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Jonathan Grigg,1 Anjan Nibber,2 James Y Paton,3 Alison Chisholm,2 Theresa W Guilbert,4 Alan Kaplan,5 Steve Turner,6 Nicolas Roche,7 Elizabeth V Hillyer,8 David B Price8,9 On behalf of the Respiratory Effectiveness Group 1Blizard Institute, Queen Mary University of London, London, UK; 2Respiratory Effectiveness Group, Cambridge, UK; 3School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK; 4Pulmonary Division, Cincinnati Children’s Hospital Medical Center, and Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; 5Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada; 6Department of Child Health, Royal Aberdeen Children’s Hospital, University of Aberdeen, Aberdeen, UK; 7Respiratory Medicine, Cochin Hospital Group, AP-HP, University of Paris Descartes (EA2511), Paris, France; 8Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore; 9Academic Primary Care, University of Aberdeen, Aberdeen, UK Background: An inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent wheezing/asthma attacks in preschoolers with recurrent wheeze when added to short-acting β-agonist (SABA).Objective: The aim of this historical matched cohort study was to assess the effectiveness of these treatments for preventing wheezing/asthma attacks.Methods: Electronic medical records from the Optimum Patient Care Research Database were used to characterize a UK preschool population (1–5 years old) with two or more episodes of wheezing during 1 baseline year before first prescription (index date) of ICS or LTRA, or repeat prescription of SABA. Children initiating ICS or LTRA on the index date were matched 1:4 to those prescribed only SABA for age, sex, year of index prescription, mean baseline SABA dose, baseline attacks, baseline antibiotic prescriptions, and eczema diagnosis. Wheezing/asthma attacks (defined as asthma-related emergency attendance, hospital admission, or acute oral corticosteroid prescription) during 1 outcome year were compared using conditional logistic regression.Results: Matched ICS and SABA cohorts included 990 and 3,960 children, respectively (61% male; mean [SD] age 3.2 [1.3] years), and matched LTRA and SABA cohorts included 259 and 1,036 children, respectively (65% male; mean [SD] age 2.6 [1.2] years). We observed no significant difference between matched cohorts in the odds of a wheezing/asthma attack: ICS vs SABA, OR (95% CI) 1.01 (0.85–1.19) and LTRA vs SABA, OR (95% CI) 1.28 (0.96–1.72).Conclusion: We found no evidence that initiation of ICS or LTRA therapy is associated with fewer attacks during 1 outcome year than SABA alone for a heterogeneous group of preschool children with recurrent wheeze in the real-life clinical setting. Keywords: electronic medical records, inhaled corticosteroids, leukotriene receptor antagonists, observational study, ICS particle size, short-acting β-agonist

Background: The value of interferon-gamma release assays (IGRA) to diagnose active tuberculosis (TB) in children is not established, but these assays are being widely used for this purpose. The authors examined the sensitivity of commercially available IGRA to diagnose active TB in children in the UK compared with the tuberculin skin test (TST).Methods: The authors established a paediatric tuberculosis network and conducted a retrospective analysis of data from children investigated for active TB at six large UK paediatric centres. All centres had used TST and at least one of the commercially available IGRA (T-Spot.TB or Quantiferon-Gold in Tube) in the diagnostic work-up for active TB. Data were available from 333 children aged 2 months to 16 years. The authors measured the sensitivity of TST and IGRA in definite (culture confirmed) and probable TB in children, agreement between TST and either IGRA, and their combined sensitivity.Results: Of 333 children, 49 fulfilled the criteria of definite TB, and 146 had probable TB. Within the definite cohort, TST had a sensitivity of 82%, Quantiferon-Gold in tube (QFT-IT) had a sensitivity of 78% and T-Spot.TB of 66%. Neither IGRA performed significantly better than a TST with a cut-off of 15 mm. Combining the results of TST and IGRA increased the sensitivity to 96% for TST plus T-Spot.TB and 91% for TST plus QFG-IT in the definite TB cohort.Conclusions: A negative IGRA does not exclude active TB disease, but a combination of TST and IGRA increases the sensitivity for identifying children with active TB. [ABSTRACT FROM AUTHOR]

Background: A socioeconomic gradient in childhood obesity is known to be present by the age of school entry in the UK. The origin of this gradient is unclear at present, but must lie in socioeconomic differences in habitual physical activity, sedentary behaviour, or dietary intake.Aims: To test the hypothesis that habitual physical activity and/or sedentary behaviour are associated with socioeconomic status (SES) in young Scottish children.Methods: Observational study of 339 children (mean age 4.2 years, SD 0.3) in which habitual physical activity and sedentary behaviour were measured by accelerometry over six days (study 1). In a second study, 39 pairs of children of distinctly different SES (mean age 5.6 years, SD 0.3) were tested for differences in habitual physical activity and sedentary behaviour by accelerometry over seven days.Results: In study 1, SES was not a significant factor in explaining the amount of time spent in physical activity or sedentary behaviour once gender and month of measurement were taken into account. In study 2, there were no significant differences in time spent in physical activity or sedentary behaviour between affluent and deprived groups.Conclusion: Results do not support the hypothesis that low SES in young Scottish children is associated with lower habitual physical activity or higher engagement in sedentary behaviour. [ABSTRACT FROM AUTHOR]

Unlabelled: Ninety children aged 6 to 13 y and suffering from chronic asthma were included in a prospective follow-up study lasting 18 mo in order to assess whether life events involving substantial positive effects on the child can protect against the increased risk associated with stressful life events. The main outcome measures included positive life events, positive long-term experiences, severely negative life events, chronic psychosocial stress and new asthma exacerbation. The results showed that, provided they occurred in close proximity to severely negative life events, positive life events, generally related to the child's own achievements, afforded protection against the increased risk of a new asthma exacerbation precipitated by severe events in children whose lives were marked by low to medium levels of chronic stress. No such effect was found in children exposed to high chronic stress nor did long-term positive experiences, such as when the child has a rewarding hobby, affect the asthma risk.Conclusion: Life events with a definite positive effect can counteract the increased risk of an asthma exacerbation precipitated by a severely negative life event, provided the chronic stress is only of low to medium level. Because this protective influence does not apply where there is high chronic stress, reducing this condition must be seen as a priority in children suffering from asthma, as these children are also more vulnerable to negative life events precipitating asthma exacerbation. [ABSTRACT FROM AUTHOR]

Background: In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients.Aims: To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence.Methods: Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions.Results: Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year.Conclusion: The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further. [ABSTRACT FROM AUTHOR]

There is an increasing tendency for young children to participate in training and competitive running. The impact long-term training has upon stimulating functional physiological adaptation has yet to be fully understood. In this study cardio-respiratory and kinematic differences were assessed at submaximal and maximal exercise intensities in run-trained and non-run-trained boys. Thirty three pre-pubertal boys volunteered to take part in the study. The subjects were in two groups: 15 run-trained subjects [age 11.7+/-1.06 yrs, mean+/-SD] and 18 non-run-trained (control) subjects [age 11.3+/-0.90 yrs]. Two separate (4x3 min) submaximal protocols were used for the trained and non-run-trained groups, with two of the speeds overlapping for comparison purposes. In addition, all boys also performed a maximal oxygen consumption test. Mean VO2max value for the run trained group was 60.5+/-3.3 ml/kg/min and for the control group 51.1+/-4.3 ml/kg/min, (p<0.001). No significant differences were found for submaximal running economy at either comparison speed. In addition, no significant (p>0.05) differences were noted between the groups for any of the kinematic variables at the two comparison speeds. However, selected physiological differences did exist at the submaximal running speeds. The source of the differences that did exist between the two groups may be the result of training, genetic pre-selection or developmental differences between the groups. [ABSTRACT FROM AUTHOR]

Objective: Recovery from acute wheeze and asthma attacks should be supported with safety netting, including treatment advice. We evaluated emergency department (ED) discharge practices for acute childhood wheeze/asthma attacks to describe variation in safety netting and recovery bronchodilator dosing., Design: Two-phase study between June 2020 and September 2021, comprising (1) Departmental discharge practice survey, and (2) Analysis of written discharge instructions for caregivers., Setting: Secondary and tertiary EDs in rural and urban settings, from Paediatric Emergency Research in the UK and Ireland (PERUKI)., Main Outcome Measures: Describe practice and variation in discharge advice, treatment recommendations and safety netting provision., Results: Of 66/71 (93%) participating sites, 62/66 (93.9%) reported providing written safety netting information. 52/66 (78.8%) 'nearly always' assessed inhaler/spacer technique; routine medication review (21/66; 31.8%) and adherence (16/66; 21.4%) were less frequent. In phase II, 61/66 (92.4%) submitted their discharge documents; 50/66 (81.9%) included bronchodilator plans. 11/66 (18.0%) provided Personalised Asthma Action Plans as sole discharge information. 45/50 (90%) provided 'fixed' bronchodilator dosing regimes; dose tapering was common (38/50; 76.0%). Median starting dose was 10 puffs 4 hourly (27/50, 54.0%); median duration was 4 days (29/50, 58.0%). 13/61 (21.3%) did not provide bronchodilator advice for acute deterioration; where provided, 42/48 (87.5%) recommended 10 puffs immediately. Subsequent dosages varied considerably. Common red flags included inability to speak (52/61, 85.2%), inhalers not lasting 4 hours (51/61, 83.6%) and respiratory distress (49/61, 80.3%)., Conclusions: There is variation in bronchodilator dosing and safety netting content for recovery following acute wheeze and asthma attacks. This reflects a lack of evidence, affirming need for further multicentre studies regarding bronchodilator recovery strategies and optimal safety netting advice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background: Time spent in 24-h movement behaviors is important to health and wellbeing in childhood, but levels of these behaviors in children with chronic disease are unknown., Methods: A case-control-study included 80 children with chronic disease; 20 with type 1 diabetes mellitus (T1DM), 20 with juvenile idiopathic arthritis (JIA), 20 with congenital heart disease (CHD), 20 with cystic fibrosis (CF); pair-matched individually for age, sex, and timing of measures with 80 healthy children. Habitual time spent in movement behaviors and step counts were all measured with an activPAL accelerometer over 7 days. Comparisons against recommendations and differences between the groups were made., Results: Time spent in physical activity and step counts/day were significantly lower in T1DM and CHD groups compared to controls. Only 20/80 children with chronic disease and 29/80 controls met step count recommendations. Sedentary time was significantly higher in children with CF compared to controls. Time spent asleep was slightly greater in children with chronic disease, significant only for the JIA group. Sleep disruption was consistently greater in those with chronic disease, reaching significance for T1DM, CHD, and CF groups., Conclusions: For some groups of children with chronic disease, 24-h movement behaviors may differ substantially from recommendations, and slightly but systematically from their healthy peers. Optimizing levels of 24-h movement behaviors should confer a number of benefits for child health, development, and wellbeing.

The Global Lung Function Initiative (GLI) all-age reference equations for carbon monoxide transfer factor were published in 2017 and endorsed by the European Respiratory Society and American Thoracic Society. In order to understand the impact of these new reference equations on the interpretation of results in children referred from haematology and oncology paediatric services, we retrospectively analysed transfer factor results from any paediatric patient referred from haematology/oncology in the period 2010-2018. We examined transfer factor of the lung for carbon monoxide ( T LCO ), transfer coefficient of the lung for carbon monoxide ( K CO ) and alveolar volume ( V A ) from 241 children (age range 7-18 years, 130 male). The predicted values from Rosenthal and GLI were plotted against height. The difference in interpretation of results was analysed by looking at the percentage of patients below the lower limit of normal for each parameter. Overall, the Rosenthal predicted values for T LCO were higher than those predicted by GLI. Predicted K CO using Rosenthal was higher in all observations. In contrast, the Rosenthal predicted V A was generally lower than the GLI value. The GLI predicted values for transfer factor show considerable differences compared with currently used paediatric UK reference values, differences that will have a significant impact on interpretation of results., Competing Interests: Conflict of interest: P.D. Burns has nothing to disclose. Conflict of interest: J.Y. Paton has nothing to disclose., (Copyright ©ERS 2021.)

Globally, asthma is one of the most common chronic conditions that affect individuals of all ages. When poorly controlled, it negatively impacts patient's ability to enjoy life and work. At the population level, effective use of recommended strategies in children and adults can reduce symptom burden, improve quality of life and significantly reduce the risk of exacerbation, decline of lung function and asthma-related death. Inhaled corticosteroid as the initial maintenance therapy, ideally started within 2 years of symptom onset, is highly effective in both children and adults and across various degrees of asthma severity. If asthma is not controlled, the choice of subsequent add-on therapies differs between children and adults. Evidence supporting pharmacological approach to asthma management, especially for those with more severe disease, is more robust in adults compared to children. This is, in part, due to various challenges in the diagnosis of asthma, in the recruitment into clinical trials and in the lack of objective outcomes in children, especially those in the preschool age group. Nevertheless, where evidence is emerging for younger children, it seems to mirror the observations in adults. Clinicians need to develop strategies to implement guideline-based recommendations while taking into consideration individual variations in asthma clinical phenotypes, pathophysiology and treatment responses at different ages.

Background: Obesity has been hypothesized to be associated with reduced moderate-to-vigorous physical activity (MVPA) and increased sedentary time (ST). It is important to assess whether, and the extent to which, levels of MVPA and ST are suboptimal among children and adolescents with obesity. The primary objective of this study was to examine accelerometer-measured time spent in MVPA and ST of children and adolescents with obesity, compared with MVPA recommendations, and with non-obese peers., Methods: An extensive search was carried out in Medline, Cochrane library, EMBASE, SPORTDiscus, and CINAHL, from 2000 to 2015. Study selection and appraisal: studies with accelerometer-measured MVPA and/or ST (at least 3 days and 6 h/day) in free-living obese children and adolescents (0 to 19 years) were included. Study quality was assessed formally. Meta-analyses were planned for all outcomes but were precluded due to the high levels of heterogeneity across studies. Therefore, narrative syntheses were employed for all the outcomes., Results: Out of 1503 records, 26 studies were eligible (n = 14,739 participants; n = 3523 with obesity); 6/26 studies involved children aged 0 to 9 years and 18/26 involved adolescents aged 10.1 to19 years. In the participants with obesity, the time spent in MVPA was consistently below the recommended 60 min/day and ST was generally high regardless of the participant's age and gender. Comparison with controls suggested that the time spent in MVPA was significantly lower in children and adolescents with obesity, though differences were relatively small. Levels of MVPA in the obese and non-obese were consistently below recommendations. There were no marked differences in ST between obese and non-obese peers., Conclusions: MVPA in children and adolescents with obesity tends to be well below international recommendations. Substantial effort is likely to be required to achieve the recommended levels of MVPA among obese individuals in obesity treatment interventions. This systematic review has been registered on PROSPERO (International Database of Prospective Register Systematic Reviews; registration number CRD42015026882).

Context: Moderate-to-vigorous physical activity (MVPA) and sedentary time (ST) are important for child and adolescent health., Objective: To examine habitual levels of accelerometer measured MVPA and ST in children and adolescents with chronic disease, and how these levels compare with healthy peers., Methods: Data sources: An extensive search was carried out in Medline, Cochrane library, EMBASE, SPORTDiscus and CINAHL from 2000-2017. Study selection: Studies with accelerometer-measured MVPA and/or ST (at least 3 days and 6 hours/day to provide estimates of habitual levels) in children 0-19 years of age with chronic diseases but without co-morbidities that would present major impediments to physical activity. In all cases patients were studied while well and clinically stable., Results: Out of 1592 records, 25 studies were eligible, in four chronic disease categories: cardiovascular disease (7 studies), respiratory disease (7 studies), diabetes (8 studies), and malignancy (3 studies). Patient MVPA was generally below the recommended 60 min/day and ST generally high regardless of the disease condition. Comparison with healthy controls suggested no marked differences in MVPA between controls and patients with cardiovascular disease (1 study, n = 42) and type 1 diabetes (5 studies, n = 400; SMD -0.70, 95% CI -1.89 to 0.48, p = 0.25). In patients with respiratory disease, MVPA was lower in patients than controls (4 studies, n = 470; SMD -0.39, 95% CI -0.80, 0.02, p = 0.06). Meta-analysis indicated significantly lower MVPA in patients with malignancies than in the controls (2 studies, n = 90; SMD -2.2, 95% CI -4.08 to -0.26, p = 0.03). Time spent sedentary was significantly higher in patients in 4/10 studies compared with healthy control groups, significantly lower in 1 study, while 5 studies showed no significant group difference., Conclusions: MVPA in children/adolescents with chronic disease appear to be well below guideline recommendations, although comparable with activity levels of their healthy peers except for children with malignancies. Tailored and disease appropriate intervention strategies may be needed to increase MVPA and reduce ST in children and adolescents with chronic disease.

Background: While exercise testing is increasingly used as a prognostic indicator in cystic fibrosis (CF), it is reported to be underused in UK CF centres, particularly in children. Here, we evaluated the cardiopulmonary exercise testing (CPET) results in children and young people with CF at CF annual review and its possible clinical value., Method: An observational study comparing CPET results using a cycle ergometer ramp test (peak oxygen uptake (Vo 2peak )) and pulmonary function (forced expiratory volume in 1 s (FEV 1 )) was performed with body mass index (BMI) used as a disease severity marker. Data were identified from clinical case notes and our CF database., Results: Thirty-eight children and young people (mean age 11±2.4, range 7-14 years; 17 males and 21 females) completed at least one CPET with 95% achieving technically satisfactory tests allowing measurement of Vo 2peak . Mean Vo 2peak was 107 ±17.6% predicted, range 74%-150% predicted, with 8% having a reduced Vo 2peak of <85% of predicted. Mean FEV 1 z-score was -0.77±1.24, range -4.42 to 2.24. We did not demonstrate a significant correlation between Vo 2peak % predicted and FEV 1 z-score (r=0.25, p=0.13), or between Vo 2peak % predicted and BMI z-score (r=-0.05, p=0.77). Twenty-eight of 38 completed a second CPET the following year with 71% showing a decline in Vo 2peak (mean decline of 8% of predicted value, equivalent to 3.8 mL/kg/min)., Conclusion: CPET is feasible with 95% of children and young people achieving technically satisfactory assessments starting from age 7. In this group with relatively mild CF, mean Vo 2peak was normal with no significant correlation between Vo 2peak and FEV 1 or BMI, as markers of disease severity. The majority demonstrated a normal Vo 2peak . However, 71% showed a downward trend on repeat testing 12-18 months later., Competing Interests: Competing interestsNone., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

HERMES: European accreditation of training centres in paediatric respiratory medicine http://ow.ly/ZBmUg.

Background: The American Academy of Pediatrics recommends a permissive hypoxaemic target for an oxygen saturation of 90% for children with bronchiolitis, which is consistent with the WHO recommendations for targets in children with lower respiratory tract infections. No evidence exists to support this threshold. We aimed to assess whether the 90% or higher target for management of oxygen supplementation was equivalent to a normoxic 94% or higher target for infants admitted to hospital with viral bronchiolitis., Methods: We did a parallel-group, randomised, controlled, equivalence trial of infants aged 6 weeks to 12 months of age with physician-diagnosed bronchiolitis newly admitted into eight paediatric hospital units in the UK (the Bronchiolitis of Infancy Discharge Study [BIDS]). A central computer randomly allocated (1:1) infants, in varying length blocks of four and six and without stratification, to be clipped to standard oximeters (patients treated with oxygen if pulse oxygen saturation [SpO2] <94%) or modified oximeters (displayed a measured value of 90% as 94%, therefore oxygen not given until SpO2 <90%). All parents, clinical staff, and outcome assessors were masked to allocation. The primary outcome was time to resolution of cough (prespecified equivalence limits of plus or minus 2 days) in the intention-to-treat population. This trial is registered with ISRCTN, number ISRCTN28405428., Findings: Between Oct 3, and March 30, 2012, and Oct 1, and March 29, 2013, we randomly assigned 308 infants to standard oximeters and 307 infants to modified oximeters. Cough resolved by 15·0 days (median) in both groups (95% CI for difference -1 to 2) and so oxygen thresholds were equivalent. We recorded 35 serious adverse events in 32 infants in the standard care group and 25 serious adverse events in 24 infants in the modified care group. In the standard care group, eight infants transferred to a high-dependency unit, 23 were readmitted, and one had a prolonged hospital stay. In the modified care group, 12 infants were transferred to a high-dependency unit and 12 were readmitted to hospital. Recorded adverse events did not differ significantly., Interpretation: Management of infants with bronchiolitis to an oxygen saturation target of 90% or higher is as safe and clinically effective as one of 94% or higher. Future research should assess the benefits and risks of different oxygen saturation targets in acute respiratory infection in older children, particularly in developing nations where resources are scarce., Funding: National Institute for Health Research, Health Technology Assessment programme., (Copyright © 2015 Cunningham et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd.. All rights reserved.)

At the end of his mandate as Breathe Chief Editor, James Paton reflects on the previous 3 years http://ow.ly/RctU8.

The use of data to challenge and improve healthcare has a long and distinguished history but has often failed to bring about expected improvements. It has never become fully embedded in clinical practice, probably because data alone are insufficient to drive change. There is now a greater appreciation that changing and improving healthcare requires changing behaviours. Clinical audit remains one of the important tools that can be used to facilitate such change., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Setting: Large specialist paediatric TB clinics in the UK., Objective: To evaluate clinical practice and compare with national and international guidelines., Design: A survey based on an electronic questionnaire on the management of latent tuberculous infection (LTBI) and tuberculosis (TB) disease was conducted in 13 specialist paediatric TB clinics. The consensus and discrepancies were evaluated by descriptive analysis., Results: Practice was reportedly different when choosing age limits for preventive treatment for TB contacts with initially negative tuberculin skin tests (TSTs), interpretation of TST results and use of interferon-gamma release assays (IGRAs) in the context of LTBI. In relation to management of children with TB disease, practices varied for duration of treatment of osteoarticular TB, monitoring for ethambutol ocular toxicity and use of pyridoxine. There was limited experience with multidrug-resistant TB (MDR-TB), and over half of the clinics monitored MDR-TB contacts without giving preventive treatment., Conclusions: The survey showed heterogeneity in several aspects of clinical care for children with TB. Available paediatric TB guidelines differ substantially, explaining the wide variations in management of childhood TB. Prospective paediatric studies are urgently required to inform and standardise clinical practice, especially in the context of evolving drug resistance.

Background: Sitting time and breaks in sitting influence cardio-metabolic health. New monitors (e.g. activPAL™) may be more accurate for measurement of sitting time and breaks in sitting although how to optimize measurement accuracy is not yet clear. One important issue is the minimum sitting/upright period (MSUP) to define a new posture. Using the activPAL™, we investigated the effect of variations in MSUP on total sitting time and breaks in sitting, and also determined the criterion validity of different activPAL™ settings for both constructs., Methods: We varied setting of MSUP in 23 children (mean (SD) age 4.5 y (0.7)) who wore activPAL™ (24 hr/d) for 5-7 d. We first studied activPAL™ using the default setting of 10 s MSUP and then reduced this to 5 s, 2 s and 1 s. In a second study, in a convenience sample of 30 pre-school children (mean age 4.1 y (SD 0.5)) we validated the activPAL™ measures of sitting time and breaks in sitting at different MSUP settings against direct observation., Results: Comparing settings of 10, 5, 2 and 1 s, there were no significant differences in sitting time (6.2 hr (1.0), 6.3 hr (1.0), 6.4 hr (1.0) and 6.3 hr (1.6), respectively) between settings but there were significant increases in the apparent number of breaks - (8(3), 14(2), 21(4) and 28 (6)/h) at 10, 5, 2 and 1 s settings, respectively. In comparison with direct observation, a 2 s setting had the smallest error relative to direct observation (95% limits of agreement: -14 to +17 sitting bouts/hr, mean difference 1.83, p = 0.2)., Conclusion: With activPAL™, breaks in sitting, but not total sitting time, are highly sensitive to the setting of MSUP, with 2 s optimal for young children. The MSUP to define a new posture will need to be empirically determined if accurate measurements of number of breaks in sitting are to be obtained.

Introduction: Invasive pneumococcal disease due to serotype 19A has become a major concern, particularly in the USA and Asia. We describe the characteristics of pneumococcal serotype 19A related empyema and changes in its incidence in the UK., Methods: Data from paediatric empyema patients between September 2006 and March 2011 were collected from 17 respiratory centres in the UK. Pneumococcal serotypes were identified as part of the Health Protection Agency enhanced paediatric empyema surveillance programme., Results: Four serotypes accounted for over 80% of 136 cases (Serotype 1 : 43%, 3 : 21%, 7 : 11% and 19A:10%). The incidence of empyema due to serotype 19A quadrupled from 0.48 (0.16-1.13) cases per million children in 2006/2007 to 2.02 (1.25-3.09) in 2010/2011. Severity of disease was significantly increased in children with 19A infection when compared to other serotypes., Conclusions: The incidence of empyema due to pneumococcal serotype 19A infection has increased significantly and is associated with substantial morbidity.