David Tuthill

General paediatricians and the case of resolving peanut allergy

Children with peanut allergy are almost always advised to avoid nuts for life. There have been recent reports from academic centres that in some cases the allergy might resolve and thus these dietary restrictions can be lifted. To evaluate resolution of peanut allergy in a selected group of children in a general paediatric setting. Children 4–16 yr old with a clear history of an allergic reaction to peanuts who had not had any reaction in the previous 2 yr were eligible. Specific immunoglobulin E (IgE) or skin prick test (SPT) at the time of diagnosis was sought. A SPT and specific IgE was then done and if this was ≤8 mm and ≤17.5 kU[A]/l respectively, a double‐blind placebo‐controlled food challenge was undertaken. A negative challenge consisted of tolerance to a cumulative dose of 15.8 g peanuts followed by an open challenge. From the 82 case notes reviewed 54 children were eligible to participate. Twenty‐nine agreed to participate and underwent SPT (29) and specific IgE (28). Of these children eight were eligible for food challenge. Four challenges were negative and four positive. Peanut allergy may resolve in approximately 15% of selected children attending an allergy clinic run by general paediatricians in a district general hospital. Food challenge constitutes the appropriate way of removing the burden that comes with a diagnosis of peanut allergy and enables dietary restriction to cease.

A simplified gentamicin dosing chart is quicker and more accurate for nurse verification than the BNFc

Background: At least 5% of paediatric admissions are complicated by medication error. Nurses can prevent some errors by correctly verifying prescriptions before administering drugs, which requires adequate drug calculation skills and familiarity with the BNFc. We wished to explore whether a newly devised chart would improve nurses’ dose calculation ability and thus potentially reduce doctors’ prescription errors. Aims: To explore nurses’ ability to calculate doses of gentamicin for neonates and children using a new simple dosing chart compared with the BNFc. Methods: Two gentamicin dosing charts (paediatric and neonatal) devised by a multidisciplinary group to simplify dose calculation and selection of frequency were compared with the BNFc using four questions (two neonatal, two paediatric) asking ward nurses to calculate gentamicin doses. Answers were scored for both the correct dosage and correct frequency. Results: 51 nurses participated. 11 nurses (22%) answered all four questions correctly. A higher proportion correctly answered both the dosage and frequency questions simultaneously when using the chart compared with the BNFc: paediatric questions 100% (51/51 chart) versus 80% (41/51 BNFc) (OR 0.20) and neonatal questions 55% (28/51 chart) versus 35% (18/51 BNFc) (OR 0.2). Errors when using the BNFc were due to selection of the incorrect regimen (23%), wrong frequency (17%) and one 10-fold dosing error. When using the chart, there were no dosing errors, only frequency errors for the neonatal regimen. Conclusion: The chart was more reliable, quicker and may be useful for patient safety. Revising the format of the BNFc may be beneficial for nurses.

Neonates do not need to be handled for radiographs

Background: The handling of sick neonates may have detrimental effects such as hypoxia or bradycardia. Such handling is inevitable due to the frequent need for practical procedures; however, minimising handling reduces these adverse events and may improve outcome. Radiography is one of the commonest procedures performed on neonates. Usually the infant is lifted and placed onto the radiographic cassette; however, modern incubators often incorporate a tray beneath the mattress in which the radiographic cassette can be placed without the need to disturb the infant. Objective: To compare the quality of chest radiographs taken using the standard direct contact method, with those taken using the under-tray technique. Materials and methods: A series of chest radiographs taken over a 21-month period were analysed independently by two consultant paediatric radiologists unaware of the radiographic details. The position of the radiograph, i.e. direct contact or under-tray, was determined by the radiographer. Radiographic quality was scored on the following features: exposure, blurring, rotation, cut-off or coning, and side markers. A subjective score was also included. The results from each radiologist were analysed separately. Results: Seventy chest radiographs were analysed—25 standard method, 45 under-tray. A statistically significant advantage for the under-tray method was seen on two analyses—radiologist 1 for exposure, and radiologist 2 for cut-off. No other significant differences were noted. There were no differences in the infants’ weights or radiation exposure. Conclusions: The under-tray method for taking radiographs may produce films of at least equivalent quality to the standard method. Since the standard method involves handling with potential desaturation and bradycardia, this technique should cease.

G86 Anapen, EpiPen and Jext Auto-Injectors; Assessment of Successful Use After Current Training Package

Background Anaphylaxis is a severe life threatening allergic reaction. Prompt administration of epinephrine(adrenaline) is the first line treatment. There are currently three epinephrine auto-injector devices available in the UK; original Anapen, new EpiPen and Jext, each of which differ in their advised method of use. International standards recommend training for all patients prescribed epinephrine auto-injectors, we meet these. If families can more successfully use a particular trainer device, this may have important clinical effects. Aims To assess the effectiveness of the training by evaluating “epinephrine naive” families’ ability to successfully use an auto-injector trainer device. Methods Adults and children over 12, with no experience of auto-injector use were invited to participate in this service evaluation. They were randomly allocated to be trained in the use of one of the available auto-injectors. Their performance was assessed using a ten point marking sheet based on the correct method of administration of epinephrine for the individual device. Six marks were for procedures identical to all three devices (e.g. massage the site of injection) and four were device specific to reflect the differences in administration technique. Success rates were analysed by Chi-square with p < 0.05 being deemed significant (http://graphpad.com/quickcalcs/contingency 2). Results There were 120 participants. Abstract G86 Table 1 Anapen(n = 40) EpiPen(n = 40) Jext(n = 40) Chi squared p valueEpipen: Jext Chi squared p valueEpipen: Anapen All participants(n = 120) Scoring 6/6 for identical procedures 16(40%) 13(33%) 16(40%) ns ns 45(38%) Scoring 4/4 for device specific procedures 36(90%) 18(45%) 22(55%) ns 0.0001 76(63%) Performing all procedures correctly 10/10 16(40%) 8(20%) 10(25%) ns ns 34(28%) Successfully firing auto-injector trainer pens 39(98%) 28(70%) 39(98%) 0.0024 0.0024 106(88%) Conclusions Only 28% of participants were able to perform the individual device’s 10 steps correctly. Overall the trainer devices fired in 88%, with a failure rate of 2 to 30%; a clinically and statistically significant result. The Epipen’s swing and hit delivery method may affect its successful delivery compared to the Jext and Anapen’s methods.

G422 Dentists, doctors, nurses and neglect: do you see what i see?

Background Neglect is the most common form of child abuse in the UK. One area of neglect that is frequently overlooked is dental neglect. This rarely occurs alone and is part of a wider picture. Referrals for dental neglect are made infrequently by dentists; Possibly because no clear threshold for referral exists and they perceive concerns about the “Safeguarding” referrals system. Paediatric staff have limited oral health knowledge, and this combined with dentists reluctance to communicate concerns surrounding child protection, means that there is ample potential for dental neglect to be missed. Aims We explored whether dentists, doctors and nurses, could agree on a threshold to act with regard to suspected dental neglect or child protection issues. Methods A cross-sectional survey of hospital and community: doctors, dentists and nurses was conducted. Semi-structured interviews using a series of 5 vignettes involving oral health and child protection, focused on the following issues; An unkempt 4 year old with extensive dental caries who came on the third calling for a dental check up A 6 year old requiring one filling An obese, bullied, 14 year old with multiple carious cavities and dental erosions Bottle caries in a 4 year old whose 2 sisters have previously required dental extractions under general anaesthetic A 4 year old with substantial ear bruising who requires one filling Participants were asked to select from a list their dental and safeguarding actions. There was no child protection action required for case 2. Results 150 responses (50 doctors, 50 dentists, 50 nurses) were obtained from 171 professionals approached. Just 3/14 dental practices agreed to participate. Less than 50% of doctors identified appropriate dental actions for 4/5 cases, and < 50% dentists identified appropriate safeguarding actions for 4/5 cases (Figures 1 and 2). Abstract G422 Figure 2 Percentage of optimal child protection action selected by profession Abstract G422 Figure 1 Percentage of optimal dental action selected by profession Conclusion Many dentists are uncertain about child protection issues and may not act upon abuse that appears obvious to other healthcare professionals. Likewise, doctors are uncertain about dental neglect. Minimal joint standards for dental neglect thresholds and the appropriate response need to be agreed.

G58(P) A National Audit of Parenteral Nutrition Practise in UK Neonatal Intensive Care Units: Is Practise Consistent with Guidelines?

Background Parenteral nutrition (PN) is a lifesaving modality providing vital nutrients for neonates unable to tolerate enteral feeding. It has serious complications, including metabolic derangements, infection and line displacements which can be fatal. Positive outcomes can be maximised and complications minimised by appropriate biochemical monitoring, multidisciplinary involvement, adherence to evidence based clinical guidelines and careful venous line management. Objective To audit current PN practises in all UK neonatal units against ESPGHAN European guidelines 2005 on protein and lipid introduction, American clinical guidelines for hyperglycaemia and hypoglycaemia in neonates receiving PN 2012, and the UK National Confidential Enquiry into Outcome and Death (NCEPOD) recommendations 2010 for venous access. Methods A questionnaire was devised by a pharmacist, paediatrician and neonatologist. Questions focused on key areas commonly encountered in routine PN practise, for which guidance is available. These included protein and lipid introduction, monitoring and complications of lipids, management of hyperglycaemia and venous access. One researcher conducted a telephone survey to registrars working in all 58 level 3 neonatal intensive care units (NICU) throughout the UK. Results The response rate was 58/58 units (100%). For preterm neonates requiring PN, protein is commenced on day 1 in 88% of units and lipids by day 3 in 91%. Most units exclusively use central lines for PN administration. All units use x-ray verification of catheter tip position with 19 units also using contrast. Triglyceride levels are not monitored in 22 units. Management of hyperglycaemia is variable, with 25 units using insulin first line and not altering glucose infusion. Seven units avoid insulin use completely. Conclusion Many nutritional support practises were consistent and in line with guidelines. However over a third of units fail to monitor triglyceride levels despite the known consequences of high lipid infusions and recommendations for monitoring. The high usage of insulin in the management of hyperglycaemia may not be advantageous considering recent findings around the risks of hypoglycaemia and mortality. The use of contrast for line verification is not nationally standardised.

How does the CHALICE rule affect CT scanning in children with head injuries

Publication of the CHALICE (childrens head injury algorithm for the prediction of important clinical events) rule for paediatric head injuries1 and its adoption by the National Institute for Health and Clinical Excellence (NICE)2 may have significant implications for patient management. The effects of these have been explored in a recently published Australian audit aimed at externally validating this rule.3 This study showed that implementation of CHALICE would result in a significant increase in the use of CT scanning in suspected head injury cases and …