Paediatrics and Neonatology - Current Awareness:December 2017

Cochrane Reviews(published November 2017)

“Medical and dietary interventions for preventing recurrent urinary stones in children” Adam Kern, Gwen Grimsby, Helen Mayo, Linda A Baker

Authors' conclusions: Oral potassium citrate supplementation may reduce recurrent calcium urinary stone formation in children following SWL; however, our confidence in this finding is limited. A substantial number of children stopped the medication due to adverse events. There is no trial evidence on retreatment rates. There is a critical need for additional well-designed trials in children with nephrolithiasis.

“Methylphenidate for children and adolescents with autism spectrum disorder”Nancy Sturman, Laura Deckx, Mieke L van Driel

Authors' conclusions: We found that short-term use of methylphenidate might improve symptoms of hyperactivity and possibly inattention in children with ASD who are tolerant of the medication, although the low quality of evidence means that we cannot be certain of the true magnitude of any effect. There was no evidence that methylphenidate has a negative impact on the core symptoms of ASD, or that it improves social interaction, stereotypical behaviours, or overall ASD. The evidence for adverse events is of very low quality because trials were short and excluded children intolerant of methylphenidate in the test-dose phase. Future RCTs should consider extending the duration of treatment and follow-up. The minimum clinically important difference also needs to be confirmed in children with ASD using outcome scales validated for this population.

“Inhaled magnesium sulfate in the treatment of acute asthma” Rachel Knightly, Stephen J Milan, et al

Authors' conclusions: Treatment with nebulised MgSO₄ may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but our confidence in the evidence is low and there remains substantial uncertainty. The recent large, well-designed trials have generally not demonstrated clinically important benefits. Nebulised MgSO₄ does not appear to be associated with an increase in serious adverse events. Individual studies suggest that those with more severe attacks and attacks of shorter duration may experience a greater benefit but further research into subgroups is warranted.Despite including 24 trials in this review update we were unable to pool data for all outcomes of interest and this has limited the strength of the conclusions reached. A core outcomes set for studies in acute asthma is needed. This is particularly important in paediatric studies where measuring lung function at the time of an exacerbation may not be possible. Placebo-controlled trials in patients not responding to standard maximal treatment, including inhaled β₂-agonists and ipratropium bromide and systemic steroids, may help establish if nebulised MgSO₄ has a role in acute asthma. However, the accumulating evidence suggests that a substantial benefit may be unlikely.

Research and Case Reports

R. Dwivedi and Others (2017) “Surgery for Drug-Resistant Epilepsy in Children“; New England Journal of Medicine; 377 :1639-1647

Background: Neurosurgical treatment may improve seizures in children and adolescents with drug-resistant epilepsy, but additional data are needed from randomized trials.Methods: In this single-center trial, we randomly assigned 116 patients who were 18 years of age or younger with drug-resistant epilepsy to undergo brain surgery appropriate to the underlying cause of epilepsy along with appropriate medical therapy (surgery group, 57 patients) or to receive medical therapy alone (medical-therapy group, 59 patients). The patients in the medical-therapy group were assigned to a waiting list for surgery. The primary outcome was freedom from seizures at 12 months. Secondary outcomes were the score on the Hague Seizure Severity scale, the Binet–Kamat intelligence quotient, the social quotient on the Vineland Social Maturity Scale, and scores on the Child Behavior Checklist and the Pediatric Quality of Life Inventory.Results: At 12 months, freedom from seizures occurred in 44 patients (77%) in the surgery group and in 4 (7%) in the medical-therapy group (P<0.001). Between-group differences in the change from baseline to 12 months significantly favored surgery with respect to the score on the Hague Seizure Severity scale (difference, 19.4; 95% confidence interval [CI], 15.8 to 23.1; P<0.001), on the Child Behavior Checklist (difference, 13.1; 95% CI, 10.7 to 15.6; P<0.001), on the Pediatric Quality of Life Inventory (difference, 21.9; 95% CI, 16.4 to 27.6; P<0.001), and on the Vineland Social Maturity Scale (difference, 4.7; 95% CI, 0.4 to 9.1; P=0.03), but not on the Binet–Kamat intelligence quotient (difference, 2.5; 95% CI, −0.1 to 5.1; P=0.06). Serious adverse events occurred in 19 patients (33%) in the surgery group, including hemiparesis in 15 (26%).Conclusions: In this single-center trial, children and adolescents with drug-resistant epilepsy who had undergone epilepsy surgery had a significantly higher rate of freedom from seizures and better scores with respect to behavior and quality of life than did those who continued medical therapy alone at 12 months. Surgery resulted in anticipated neurologic deficits related to the region of brain resection.

Boettiger, Michele et al. (2017) “Nurses' Early Recognition of Neonatal Sepsis”, Journal of Obstetric, Gynecologic & Neonatal Nursing , Volume 46 , Issue 6 , 834 – 845

Objective: To determine nurses' perceptions of the most common physiologic and behavioral indicators of neonatal sepsis.Design: Descriptive correlational study.Setting: A women's and children's hospital in an academic medical center in the southwestern United States.Participants: Nurses (N = 181) who cared for neonates in the mother–infant and NICU settings.Methods: Participants completed an e-mail survey developed from the literature to ascertain their perceptions of which physiologic and behavioral indicators were most often associated with neonatal sepsis. Descriptive and inferential statistics were used to analyze the data.Results: Participants identified six signs and symptoms as indicators most often associated with sepsis: two were physiologic and four were behavioral. Recognition of these indicators was not related to level of nursing education but was associated with working in the NICU. Seventy-three percent of participants reported that they suspected that newborns were septic before evaluation and diagnosis of septicemia.Conclusion: Nurses can identify the physiologic and behavioral indicators related to neonatal sepsis. Early recognition, expressed as their intuitive knowing, should be considered a valuable clinical tool. Understanding that different practice settings influence identification of signs and symptoms is important. Integration of this knowledge into formal care surveillance could potentially lower the threshold for early evaluation and treatment and thereby improve outcomes.

Bhatt, Darshna et al. (2017) “Predicting Mortality or Intestinal Failure in Infants with Surgical Necrotizing Enterocolitis”, The Journal of Pediatrics , Volume 191, 22 - 27.e3

Objective: To compare existing outcome prediction models and create a novel model to predict death or intestinal failure (IF) in infants with surgical necrotizing enterocolitis (NEC).Study design: A retrospective, observational cohort study conducted in a 2-campus health system in Atlanta, Georgia, from September 2009 to May 2015. Participants included all infants ≤37 weeks of gestation with surgical NEC. Logistic regression was used to model the probability of death or IF, as a composite outcome, using preoperative variables defined by specifications from 3 existing prediction models: American College of Surgeons National Surgical Quality Improvement Program Pediatric, Score for Neonatal Acute Physiology Perinatal Extension, and Vermont Oxford Risk Adjustment Tool. A novel preoperative hybrid prediction model was also derived and validated against a patient cohort from a separate campus.Results: Among 147 patients with surgical NEC, discrimination in predicting death or IF was greatest with American College of Surgeons National Surgical Quality Improvement Program Pediatric (area under the receiver operating characteristic curve [AUC], 0.84; 95% CI, 0.77-0.91) when compared with the Score for Neonatal Acute Physiology Perinatal Extension II (AUC, 0.60; 95% CI, 0.48-0.72) and Vermont Oxford Risk Adjustment Tool (AUC, 0.74; 95% CI, 0.65-0.83). A hybrid model was developed using 4 preoperative variables: the 1-minute Apgar score, inotrope use, mean blood pressure, and sepsis. The hybrid model AUC was 0.85 (95% CI, 0.78-0.92) in the derivation cohort and 0.77 (95% CI, 0.66-0.86) in the validation cohort.Conclusions: Preoperative prediction of death or IF among infants with surgical NEC is possible using existing prediction tools and, to a greater extent, using a newly proposed 4-variable hybrid model.

DynaMed Plus Updates

Topic / Topic
Narcolepsy / Narcolepsy

New NICE Guidance

Reference / Guidance / Topic
NG80 / Asthma: diagnosis, monitoring and chronic asthma management / NICE Guideline

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