Peter Heinz

How to use … the Monospot and other heterophile antibody tests

Epstein-Barr virus (EBV) is a highly prevalent virus, transmitted via saliva, which often causes asymptomatic infection in children but frequently results in infectious mononucleosis in adolescents. Heterophile antibody tests, including the Monospot test, are red cell or latex agglutination assays, which detect antired cell antibodies produced as part of a polyclonal antibody response occurring during EBV infection. Heterophile antibody tests are rapid, cheap and specific tests that can be performed from the onset of symptoms of infectious mononucleosis. In adolescents, heterophile antibody tests have high specificity and sensitivity in the diagnosis of primary acute EBV infection. However, the tests have low sensitivity and low negative predictive value in young children and are not useful under the age of 4. Heterophile tests may be positive in other viral infections, autoimmune disease and haematological malignancies, but do not appear to be positive in primary bacterial infection. Virus-specific serology is required in children under the age of 4 or if an older child is heterophile negative. Virus-specific serology allows diagnosis and the pattern of positivity and negativity enables the clinician to stage the EBV infection. Virus-specific serology appears to have better sensitivity in young children, but there is cross-reaction with other herpesvirus infections, a longer turnaround time and it is more expensive to perform. Further research is needed to establish which children benefit from and hence require testing for heterophile antibodies, the cost-effectiveness of EBV investigations and whether heterophile titres have predictive value for the severity of infection and the likelihood of complications.

Media use in children: American Academy of Pediatrics recommendations 2016

Media use among children and adolescents is common. The term is used for broadcast and interactive communication, including television, radio, video games, mobile phones and the internet (social media websites and ‘video-chatting’). Television contributes most to media usage time (Ofcom, 2015)1 closely followed by devices connected to the internet. On average, children aged 8–15 years watch 15 hours of television per week,1 and one in four teenagers describe themselves as ‘constantly connected’ to the internet.2 The advantages of being able to easily access information and entertainment and to stay in contact with friends and family contrast with evidence linking increased media use and rising levels of obesity.3 There are also associated risks of sleep disturbance, issues surrounding online safety, compromised privacy and cyberbullying. In November 2016, the American Academy of Paediatricians (AAP) published two policy statements entitled ‘Media and Young Minds’4 and ‘Media Use in School Aged Children and Adolescents’.5 Supported by a number of linked resources, they aim to address some of these issues, provide recommendations on managing the use of media and encourage parents to work together with paediatricians and schools. In 1999, the AAP issued a policy statement addressing media use by children and adolescents.6 A further policy statement was published in 2011 addressing the use of media specifically by children under 2 years of age. While the previous statements have recommended avoiding the use of media in children less than 2 …

New models of care: the future of child health services. What does this mean for you and your patients?

Our inboxes are full; papers, statements, alerts, guidelines, standards, systems, networks, interest groups, key performance indicators, job plans, appraisals, revalidation, educational supervision and training, research demands, undergraduate curriculum, continual professional development and somewhere there are the patients we look after. When do we stop and review our priorities? How do we decide what journals to read? What statements to digest? What new systems to develop that will optimise care for our patients? It seems impossible. Here is one landmark publication that every paediatrician must have read: the Nuffield Trusts briefing on new models of care for child health.1 The Nuffield Trust has a long track record of commissioning research on how to improve the health system in the UK. The document lists current dilemmas in delivering paediatric care, makes the case for a fundamental change in how this is delivered and critically appraises 12 novel models of paediatric care. As a community of paediatricians we need to respond to the challenge. We need to stop and reconsider how we deliver our service to children (including infants), young people (CYP) and their families under conditions that seem to become more demanding than ever (given a cash strapped National Health Service (NHS)). We cannot do this on our own. We will have to come out of our silo, work and integrate with primary care and other, non-medical, services for children. Most importantly we need to listen to our patients and families and respond to their needs. Why is this document important? Child health mortality and morbidity patterns have changed over the last 40 years. Epidemiological data show a transition from primarily acute infectious diseases as the major causes of death to non-communicable causes in CYP with complex and chronic conditions. In the UK the health outcomes for CYP are some of the …

G27(P) Paediatric emergency ambulance transport: who calls 999 and why

Aims To explore the reasons for requesting an emergency ambulance transport to our paediatric emergency department (20,000 attendances p.a.) during office hours from the perspective of the caller. Methods Use of a questionnaire exploring the reasons for calling an emergency ambulance, applied to children aged less than 16 years brought in by ambulance on 5 consecutive weekdays between the hours of 08.00 to 19.00 and comparison to the clinical outcome. The documentation provided by the ambulance crew was examined for the priority given to the call. Results 29 patients presented by ambulance during this time period. Data could be obtained for 27. There were 3 main categories of callers: parents (38%), schools (27%) and General Practitioners (19%) accounting for 84% of callers. 50% of all patients were discharged home from the emergency department, the other half admitted either for surgery or to an in-patient ward (short-stay in 8%). All calls from GPs were given the highest call priority by the ambulance service, 80% patients in this group were admitted. A different picture emerges for calls made by parents and schools respectively: parents’ calls were given high priority in about 50% of cases and 40% of transported children were admitted as inpatients. The reason for parents calling an ambulance was their belief that medical intervention was required. However, only in 40% of cases this was necessary (oxygen, bronchodilators and antipyretics). In contrast, 999 calls made from schools were given second and third priority in all cases. Only 28% of these patients were admitted from ED. Conclusion The appropriateness of 999 calls during daytime hours varies widely amongst groups of callers. Whilst calls from GP surgeries often result in admission, parents seem to be able to make a reliable assessment of their child’s need for urgent medical intervention in only about 50% of cases and in the rest alternative transport may well have been feasible. As far as schools are concerned, the majority of ambulance transport probably is unjustified and poses an area of potential relief for a service stretched to its limits.