Search

You are seeing an 11-year-old boy in a general paediatric clinic referred with short stature. His height is below the 0.4th centile. The mid-parental height is on 50th centile. Baseline investigations, including renal and liver function, coeliac screen and thyroid function tests are normal. You have a suspicion of growth hormone deficiency. Should you check an insulin-like growth factor-1 level or proceed with a growth hormone provocation test? The current paper will aim to give an overview of these tests and factors to consider when interpreting the results.

Objectives When caring for children in a hospital setting, tablets are often manipulated at the ward to obtain the right dose. One example is manipulation of tablets containing the slightly water-soluble substance aspirin, used in paediatric care as an antiplatelet agent. The evidence base, however, for choosing certain tablet formulations and manipulation methods over others for extraction of proportions is lacking. The aim of this study was to investigate the effect of tablet formulation and manipulation technique on the dose accuracy and precision attained when dispersing different commercially available aspirin tablets and extracting a small proportion suitable for children. Methods The manipulation methods investigated simulated those observed in the paediatric clinic. Four tablet formulations—one chewable, one conventional and two dispersible—were dispersed in 10 mL water in a medicine measure. On (1) passive dispersion, (2) mixing by stirring with the syringe, or (3) stirring and pumping the dispersion in and out of the syringe, respectively, proportions (1 mL or 2 mL) were extracted and the doses recovered were determined using a validated UHPLC (ultra high-pressure liquid chromatography) method. Results Fractions from the four different dispersed aspirin tablet formulations varied from 99% to 3% of that intended with the lowest degree of mixing, and from 96% to 34% of that intended with the highest degree of mixing. Only the dispersible tablets gave average doses within 20% of the intended dose. Conclusions Fraction extraction from dispersed aspirin tablets only gave doses within 20% of intended for the dispersible tablets, and then only for some of the manipulation methods: ‘passive dispersion’ for the 75 mg dispersible tablet and ‘stirring and pumping’ for the 300 mg dispersible tablet. The tablets not intended for dispersion gave unsatisfactory results, outside 20%, regardless of manipulation method. The findings underline the importance of considering both tablet formulation and dose extraction technique when manipulations are required.

A common presentation to the general paediatric clinic is a child or young person’s difficult bowel habit, which is often a potent source of anxiety for parents and carers. A large proportion of these children will have a functional cause for their symptoms, with unnecessary investigation and non-evidence-based treatments adding to their difficulties. This article aims to explain what encompasses the normal bowel habit in children and young people, reassure where appropriate and identify those patterns that may be suggestive of a disorder or disease requiring treatment. We illustrate both extremes of the spectrum of normal bowel habit in children with two case studies.

Down’s syndrome (DS) is the most common chromosomal abnormality seen in live born children and it is the most common genetic cause of intellectual disability. It is associated with abnormalities in many body systems, some of which can cause life threatening complications. This article aims to cover the important aspects to cover when seeing children with DS for their routine follow-up in the neurodevelopmental or general paediatric clinic.

An 8-month-old child presented after an emergency referral from a paediatric clinic. She had sustained a small burn injury to the left volar wrist during the sweat test for cystic fibrosis. The injury was managed conservatively. There is limited literature on burn injuries sustained during the sweat test, despite it being a known risk and the incidence is reported as very small. We wonder if such events are not being reported because the injury caused is usually minor and so may be more prevalent than previously considered.

Objective Palatability of ampicillin–cloxacillin, amoxicillin–clavulanate, cefixime and cefuroxime axetil was assessed at the outpatient paediatric clinic of a Nigerian specialist hospital. Methods Healthy children (n = 24; mean age 8.37 ± 2.33 years) and care givers (n = 31; mean age 35.22 ± 10.1 years) were included. Each consenting volunteer rated the ‘blinded’ taste of each antibiotic liquid preparation on a 10-point visual analogue scale (VAS) with various facial hedonic expressions. Independent observers also rated each cohort9s taste perception of each drug. Best and worst tasting drugs were also assessed. Results Cefixime and ampicillin–cloxacillin scored the highest (mean scores 7.83 ± 3.06 and 7.93 ± 2.03) and lowest (mean scores 4.83 ± 3.11 and 2.58 ± 1.28) points on the VAS scale for children and adults, respectively. Nearly all (93.5%) adults chose ampicillin–cloxacillin as the worst tasting (p Conclusions Cefixime was the best-tasting drug among children and adults.

Background An unprecedented global effort at scaling up universal access to antiretroviral therapy has decreased the progression of HIV. However, due to challenges with supplies and adherence to intermittent antiretroviral therapy (ART) for mothers, infants continue to be infected, some with resistant viruses. Exposure to these resistant strains leads to non-responsiveness to therapy resulting in virological failure. Children are more vulnerable to HIV drug resistance because of their life long treatment, the possible selection of resistant strains as a result of prophylaxis for mothers with HIV enrolled in PMTCT. The objective of the study was to determine the prevalence and risk factors of virological resistance among HIV-1-positive children on antiretroviral therapy. Methods This was a longitudinal study that was performed at the HIV paediatric clinic of the Komfo Anokye Teaching Hospital, Kumasi, Ghana. Blood samples of children below the age of 18 years who had been on therapy for at least 3 months were analysed for virological load using real-time COBAS AmpliPrep/COBAS Taqman PCR. The samples were analysed at two consecutive time points when they came for their ART refill. Socio-demographic and clinical information was collected from their folders and also from the mother. Results A total of 188 subjects were enrolled into the study from September 2015 to June 2016. The average duration on ART was 36 months (IQR=12–72 months). Of all subjects recruited, 134 (71.3%) were found to be on regular drug ART. Of these, 21 (15.7%) had virological failure and 102 (76.1%) had virological suppression. A regression analysis showed that subjects whose parents were unemployed had 5.4 (1.4–20.9) chances of virological failure compared to those with parents employed. Conclusions The risk of virological failure among HIV-positive children is still high. Efforts must be made to further identify the potential causes of virological failure among these children.

Objective To present a structured approach for an outpatient consultation of a child with hypermobility. Method Review of the literature and a description of the approach commonly adopted in a paediatric out-patient setting. Conclusions A focused history and examination is the key to reaching an appropriate differential diagnosis and planning management for children with hypermobility. Case A 10-year-old child is referred to your general paediatric clinic with frequent ‘cracking and clicking’ of her joints and a history of intermittent aches and pains over the last 6 months.

Nine boys of secondary school age were referred with undescended testes (UDT) to paediatric surgeons over a period of 8 years. All were referred from the same community paediatric clinic for children with severe learning disabilities. UDT cause concern because of a threefold increase in the incidence of cancer. Cosmesis and reduced fertility were seen as less relevant issues for these boys. The late identification and incidence of UDT are discussed. It is suggested that awareness of this issue should be raised and screening introduced. Advice is needed on the appropriate management of UDT in this group of boys.

Graduating in 1947 my career plan was to join my father in general practice. Hands-on experience of paediatrics was needed. In 1948 I successfully applied for the new service post in the casualty department of Alder Hey Hospital. This was not a training post. The unexpected survival of a severe casualty case of meningococcal septicaemia came to the attention of Prof Capon. The post was regraded as medical registrar. A neonatal appointment to Dr. Hudson’s Walton Hospital unit followed and led to an MD thesis on neonatal hypoglyaemia, supervised by Robert Todd, University Senior Lecturer. Appointment as registrar and then as senior registrar in the University Department of Child Health involved duties split between the cardiac department in the Royal Liverpool Children’s Hospital and medical services in Alder Hey Hospital. Dr. Hay, later Professor, took his new trainee to the cardiac laboratory, first as an observer, then as assistant, later as an operator, and finally as a clinical discussant. Dr Todd opened the door to his huge personal collection of abstracts from the journals. Prof Capon’s own monthly clinical presentations included the smell of congenital syphilis, pink disease from absorption of mercurial ointment, scurvy in a baby whose vitamin C had been lost through boiling the feed, erythema nodosum in rheumatic fever and many otherconditions now rarely seen. The senior registrar assisted in specialty clinics and had his own general paediatric clinic, with backup if required. He attended a joint paediatric-psychiatric clinic. He attended the meetings of the Medical Board. These were exceptional learning opportunities. John Hay and Robert Todd incorporated the senior registrar in their own research and publications. They each later actively supported new academic developments in Dublin. John Hay was the first to answer the call for a dvice when dealing with the new problem of LQTS in 1962. The link was long-lasting.

IntroductionIn order to develop rational, patient tailored dosing schemes, population PK/PD studies in children and infants are needed. The emergence of new laboratory techniques (LC-MS/MS) and statistical tools (population PK/PD modeling) allows for the analysis of sparse and unbalanced data and has increased the possibilities to perform (observational) PK/PD studies in the paediatric clinic.To improve the quality of future pediatric PK/PD investigations the experience and knowledge about these tools should be shared and a basic study template agreed upon.ObjectiveWe aim to present a possible blue-print to assist paediatricians in the design and conduct of multicentre PK/PD studies in children and infants.MethodsBased on a review of the existing literature and multiple interviews with paediatricians and pharmacologists involved in multicenter paediatric PK/PD research a blue-print is drafted containing recommendations and examples for the design and implementation of PK/PD studies in children. The draft blue-print will be available at the conference and participants are asked for feed-back.ResultsPK/PD research to determine dosing in children and infants is preferably performed in a multi-center infrastructure in order to include a sufficient number of subjects within a reasonable time, covering all covariates relevant for dosage. The multi-center collaboration may also enable the analysis of multiple drugs in one cohort increasing cost-efficiency. Formal monitoring is needed to guarantee the quality of collected data.DiscussionIf performed well, the results of these studies will contribute to the evidence base underlying clinical guidelines and regulatory decisions concerning labeling adjustments.

Background and aims Huge inequalities exist in child health globally. Current under five mortality rates vary significantly between countries from 2.3 per 1000 live births in Singapore to 152.5 per 1000 live births in Guinea-Bissau. In the UK, children from poorer socio-economic backgrounds are more likely to be born small, die during their first year of life and die from an accident in childhood. We aimed to develop and evaluate a student-selected component (SSC) introducing medical students to inequalities in child health. Methods The student-selected component (SSC) ran one afternoon a week for eight weeks. Students participated in four interactive workshops on topics around child inequality and attended a relevant paediatric clinic or service. Students completed a self-directed project exploring an area of possible inequality for children, produced a poster and gave a short presentation at the end of the SSC, which was assessed. We evaluated the SSC by e-mailing a structured questionnaire to all participants and analysed responses thematically. Results Twelve second year students undertook the SSC. All 12 completed the post-programme questionnaire. Medical students gained the following from participating in the SSC: An increased understanding of the inequalities that exist in child health. “I was quite shocked at how large the differences were especially within the UK. Research and presentation skills. An awareness of the need for effective interventions to reduce inequality and improve children’s health. “ It’s not just a matter of throwing money towards services for children but preventing the inequalities from happening in the first place.” An increased motivation to see the situation improve. “ This has fired me up to want to do something about this in the future.” Seven out of 12 students (58%) reported that doing the SSC had either confirmed or increased their desire to pursue paediatrics as a career. Three further students reported they had wanted to do paediatrics before doing the SSC. Conclusions Introducing medical students to child health inequalities early on in their undergraduate training can have significant benefits, particularly in helping students to understand the broader social determinants of health, and encouraging more medical students to take up careers in child health.

OBJECTIVE--To identify children suffering morbidity from excessive intake of energy from fluids. DESIGN--Prospective enrolment of outpatients in a supervised reduction of energy rich fluid intake. SETTING--Outpatient paediatric clinic. SUBJECTS--Eight children (four boys, mean age 20.8 months, mean duration of symptoms seven months) who were referred with non-specific symptoms such as poor appetite, poor behaviour at mealtimes, poor weight gain, and loose stools. RESULTS--All children were able to reduce their intake of energy rich fluids, as prescribed. All children demonstrated an improvement in symptoms and an increase in weight. CONCLUSIONS--A careful dietary history, which includes documentation of fluid intake may identify children whose intake of high energy drinks may be excessive. The pathogenesis, symptoms, and response to treatment of these patients are consistent enough to be regarded as a distinct clinical entity: the 'squash drinking syndrome'.

Aim To describe the etiologic spectrum, clinical characteristics and evaluate the adequateness of the tests performed in order to establish diagnosis of adenopathies in children. Materials and method Our group analysed 279 children with adenopathies consulted in the primary care paediatric clinic in a 4 years period 2009–2013. There were noted: the presence and localization of the adenopathies, the diagnosis, the tests performed and the outcome. Results Out of the 279 cases, 106 represented unspecific multiple adenopathies following past diseases and had no clinical significance. 77 cases were confirmed to be viral unspecific infections of the upper respiratory system, 16 cases were confirmed as Infectious mononucleosis, 22 cases were Acute bacterial Tonsilitis and 11 were confirmed as Group A Streptococcus Tonsilitis. Further investigation of cases with large adenopathies of unknown origin revealed less common etiologies as Toxocara and Toxoplasma infections. There was 1 case of Hodgkin lymphoma easily diagnosed based on clinical characteristics, confirmed and treated in the oncology hospital. 7 cases presented with typical left axilar satellite adenopathy following BCG vaccination. The history and clinical signs suggested the diagnosis in all the cases. In 27 of the cases with unique large adenopathies the parents refused further diagnostic tests. Conclusions A complete history and a meticulous clinical examination represented the most important steps in establishing the etiologic diagnosis of the adenopathies in children. Specific blood tests and other investigations must be used with caution, in order to avoid unnecessary painful diagnostic procedures and unjustified costs.

During the last years many efforts have been done to improve the transition process in Finland. The routines differ throughout the country and these different routines are presented. In many centres we start preparing the youngsters at the age of 12-13 years. We invite them into the examination room without parents. After the examination the parents are welcomed into the room for discussion. Transition readiness checklists are used. Special transition days are arranged. At some centres a Web-based evaluation of the guidance given at the paediatric clinic is performed at the first visit at the adult clinic. The goal is to prepare the teenagers gradually and according to their psychological development. Disclosure of Interest M. Backstrom Grant/Research support from: Cost of medical congresses by Pfizer and AbbVie DOI 10.1136/annrheumdis-2014-eular.6107

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 son's 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.

A 15-month-old girl reviewed at a general paediatric clinic was noted to have three white lesions on the right heel. She was born prematurely at 29 weeks as the second of non-identical twins and had spent 8 weeks on the special baby care unit. Her parents reported that they had noted the lesions at 6 months of age and that their size had been progressively decreasing over the past few months. They were neither painful nor causing any other problems. Figure 1 …

Introduction This is an audit of letters done by various professionals in community paediatric clinic in a district hospital. Methods Two letters each were selected from all Consultant and Associate Specialist clinics, nurse led enuresis clinic and nurse led constipation clinic. There were a total of 14 letters. These were compared with the Sheffield Assessment Instrument for Letters (SAIL) which is the standard suggested by RCPCH. Results There was 100% compliance with standard requirement in 14 areas of RCPCH standard. The main deficiency was in writing drug dosages; only 57% letters have doses mentioned. Interestingly, more than one third of letters did not have a problem list. In 21.5% of letters, the documented examination was not appropriate to the problems and questions. Conclusion After discussion in the departmental audit meeting, the following recommendations were made SAIL checklist to be circulated among team members so that all are aware of the standards suggested by RCPCH. A reaudit was planned after 6 months to check compliance.

Aims Non-attendance of patients for clinic appointments is a significant problem within the healthcare system. The effect of non-attendance leads to poor utilisation of clinic time, a reduction in the overall management of the patient and a wider issue of incurring cost to the NHS.1 The aim of this study is to identify whether implementing a sticker reminder system can reduce the non-attendance rate within the general paediatric clinic. Methods A sticker reminder system was implemented from December 2010 to July 2011 in the general paediatric clinic (New and Review clinics). During the clinic if a follow-up appointment was offered a sticker was given to the patient (or parents) with the date and time of the follow-up appointment. The patients who had received stickers were recorded on the clinic lists. A retrospective analysis of patients9 activity via the computer system (CDA) was commenced in November to identify the proportion of patients who had attended their follow-up appointment. Results The non-attendance rate was 9.23% for all patients who had been given stickers (total of 65 patients), calculated for the period between December 2010 and July 2011 (excluding 2 patients who were not given stickers and 4 whose appointments were in the future). The control non-attendance rate was 18.4%, which was calculated from follow-up clinics in December 2009 to July 2010. There was found to be a significant difference (p 2 = 4.05). Conclusion The sticker implementation significantly improved attendance rates in the general paediatric clinic. This is a simple and non-expensive intervention which will be easy to implement on a wider scale. It is hoped that by reducing the non-attendance rates throughout the trust it will improve the overall management of the patient and on a wider scale reduce the cost to the NHS.

Aims User experience is an important indicator about quality of services. The audit was undertaken to evaluate parents experience about community paediatric clinic appointments. The aim was to obtain feedback from parents on the quality of care provided and to use the feedback to make ongoing improvements. Method The audit was conducted prospectively with parents of children seen by community paediatricians during a 6 week period, from 1st July till 15th Aug 2011. The questions were based on the PaedCCF form but were modified into a single - page, anonymised questionnaire with eight questions and free-text answers. At the end of each clinic consultation, the form was handed to parents. A marked box was kept for them to drop the completed form at the reception, before leaving the clinic. All the completed forms were sent to the audit department for further evaluation. Results In total, 344 forms were completed over the 6 week period. The responses to questions were recorded (table 1). Parents of children aged 0-19 years were represented. More than 90% of responses were recorded as good, very good or excellent and none were marked as poor. The free text box was completed by 45 parents. Of them, 41 parents made complimentary comments and 4 parents expressed concerns. Concerns from two parents were related to service delivery issues. One parent was frustrated with ‘delayed diagnosis’ and another parent would have preferred an interpreter being present during the appointment. Conclusion The total data collected represents about 10% of our total caseload. Parents reported high satisfaction scores about their experience at clinic appointments. Changes have been proposed to improve communication with parents, based on the responses in the ‘fair’ category. This simple, easy to use form enabled us to collect robust evidence about quality of services. Collection of patient feedback information is going to be an important component of revalidation. The individual forms have been sent to relevant clinicians, for use towards appraisals in preparation for revalidation.

A 6 year old girl comes to your outpatient paediatric clinic with a two month history of cough and shortness of breath, requiring, nearly three times a week, administration of β2 agonists by jet nebuliser. She has often been noticed to wheeze at school during the gymnastic class, and also when she’s laughing or crying; almost once a week she awakes during the night complaining of cough and respiratory difficulties. Your diagnosis is persistent asthma,1 and after a short course of nebulised salbutamol (albuterol) and oral steroids you decide to start, twice a day, …

The UK science writer Simon Singh and the complementary medicines expert Edzard Ernst have lent their weight to a campaign against the use of chiropractic on babies and children in Australia. Australian medical and scientific experts have also backed the campaign by Loretta Marron, a cancer survivor and former “Australian sceptic of the year” who advocates against unproved and disproved alternative therapies. Ms Marron has documented at least 50 chiropractic websites in New South Wales that offer treatment to pregnant women, babies, and children and has called on the Australian government to close a chiropractic paediatric clinic run by the Royal Melbourne Institute of Technology (RMIT) University. The university clinic is teaching “inappropriate and potentially dangerous techniques that target pregnant women, babies, infants, and children,” Ms Marron wrote in a report she recently sent to the federal health minister, Nicola Roxon. “As this is a clear breach …

A female infant aged 5.5 months of Balkan origin arrived at the emergency department of our hospital with fever of 38.8°C, tachypnoea of 60 breaths per minute, heart rate of 110 beats per minute and oxygen saturation of 100%. The patient was admitted to the Paediatric Clinic and underwent full laboratory and culture tests, which were negative for infection. Initial chest x ray at admittance showed a consolidation of the left upper lobe of the left lung and the presence of air in the left hemithorax, which was believed …

Mr and Mrs A attend your paediatric clinic with their 18 month old daughter. She has a history of repeated chest infections, failure to thrive, and steatorrhoea (fatty stools). As part of the consultation you take a family history and draw the pedigree (family tree) (fig 1). Fig 1 Family tree 1. What does the double line between Mr and Mrs A represent? 2. You suspect an inherited disorder. Examining the pedigree, what is the most likely pattern of inheritance--sex linked, autosomal dominant, or autosomal recessive? 3. What is the most likely diagnosis? 4. Given that Mr and Mrs A's first child--an 8 year old boy--is fit and well, what is the probability that he is a carrier of the inherited disorder? 5. While at clinic, Mrs A tells you that she is pregnant and is worried that the child could also be affected by the same condition. Who would you refer her to and why? 1. Consanguinity, which means “of the same blood.” Mr and Mrs A are genetically related as they share a common set of grandparents--they are first …

Editor,—True and perceived nut allergy is a problem that paediatricians are seeing ever more frequently and guidelines for adequate diagnosis are needed. We therefore published our experience of children presenting to a general paediatric clinic with this problem.1 In their letter O'B Hourihane et al have some points regarding the methodology we used for the diagnosis of nut allergy2; we would like to comment on some of those issues. The assumption that nut was the “only possible allergen” in …

Editor,—We agree with the views expressed by Gatzoulis et al concerning the need for dedicated clinics for adults with congenital heart disease.1 We started such a clinic in 1993. Initially this was once a month, becoming semimonthly in 1995 and weekly in 1999. The clinic is in a district general hospital serving a population of 650 000, and the initial numbers may have been present because of the early work of Bill Oliver in establishing catheter facilities on this site and the link with Great Ormond Street visiting cardiologists. One of us also runs a paediatric clinic and the other has experience in adult congenital heart disease. Forty three per cent of our 260 patients are male, and 25% of …

Five children with tuberous sclerosis and anti-convulsant-associated rickets have been seen in a general paediatric clinic over the last 5 years. It is suggested that vitamin D prophylaxis is particularly indicated in patients with tuberous sclerosis taking anticonvulsant medication.