.

Background: Mediation is a process which allows conflicting parties to come together with the support of a mediator to try and find an agreed way forward. Mediation has been increasingly used in paediatric medical treatment disputes, but there is little empirical data exploring participant experiences of mediation and/or the role of religion in resolving these disputes.

Method: This qualitative study aimed to improve understanding of the role of mediation in resolving paediatric medical treatment disputes, in light of high-profile conflict about children's medical treatment reaching the courts in England and Wales in recent years. Analysis of 17 semi-structured interviews with healthcare professionals, mediators and a family member of a patient was carried out and analysed thematically. The role of religion was an inductive theme identified in data analysis.

Results: The analysis found that religion was a relevant factor for the majority of participants. Three themes in relation to the role of religion are identified: religious beliefs as a factor in the cause of conflict and entrenched views, religious beliefs and compromise in mediation, the role of religious support for family members in mediation. The findings show that there was no evidence to suggest that when religious disputes were mediated, it led to agreements undermining the child's best interests, that the presence of religious views among family members did not mean that the dispute could not be mediated and that there may be benefit in having religious supporters present at mediation. Instead, the research showed that openness to mediation and openness to resolution was key.

Conclusions: That mediation can be used in paediatric best interests disputes with a religious dimension and that mediators should develop further ways of delineating which cases could be effectively mediated. Finally, the article sets out some suggestions for areas of further research.