Anjum Gandhi

Prescribing in obese children: how good are paediatricians?

Childhood obesity is increasing nationally and worldwide. Using the childs total body weight to calculate drug doses for certain medications could result in incorrect dosing. The aim of this study was to assess whether paediatric doctors have knowledge about prescribing correct doses of medications for obese children by using methods to calculate the ‘ideal body weight’ (IBW). A questionnaire was sent to paediatric doctors asking whether they understand IBW and how to calculate it using the McLaren method. The results suggested that most paediatric doctors did not determine whether a child was obese when calculating drug doses. There was relatively poor understanding about the concept of IBW and only 9% of paediatricians in this study knew how to calculate it. There should be more training and guidance about calculating IBW in obese children to avoid potentially toxic errors.

Using CRP in neonatal practice

Abstract Objective: C-reactive protein (CRP) is the most widely used infection marker in neonatal practice. Combined with difficulty in early recognition of neonatal sepsis, the number of infants with risk factors for infection, and postnatal maladaptation of non-infectious origin; CRP is often used as a decision making tool for antibiotic therapy. We wished to examine practice regarding neonatal infection and use of CRP. Methods: We designed an online multiple choice questionnaire, asking senior clinicians for their response to realistic postnatal ward scenarios. Results: We had 91 replies, showing a great degree of variation, with no pattern emerging for experience, region, or even individual neonatal units. This was true even for situations covered by the guidelines that have an evidence basis. Conclusions: A recurring theme was duration of antibiotic therapy for an elevated CRP, and once levels are falling, when it is safe to stop treatment. Given a lack of good quality evidence, the National Institute of Clinical Excellence (NICE) guidelines are purposefully non-specific. Further research is required, and if incorporated in future national guidelines, should help promote more widespread use and so reduce potential over- and under-treatment of this patient subset. However, this also requires a greater willingness on the part of pediatricians to ensure practice is evidence based.

A neonatal case of congenital coronary artery fistula

Coronary artery fistulae (CAF) are rare forms of congenital heart disease with an incidence of one in 50 000 live births. The authors present the case of an asymptomatic neonate with a precordial murmur. Pre and postductal saturations, blood pressure and ECG were normal. Echocardiography revealed a large right coronary artery fistula to the right ventricle (4.5 mm). At 11 months, transcatheter occlusion of the fistula with a vascular plug was performed. A year on, the child was thriving, ECG and echocardiogram remained normal. CAF complications and symptoms (including aneurysm, myocardial ischaemia, angina, heart failure and dyspnoea) are commoner in older patients, so traditionally we intervene early. With increasing case reports of spontaneous closure of even large and symptomatic fistulae, management of especially asymptomatic children is unclear. Long-term complications of intervention also remain largely unknown. As such more information is required on the conditions natural history to better manage patients and counsel parents.

Non-pharmacological analgesia: effective but underused

Losacco et al s1 review of practice across European neonatal units regarding the use of non-pharmacological analgesia (NPA) for painful procedures in neonatal units has highlighted the relatively infrequent use of these techniques. This is despite good evidence confirming the effectiveness of NPA2 and evidence of deleterious effects of pain in babies, both short term3 (decreased oxygenation, haemodynamic instability and raised intracranial pressure) and long term4 (neurodevelopmental delay and altered perceptions of pain in later life). We have recently conducted an audit on the use of NPA for neonates, comparing our current practice at Good Hope Hospital, Birmingham, UK, against our hospital guidelines. As a part of this process, we have also carried out a review of literature on the use of NPA and assessed whether the current hospital guidance meets evidence-based recommendations. Clinical staff in various neonatal and paediatric clinical areas at Good Hope Hospital were requested to fill in questionnaires every time they carried out a painful procedure in an infant. Forty-six questionnaires were filled in total; 8 from the postnatal wards, 11 from the childrens assessment unit or paediatric ward and 27 from the neonatal unit. For postnatal wards, the ages for which the procedures were carried out ranged from day 1 to 4. Five of the eight babies were given sucrose (0.6 ml …

Cricoarytenoid arthritis presenting as croup.

Juvenile rheumatoid arthritis (JRA) is one of the most common rheumatic diseases of childhood and a major cause of chronic disability. Most standard paediatric textbooks and review articles about this condition do not mention cricoarytenoid joint fixation as a presenting feature or complication.1 There are only a few cases reported worldwide, primarily in emergency medicine or anaesthesia journals.2 Early recognition of this potentially life-threatening condition can prevent the need for tracheostomy.

Case Report: A teenager with lumbar striae distensae (when a bruise is not a bruise)

A 14-year-old boy was referred to a paediatric clinic after a recent diagnosis of coeliac disease, which was well controlled on a gluten-free diet. During the consultation, the mother raised concerns regarding marks that had developed over her sons back over the past 6 months. On examination, a number of horizontal, coloured bruise-like marks were noted over the lower back. The appearance was suspicious of bruising and possible non-accidental injury, although a history of trauma or injury was denied. Blood tests including a coagulation screen were arranged which were normal and the patient was followed up twice during a 6-month period. He remained well but the bruising was persistent. It was concluded that these were striae associated with pubertal growth. This case summarises the importance of careful surveillance of bruising in children and illustrates the association between striae and pubertal growth which may be confused with non-accidental injury.

Nosebleeds in Children as a Potential Marker for Nonaccidental Injury and Serious Underlying Pathology: How Aware Are Hospital Clinicians?

Paediatric epistaxis is common and usually of benign origin. However, the differential diagnosis includes serious underlying pathology (e.g., bleeding disorders and blood cancers) and in the very young can be a marker of potential physical abuse. To assess if paediatric and A&E doctors were aware of the important differential, we asked them to complete a Likert scale questionnaire on several different clinical scenarios. Our results show that a significant proportion of doctors of all grades and in both specialties were either not aware of or not concerned about epistaxis in an infant as a possible sign of nonaccidental injury and were not willing to carry out simple blood tests to investigate recurrent nosebleeds in an older child. Our results highlight the need for education and evidence-based guidelines to avoid missing important, if infrequent, causes of paediatric epistaxis, both in the hospital and community setting.

G316 Paediatricians’ understanding about prescribing in obese children – there is scope for improvement

Aims Childhood obesity is increasing in the UK and worldwide. Recent Public Health England data confirms that in England 19.1% of year-6 school children are obese and 14.4% are overweight. It is also recognised that increased fat and lean masses in obese children affect pharmacokinetics and the distribution of drugs in tissues. Using the child’s Total Body Weight (TBW) to calculate doses could result in incorrect dosing. This study was prompted by an incident of drug toxicity in an obese child where a very large dose was administered based on TBW. We aim to assess whether paediatric doctors have knowledge about prescribing correct doses of medications for obese children by using methods to calculate the ‘Ideal Body Weight’ (IBW). Method A questionnaire was sent to all paediatric trainees and consultants in the region asking whether they take into account the patient’s weight when prescribing for obese children, whether they understand ‘IBW’ and how to calculate it using the McLaren method. Results Of the respondents, only 3% (3/109) calculated BMI and determined if the child was obese for its age when prescribing medications.Abstract G316 Figure 1 35% (38/109) of prescribers gave special considerations to the weight when calculating drug doses in obese childrenAbstract G316 Figure 2 16% (17/109) of prescribers are familiar with, and understand, the terms Total Body Weight (TBW), Ideal Body Weight (IBW), Adjusted Body Weight (ABW) and Lean Body Weight (LBW) Conclusion The findings suggested that most paediatric prescribers did not ascertain if a child was obese when calculating drug doses. There was relatively poor understanding about the concept of IBW, which is the recommended weight to be used for dose calculations for certain drugs. We noted that although the British National Formulary for Children (BNFC) highlighted which drugs need IBW estimation, it did not provide a method for calculating it. These deficiencies should be addressed at the medical student and junior doctor level with appropriate prescribing training. In addition, the BNFC should include more guidance about calculating IBW in obese children to avoid potentially toxic errors.Abstract G316 Figure 3 9% (10/109) of prescribers knew how to calculate IBW using the McLaren method

Intractable neonatal jaundice due to hereditary spherocytosis and Gilbert’s syndrome

In this article the authors present a case of pathological neonatal jaundice resistant to phototherapy in a baby with a family history of Gilbert’s syndrome and hereditary spherocytosis. Her presentation was ultimately explained with a diagnosis of both conditions, and required treatment with phenobarbitone. The authors discuss the mechanism by which Gilbert’s syndrome results in hyperbilirubinaemia and its similarities with Crigler–Najjar syndrome. The presentation of hereditary spherocystosis in the neonatal period is also explored, as is the mechanism of exaggerated hyperbilirubinaemia when the two conditions co-exist.