Archives of Disease in Childhood
ISSN / EISSN : 0003-9888 / 1468-2044
Published by: BMJ (10.1136)
Total articles ≅ 32,526
Latest articles in this journal
Archives of Disease in Childhood; https://doi.org/10.1136/archdischild-2022-323839
Serious illness requiring intensive care is relatively rare in childhood. Across the four nations of the UK, 26 PICUs are commissioned, but in 2020 a single PICU was unlikely to admit more than a few children with severe COVID-19. However, among them there were some with a pandemic-related paediatric phenotype, the paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS; affecting the kidneys, heart, lungs and brain).3 The existence of an excellent national audit, collecting data from PICUs, allowed it to be characterised, while further insights came from enrolment of children in large national studies, such as the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) study and Randomised Evaluation of COVID-19 Therapy (RECOVERY) trials.
Archives of Disease in Childhood; https://doi.org/10.1136/archdischild-2021-323470
Objective Understanding pathways to detection for childhood visual impairment (VI) is critical for planning services. We aimed to describe patterns of detection for childhood VI. Design and setting Cross-sectional study using data from British Childhood Visual Impairment and Blindness Study 2. Patients Children newly diagnosed with VI, severe vision impairment or blindness (SVI/BL)—that is, visual acuity worse than logMAR 0.5 in both eyes—were identified through active surveillance, with data collection at diagnosis and 1 year later. Outcome measure Method of detection of vision/eyes problem. Results 784 children (45%, 356 girls) were identified, of whom 313 (40%) had VI, 471 (60%) had SVI/BL. Additional non-ophthalmic disorders or impairments (VI/SVI/BL ‘plus’), were diagnosed in 72% (559/784). Of the 784, 173 children were detected through routine screening (22%), 248 through targeted examinations (32%) and 280 through family self-referral (36%). Parents and carers had only reported symptoms in 55% of children who manifested them, with evidence that families living in socioeconomically deprived areas were less likely to report concerns. Paediatricians were the professionals most likely to raise initial suspicion of visual disability. Conclusions Our findings show that targeted screening and surveillance is important for the detection of full spectrum childhood visual impairment (VI/SVI/BL), as a significant proportion of children will not have symptoms, or their parents or carers will not report symptoms. As paediatricians were the professionals most commonly involved in detection, it would be helpful if their core competencies included the skills needed to undertake simple assessments of vision.
Archives of Disease in Childhood; https://doi.org/10.1136/archdischild-2021-323308
Objective: To examine the association between gestational age at birth and risk of clinically diagnosed intellectual disability (ID) week by week to provide a detailed description of ID risk across the entire range of gestational ages and by severity of ID.Methods: All individuals born alive in Sweden 1974–2017 were prospectively followed up from birth until 2017 using national registers. The HRs for ID according to weekly gestational age and gestational age categories were determined using Cox models. Sibling analyses were conducted to adjust for familial confounding.Results: The study included 3 572 845 live births. During the follow-up, 26 596 ID cases were registered. The adjusted weekly estimates showed a gradual increase in risk of ID from week 40 to week 24 (adjusted HR37weeks=1.80 (1.74 to 1.87), aHR32weeks=3.93 (3.73 to 4.13), aHR28weeks=7.53 (6.95 to 8.16), aHR24weeks=21.58 (18.62 to 25.00)) and from week 41 onwards (aHR42weeks=1.26 (1.19 to 1.32)), with statistically significantly higher risks across the range of gestational age compared with infants born at week 40. The associations were consistent in mild, moderate and severe/profound ID but most prominent for severe/profound ID.Conclusion: The risk of ID increased weekly as the date of delivery moved away from 40 weeks, both preterm and post-term. The results remained robust after detailed adjustment for confounding, including familial confounding.
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.28
Clinical Pearl: What the case involved: 16 month old female presented to local emergency department with short sudden episodes of floppiness and head dropping, followed by immediate return to normal self. Referred to regional centre for neurology review, 24 hour ECG noted marked bradycardia during episodes of head dropping. On cardiology review there were no abnormalities detected on examination, echo or 12 lead ECG. Multi-disciplinary team approach required to determine management. 24 hour ECG evidenced abrupt onset of complete atrio-ventricular block, ventricular standstill of up to 7 seconds with spontaneous recovery of atrio-ventricular conduction.Pharmacist contribution: Literature reviewed and treatment options determined by multi-disciplinary team. Evidence strongly supportive of theophylline.1–3 Issues with prescribing and use of unlicensed medicines considered and authorisation obtained. Treatment commenced and 24hour ECG performed and analysed daily to determine effect of theophylline on number of atrio-ventricular block episodes. Pharmacokinetic knowledge applied to determine appropriate dose, dosage interval, interpretation of levels and response to treatment. A family centred care approach was taken throughout and parents understood and engaged with the treatment plan. A response to treatment was observed as demonstrated by reduced clinical symptoms, confirmed by ECG findings which showed a small reduction in the number of atrio-ventricular block episodes. However, parents and nursing staff reported notable drug side effects of sweating, agitation and bad behaviour two hours post dose, despite achieving therapeutic concentratrions. Parents also felt the frequency of drug administration required at home would be difficult to manage and they had a level of anxiety regarding the unpredictable frequency of the episodes and feeling the need to be in attendance at all times. In the long-term this could have significant implications for family life. On review the multi-disciplinary team and parents agreed the response to theophylline was not adequate enough for a long-term option and the patient proceeded to pacemaker insertion. All were in agreement that this was the correct decision.Outcome: Permanent pacemaker inserted, programmed to VVI mode. This mode will prevent bradycardia by pacing the ventricle if there is a loss of atrio-ventricular synchrony and inhibit ventricular pacing in response to intrinsic ventricular rhythm. Most recent pacing check: ventricular pacing 1.8% of the time = approx. 2.7hours/weekLessons Learned: Advantage of multi-disciplinary team approach to care. The benefits of engaging parents in discussions and treatment plans were highlighted and improved the patient and family journey. The multi-disciplinary team acknowledged this and will endeavour to apply this approach in the future. The multi-disciplinary team improved their knowledge of the processes involved when using unlicensed medicines and the complex issues around this. The processes followed in this scenario confirmed the importance of evidence and research to plan future novel treatment options.Reference: Dai AI, Demiryurek AT. Effectiveness oral theophylline, piracetam and iron treatments in children with simple breath-holding spells. Journal of Child Neurology 2020;35:25-30. Garg M, Goraya JS. Treatment of cyanotic breath-holding spells with oral theophylline in a 10 year old boy. Journal of Child Neurology 2015;30:919-921. Carano N, Bo I, Zanetti E, et al. Glycopyrrolate and theophylline for the treatment of severe pallid breath-holding spells. Pediatrics 2013;131:1280-1283.
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.21
Aim: Dosing errors are the most predominant type of paediatric medication error in a hospital setting.1–3 The main aim was to investigate the effect of dosing sets, a type of clinical decision support (CDS) software, on paediatric prescribing safety in an electronic prescribing system. The secondary aim was to determine the impact of dose range checking (DRC) software on erroneous prescribing.Method: A retrospective observational clinical audit was conducted in a large tertiary paediatric hospital. The dosing sets and DRC software were fully integrated within the hospitals existing electronic prescribing system, namely MeditechV6. Data from before and after the introduction of dosing sets and DRC alert data from IV Piperacillin/Tazobactam and oral morphine prescriptions was extracted from MeditechV6 and analysed. The main outcome measures included the proportion of prescriptions with dosing errors, the type of errors and the level, and appropriateness of alert overrides.Results: The error rate did not significantly reduce following the introduction of either dosing sets. In the pre-intervention period 7/180 (3.9%) IV Piperacillin/Tazobactam prescriptions resulted in error and in the post-intervention period there were 5/180 (2.8%) prescription dosing errors (n=12, Pearson χ2 value=0.345, p=0.557). All detected errors comprised of sub-therapeutic doses and prescribing inaccuracies were more prevalent in patients over 12 years and less than 50 kilograms (kg). A total of 54/180 (30%) orders did not apply the dosing sets following implementation and 2/54 (3.7%) orders were subsequently erroneous. There was 1/120 (0.8%) prescribing error following accurate dosing set selection and 2/6 (33.3%) prescribing errors following inaccurate selection.After the introduction of dosing sets, 23/50 (46%) oral morphine to take out (TTO) prescriptions contained a dosing inaccuracy versus 11/50 (22%) prescriptions pre-introduction (p=0.011). Inpatient oral morphine prescribing inaccuracies decreased following dosing set introduction from 14/50 (28%) to 9/50 (18%) respectively (p=0.235).A total of 36/45 (80%) IV Piperacillin/Tazobactam DRC alerts were overridden at the point of prescribing and such actions were deemed clinically inappropriate for 6/36 (16.7%) prescriptions. Similarly, 6/20 (30.0%) of overridden oral morphine DRC alerts were deemed clinically inappropriate when audited against hospital guidelines.Conclusion: The introduction of drug-specific dosing sets did not significantly reduce the incidence or nature of prescribing errors for neither IV Piperacillin/Tazobactam nor oral morphine. In addition, the generation of DRC alerts did not prevent the submission of all erroneous prescriptions.References: Ghaleb MA, Barber N, Franklin BD, et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Archives of Disease in Childhood 2010;95:113–118. Wong ICK, Ghaleb MA, Franklin BD, et al. Incidence and nature of dosing errors in paediatric medications: a systematic review. Drug Safety 2004;27:661–670. Wong ICK, Wong LYL, Cranswick NE. Minimising medication errors in children. Archives of Disease in Childhood 2009;94:161-164.
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.32
Introduction: According to recent literature, the prevalence and incidence of long-term illnesses such as asthma and diabetes in young people has substantially risen over the past 13 years.1 Recent figures indicate that, in England, 4.1% of all prescriptions were prescribed for young people. More than 45 million prescriptions were dispensed for young people in 2017 by pharmacists.2Aim: The aim of this study was to investigate young people’s perspectives of the pharmaceutical services that are provided from primary care pharmacists relating to medication.Method: A cross-sectional survey using both the online and paper-based tools was conducted from March to November 2019. The population for this survey was young people from age 18 to 24 years registered as students at one of the universities in the UK. The survey consisted of twenty-four questions and they were a mix of closed-ended questions such as multiple choice and Likert scale and open-ended questions. This research gained ethical approval from the Ethics Committee of the same University (ERN_17-1672).Results: A total of 210 survey responses were returned. Most of the participants were female (62.4%). The most frequent age was 18 years (35.2%). Among participants, 15.7% were diagnosed with long-term illnesses and the majority of them (33.3%) were diagnosed with respiratory disease all of which was reported as asthma. Pharmacists were not utilised as a source of information for young people whereas the majority (60.6%) obtained information from their doctors. Most of the participants (97%) had not taken part in an MUR or NMS and 78.8% of them had never been told about any services or support groups by their pharmacist.Discussion and Conclusion: There is a lack of provision of pharmaceutical services and support by primary care pharmacists to young people with long-term illnesses. Previous evidence shows that this could be due to a lack of confidence when dealing with young people, unwillingness of pharmacists to take on more responsibilities, or a lack of training and support.3 The results would be of benefit to the policymakers to assist in the further growth of the pharmacy services. Further research will enhance understanding of the perceptions of young people about the pharmaceutical services that are offered by primary care pharmacists with respect to medications.References: Shah R, Hagell A, Cheung R. Nuffield Trust, Association for Young People’s Health. International comparisons of health and wellbeing in adolescence and early adulthood. 20 Feb 2019. https://www.nuffieldtrust.org.uk/research/international-comparisons-ofhealth-and-wellbeing-in-adolescence-and-early-adulthood Prescriptions Dispensed in the Community. Statistics for England 2007–2017 NHS Digital. 2018. Available online: https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions-dispensed-in-the-community-england---2007---2017 (accessed on 11 April 2021). Kehrer JP, Eberhart G, Wing M, Horon K. ‘Pharmacist’s role in a modern health continuum.’ Canadian Pharmacists Journal 2013;146(6):321-324.
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.41
Introduction: Infants and children with congenital heart defects are reliant on medicines to treat the symptoms of heart failure whilst they wait for corrective or palliative surgery. Medicines optimisation for this group of patients is a complex and challenging concept. This is because there are many factors that need to be considered to ensure the effective and safe use of these medicines.Infants and children undergo significant physiological and pharmacological changes over a relatively short period of time.1 In addition, this group of patients also present challenges for the safe administration of these medicines at home.2 Failure to optimise these medicines may result in reduced symptom control with negative effects on health outcomes for the family and child.The aim of this service evaluation was to identify whether patients attending for day case diagnostic catheter procedures on the children’s cardiology ward could benefit from having their medicines optimised during their hospital visit.Method: Data was collected prospectively over a period of 7 months from August 2019 to March 2020. Patients were included if they attended the children’s cardiology ward for a day case diagnostic cardiac catheter during the study period. In addition, they needed to be taking at least one long-term medicine at home.A pharmacist with experience in children’s medicines conducted a medication review with the family during their attendance. This included a consultation about which medicines were being taken at home, and listening to the experience that the family had from using their medicines. Medicines were then reviewed using up to date information such as weight, test results and medicines information resources. Anonymous data was kept using a Microsoft Excel® spreadsheet.Results: In total, 175 patients were assessed for inclusion during the study period. 57 families were found to be administering a long-term medicine at home and had their medicines reviewed. Subsequently, 13 patients had their medicines optimised.The most common recommendation was to increase the dose of a medicine for an up to date weight or because of failure to control symptoms (n=11). This was frequently seen with medicines such as aspirin, captopril and diuretics.In addition, more subtle and unexpected interventions regarding medication safety at home were also identified (n=2). For example, one family were found to be ten times under dosing their child due to an unidentified change in strength of liquid medication from primary care. Another family described their difficulty with crushing and dispersing tablets to administer using a nasogastric tube. This resulted in a block tube that required an additional hospital visit to have a new tube inserted. Additional action was taken to report and rectify these medication errors.Conclusion: This project has demonstrated the value that can be gained from a pharmacist providing ongoing reviews of medicines used by families when they attend a children’s cardiology centre. Day case admissions in a specialist hospital may be seen as low priority to professionals. However, this is an ideal opportunity to provide support to families who use medicines at home.References: Kearns GL, Abdel-Rahman SM, Alander SW, et al. Developmental pharmacology--drug disposition, action, and therapy in infants and children. New England Journal of Medicine 2003;349:1157-1167. NHS England and NHS Improvement. The NHS patient safety strategy. Safer culture, safer systems, safer patients. 2019. [Cited: 14th August 2021]. Available at: https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.45
Background: Many unlicensed medicinal products routinely used to treat the paediatric population do not undergo the same rigorous assessment that adult preparations do prior to coming to market. This means that many preparations are not authorised for paediatric use and consequently there is widespread use of unlicensed medicines and ‘off-label’ use of licensed medicines. Evaluation of excipients in unlicensed medicines is an integral part of assessing their suitability for use in paediatric patients.1 Excipients of concern include (but are not limited to) propylene glycol, ethanol, hydroxybenzoates, artificial sweeteners. Medicines are carefully selected for use based on agreed criteria. The assessment tool used in this centre is the ‘New Products Assessment Form’ and helps the assessor identify potential issues with excipients.Aim: This review aimed to reassess excipients in one manufacturer’s portfolio of unlicensed liquid preparations, stocked and regularly used at this centre. An informed decision could then be made to switch to a more suitable alternative if necessary.Method: A list of the manufacturer’s unlicensed liquid preparations was compiled, 14 in total. The company was contacted and requested to provide a comprehensive list of excipients. A New Products Assessment Form was completed for each product, which identified potential issues with excipients, in line with European Medicines Agency (EMA) guidelines. A list of all preparations where excipients exceeded acceptable daily intake (ADI) was made. Based on dosing regimens and weight/age the ADI of each excipient was calculated and documented. Where a preparation exceeded ADI for a particular excipient the manufacturing company was informed and a request for reformulation made. Alternative preparations were sought from other specialist manufacturing companies where necessary. Each product was assessed in the same manner. Pharmacy colleagues were consulted throughout the process and provided feedback on alternative preparations available. Concerns around labelling and similarities with other products, cost and reimbursement status, whether tablets could be crushed and dispersed in water as an alternative were highlighted and discussed. Relevant prescribing consultants were also informed. An informed decision was made to switch to an alternative product where indicated.Results: In total, a review of fourteen preparations stocked was conducted. Five out of 14 (36%) were changed to an alternative more appropriate preparation in terms of excipients. Four of the fourteen (29%) were suitable for use in patients across all age groups. Four of the fourteen (29%) exceeded the ADI for a particular excipient for preparations for use in neonates (suitable for all other age groups). Of the four, two were not routinely prescribed in neonates. One preparation was removed from the market. The remaining two products were considered suitable for use for their respective indications and dosing regimens.Conclusion: Unlicensed medicines and medicines that are used in neonate and paediatric patients must be carefully assessed for excipients before use.1–3 A risk benefit assessment4 should be conducted to establish if an unlicensed medicine should be used and prescribers notified of any excipients of concern.References: Annex to the European Commission guideline on ‘Excipients in the labelling and package leaflet of medicinal products for human use’ (SANTE-2017-11668). Available at: www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC500003412.pdf European Medicines Agency. Committee for Medicinal Products for Human Use (CHMP): Information for the package leaflet regarding ethanol used as an excipient in medicinal products for human use (EMA/CHMP/43486/2018); September 2018. Available at: https://www.ema.europa.eu/en/documents/scientific-guideline/information-package-leaflet-regarding-ethanol-used-excipient-medicinal-products-human-use_en.pdf NPPG Neonatal and Paediatric Pharmacists Group Newsletter No 61 Autumn 2016. Excipients in medicines for Children. Available at: www.nppg.scot.nhs.uk/wp-content/uploads/2017/04/NPPG-61.pdf Neonatal and Paediatric Pharmacists Group and Royal College of Paediatrics and Child Health, UK. Using Standardised Concentrations of Unlicensed Liquid Medicines in Children. April 2020. Available at: https://nppg.org.uk/wp-content/uploads/2020/04/NPPG-Position-Statement-18-01-V5-April-2020.pdf
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.8
Aim: To standardise the supply and monitoring of growth hormone to children across the tertiary paediatric endocrine service and ensure cost-effective prescribing of growth hormone in children.Method: Patients identified by recorded data on the Growth Analyser® database used by the paediatric endocrine team. A pharmacist reviewed the current process and using process mapping identified ways of simplifying the registration process for new starters in different health boards. Patients and families offered to register with new service during the annual tertiary endocrine review clinic, or more urgently if issues identified and raised by the patients/family to the pharmacist. The pharmacist completed registration paperwork and prescribed growth hormone 6 monthly, ensuring appropriate monitoring is conducted before prescribing. All patients transitioned to new service recorded on Excel spreadsheet comparing monthly cost on the previous service, to monthly cost on the current service.Results: 150 patients identified on growth hormone across 6 health boards prescribed majority via GP with few via homecare at an approximate cost of £800,000 a year. Over 1 year now 90 patients prescribed by the pharmacist based in the paediatric endocrine team and supplied by homecare. Resulting in cost savings of £100,000 a year, an average of £1,700 per patient, with the most significant cost saving of £4,400 a year for one patient. The time taken to start a new patient on growth hormone has reduced from an average of 6 weeks to 2 weeks, due to less burden on GP and shared care agreements. Reduced burden on specialist nurses to complete paperwork, deal with queries and chase prescriptions as managed by the pharmacist. Support to consultants to ensure patients are monitored at least every 6 months as per BSPED recommendations1 and NICE guidance.2Conclusion: Pharmacist-led prescribing of growth hormone can reduce the burden on consultants, specialist nurses, and GP’s, and standardise the supply and support that patients and their families receive when starting growth hormone. Ensuring patients receive treatment in a timely manner and receive appropriate monitoring regardless of where they live. Supplying growth hormone via homecare is more cost-effective than supplying via primary care. Utilising a pharmacist to oversee this service, identify and approach patients and their families to transition over to the new service can achieve significant cost savings to the NHS, without adding pressure to the specialist team.References: British Society for Paediatric Endocrinology and Diabetes (2017). Clinical Standards for GH Treatment in Childhood & Adolescence. Available at: https://www.bsped.org.uk/media/1372/gh-standards-document_nov2017.pdf National Institute for Health and Care Excellence. (2010). Human growth hormone (somatropin) for the treatment of growth failure in children [NICE TA188].Available at: www.nice.org.uk/guidance/TA188
Archives of Disease in Childhood, Volume 107; https://doi.org/10.1136/archdischild-2022-nppg.26
Background: In 2016, NICE published a guideline on ‘End of life care for infants, children and young people with life-limiting conditions: planning and management’.1 These guidelines recommended that pharmacists should be embedded in every paediatric palliative care team.Aim: To identify the roles of pharmacy teams in paediatric palliative (PP) care and examine the effectiveness of their services as perceived by PP doctors and nurses. To compare 2020 survey results with a study conducted in 2014 by Khan et al,2 to assess whether any changes could be observed.Method: This was a repeat of the study conducted in 2014 by Khan et al. A SurveyMonkey link was emailed to members of the APPM (Association for Paediatric Palliative Medicine) and NPPG (Neonatal and Paediatric Pharmacists Group) as well as to community pharmacies working closely with local children’s hospices in London and South East England. The questions were identical to the ones used in 2014. The data was analysed using Microsoft Excel.Results: The number of respondents totalled 107 (Response rate: 19%).The respondents consisted of 84 individuals who were pharmacists or pharmacy technicians, and the remaining 23 were non-pharmacy staff such as doctors or nurses.The majority of the pharmacy team reviewed palliative care patients on a monthly basis, and this trend had increased since 2014. Overall, an increase in patient contact was observed. The clinical involvement of the pharmacy team in PP care had increased, especially in medicines optimisation and prescribing. Since 2014, the number of pharmacists prescribing for children with palliative care needs appeared to have doubled. Other roles where pharmacy involvement appeared to have increased included advising on storage of medicines, investigating medication errors and formulary development.Conducting research/audits, writing guidelines and financial reports were not popular tasks. In 2020, only 25% of the pharmacy team were involved with writing patient information leaflets for children with palliative care needs.Lack of staffing, time and funding were the most frequently reported impediments to the pharmacy team taking on more clinical roles.In 2014 and 2020, the British National Formulary for Children (BNF-C) was the most popular reference source routinely used by all staff groups. The Palliative Care Formulary, syringe driver compatibility charts and Handbook of Drug Administration via Enteral Feeding Tubes were also popular references amongst the pharmacy team. Doctors and nurses utilised the Alder Hey Book of Children’s Doses and the APPM Master Formulary more than pharmacy staff.In 2020, doctors and nurses gave a median of 10/10 regarding their satisfaction of the pharmacy team’s contributions. The minimum score given was 6. Khan’s study1 reported a median rating of 9, but the difference observed was not considered to be statistically significant (p value >0.05).Conclusions: This study inferred that the involvement of the pharmacy team in paediatric palliative care has increased since 2014. More of the pharmacy team are handling clinical issues and the paediatric palliative healthcare team would like this growth to continue. The increase in prescribing by pharmacists was an interesting finding and it would be well-worth observing how this trend progresses. Consistent with Khan’s observations in 2014, non-pharmacy staff highly valued the pharmacy team’s contributions.References: NICE guidelines. NG 61:2016. End of life care for infants, children and young people with life-limiting conditions: planning and management. NICE 2020. Khan J, Gaze S, Tomlin S. The role of the pharmacist in paediatric palliative care. Archives of Disease in Childhood 2016;101(9):e2. doi:10.1136/archdischild-2016-311535.22