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Asthma is one of the most common chronic disorders of childhood. The typical symptoms are a result of reversible airway obstruction. There is no ‘gold-standard’ test to diagnose asthma, but the most commonly used investigation to help with a diagnosis is spirometry. This article outlines some of the technical aspects of spirometry together with how the forced expiration manoeuver and bronchodilator responsiveness testing can be performed and interpreted in a child with suspected asthma.

Background It is recognised that newly qualified doctors feel unprepared in many areas of their daily practice and that there is a gap between what students learn during medical school and their clinical responsibilities early in their postgraduate career. This study aimed to assess if undergraduate students and junior paediatric doctors met a Minimum Accepted Competency (MAC) of knowledge. Methods The knowledge of undergraduates and junior paediatric doctors was quantitatively assessed by their performance on a 30-item examination (the MAC examination). The items within this examination were designed by non-academic consultants to test ‘must-know’ knowledge for starting work in paediatrics. The performance of the students was compared with their official university examination results and with the performance of the junior doctors. Results For the undergraduate student cohort (n = 366) the mean examination score achieved was 45.9%. For the junior doctor cohort (n = 58) the mean examination score achieved was significantly higher, 64.2% (p p < 0.01). A Spearman’s rank co-efficient showed a moderate but statistically significant positive correlation between students results in their official university examinations and their score in the MAC examination. Conclusion This work demonstrates a disparity between both student and junior doctor levels of knowledge with consultant expectations from an examination based on what front-line paediatricians determined as “must-know” standards. This study demonstrates the importance of involvement of end-users and future supervisors in undergraduate teaching.

Incorrect inhaler technique and non-adherence to inhaled preventer therapy often is the cause of poorly controlled asthma. Detecting and correcting non-adherence in asthma therapy has proven difficult. In addition, while patients may be able to demonstrate correct inhaler technique at the clinic recent evidence suggests that critical errors in inhaler technique occur in the home setting. Remote video directly observed therapy (vDOT) has recently been described as a potentially useful tool for addressing non-adherence while also allowing timely correction of inhaler technique errors. In this mini-review we describe the use of vDOT in asthma management.

Background One reason that asthma remains poorly controlled in children is poor inhaler technique. Guidelines recommend checking inhaler technique at each clinical visit. However, they do not specify how best to train children to mastery of correct inhaler technique. Many children are simply shown how to use inhalers which results in less than 50% with correct inhaler technique. The aim of this scoping review is to explore published literature on teaching methods used to train children to master correct inhaler technique. Methods We searched (from inception onwards): Medline, Embase, Scopus, Web of Science, CINAHL and the Cochrane library. We included quantitative studies, (e.g. randomised controlled trials, cohort studies and case-control studies), published from 1956 to present, on teaching inhaler technique to children with asthma. Data was extracted onto a data charting table to create a descriptive summary of the results. Data was then synthesised with descriptive statistics and visual mapping. Results Thirty-three papers were identified for full text analysis. Educational interventions were found to be taking place in a variety of clinical areas and by a range of healthcare professional disciplines. ‘Brief-Instruction’ and ‘Teach-Back’ were identified as two primary methods of providing inhaler technique training in the majority of papers. Secondary themes identified were; use of written instruction, physical demonstration, video demonstrations and/or use of inhaler devices to augment inhaler technique training. Conclusion There are a variety of means by which inhaler technique has been taught to children. These methods are likely applicable to all inhaler types and often involve some form of physical demonstration. Children of all ages can be trained to use their inhaler correctly and by a range of healthcare professionals. We have not analysed the effectiveness of these different interventions, but have described what has been trialled before in an attempt to focus our attentions on what may potentially work best. The majority of these methods can be dichotomised to either ‘Brief-Intervention’ or ‘Teach-Back’. Based on our analysis of this scoping review, we consider the following as areas for future research; how many times does a given intervention have to be done in order to have the desired effect? For what duration does the intervention need to continue to have a long-lasting effect? And, what is the best outcome measure for inhaler technique?. Trial registration Systematic review registration: Open Science Framework (osf.io/n7kcw).

Background One reason that asthma remains poorly controlled in children is poor inhaler technique. Current guidelines recommend checking inhaler technique at each clinical visit. However, they do not specify how best to train children to mastery of correct inhaler technique. Currently, many children are simply shown how to use inhalers (brief intervention) which results in less than 50% with correct inhaler technique. The aim of this scoping review is to explore published literature on teaching methods used to train children to master correct inhaler technique. Methods This scoping review will follow the Arksey and O’Malley framework and the Joanna Briggs Institute guidelines. We will search (from inception onwards) MEDLINE, Embase, Scopus, Web of Science, CINAHL and the Cochrane library. We will include quantitative studies (e.g. randomised controlled trials, cohort studies and case-control studies), published from the year 1956 to present, on teaching the skill of inhaler technique to children with asthma. Two reviewers will complete all screening and data abstraction independently. Data will be extracted onto a data charting table to create a descriptive summary of the results. Data will then be synthesised with descriptive statistics and visual mapping. Discussion This scoping review will provide a broad overview of currently used educational methods to improve inhaler technique in children with asthma. The analysis will allow us to refine future research in this area by focusing on the most effective methods and optimising them. Systematic review registration Open Science Framework (osf.io/n7kcw).

BackgroundThe relationship between confidence and competence in clinical skills development is complex but important. This study aims to determine undergraduate paediatric student confidence in performing three common paediatric clinical skills framed as Objective Structured Clinical Examination (OSCE) scenarios and to compare this with subsequent assessed performance. The study also aims to explore possible barriers to successful paediatric skills completion.MethodsA mixed-methods study was conducted on medical students. Cross-sectional questionnaire data relating to confidence in performing a number of paediatric skills were compared with assessed paediatric skills competency. Focus groups were carried out to identify themes in paediatric skills completion to triangulate this data.ResultsEighty-five medical students participated in the study. Students had high levels of pre-test confidence in their ability to perform paediatrics skills. However agreement between pre-test confidence and subsequent task performance was poor and students had significantly greater belief in their skills ability than was subsequently demonstrated. Focus groups identified paediatric skills complexity, conflicting teaching and having limited supervised skills opportunities and as being possible contributory factors to this discrepancy.ConclusionsStudent paediatric skills confidence is not matched by performance. The reasons for this are diverse but mostly modifiable. A major factor is the lack of supervised skills experience with appropriate feedback to support students in learning to calibrate their confidence against their competence. A number of recommendations are made including the introduction of formative assessment opportunities.

IntroductionNocturnal pulse oximetry can be used to screen for obstructive sleep apnoea (OSA) using the McGill Oximetry Score (MOS). The MOS has a time threshold for a technically adequate study of 6 hours. It has been suggested that one night of oximetry is sufficient to screen for OSA using the MOS.Aims(1) To evaluate night-to-night variation of the MOS. (2) To determine the impact of recording three nights of oximetry on the screening yield for OSA. (3) To explore whether useful MOS data are discarded when a threshold of 6 hours of oximetry recording is used.MethodsA retrospective study of nocturnal pulse oximetry done at home over three consecutive nights in paediatric patients with suspected OSA. Studies were scored (MOS) using thresholds of ≥6 and ≥4 hours of recording.ResultsA total of 329 patients were studied. MOS scores over three nights showed only fair to moderate agreement. On the first night 126 patients (38%) screened positive for OSA. When three nights of oximetry were done 195 patients (59%) screened positive on at least one of the nights. There were 48 patients with studies of between 4 and 6 hours duration on one or more nights. If these studies are scored 20 patients (42%) would screen positive for OSA on at least one night based on scoring these studies alone.ConclusionOne night of oximetry screening may not be sufficient to screen for OSA. Lowering the time threshold to ≥4 hours may increase the screening capability of nocturnal oximetry.

A 13-year-old girl presented with a 3-day history of worsening paroxysmal cough and vomiting. She also described chest pain over the preceding 3 weeks. These acute symptoms occurred on a background of cough, dyspnoea and weight loss over a 2-month period. She had no significant past medical history. On examination, she was afebrile, pale and lethargic. Her respiratory rate was 22 breaths/min , oxygen saturations were 91% in room air and heart rate was 88 beats/min. Air entry was good throughout and there was no wheeze on auscultation. A chest X-ray performed 1 month previously was normal. A repeat chest X-ray was requested (figure 1). Figure 1 Chest X-ray on admission. 1. What abnormalities are visible on the chest X-ray? 2. What is the most likely diagnosis? 1. Asthma 2. Gastro-oesophageal reflux disease 3. Infection 4. Malignancy 5. Metabolic bone disease …

BackgroundSleep-disordered breathing is a common and serious feature of many paediatric conditions and is particularly a problem in children with Down syndrome. Overnight pulse oximetry is recommended as an initial screening test, but it is unclear how overnight oximetry results should be interpreted and how many nights should be recorded.MethodsThis retrospective observational study evaluated night-to-night variation using statistical measures of repeatability for 214 children referred to a paediatric respiratory clinic, who required overnight oximetry measurements. This included 30 children with Down syndrome. We measured length of adequate trace, basal SpO2, number of desaturations (>4% SpO2 drop for >10 s) per hour (‘adjusted index’) and time with SpO2Results132 out of 214 (62%) children had three technically adequate nights’ oximetry, including 13 out of 30 (43%) children with Down syndrome. Intraclass correlation coefficient for adjusted index was 0.54 (95% CI 0.20 to 0.81) among children with Down syndrome and 0.88 (95% CI 0.84 to 0.91) for children with other diagnoses. Negative predictor value of a negative first night predicting two subsequent negative nights was 0.2 in children with Down syndrome and 0.55 in children with other diagnoses.ConclusionsThere is substantial night-to-night variation in overnight oximetry readings among children in all clinical groups undergoing overnight oximetry. This is a more pronounced problem in children with Down syndrome. Increasing the number of attempted nights’ recording from one to three provides useful additional clinical information.

INTRODUCTION A previously healthy 4-year-old girl was referred to the emergency department with a history of abdominal pain, poor appetite, lethargy, and pallor. That morning she had vomited blood. She had previously been well. On examination, the child was pale with no evidence of lymphadenopathy, jaundice, or bruising. Initial investigations revealed a hypochromic, microcytic anemia. She was discharged after blood transfusion but later returned with anemia and shortness of breath. Subsequent investigations revealed that the child had diffuse alveolar hemorrhage. A discussion of the condition follows.

Background: Obesity is increasingly prevalent in many countries. Obesity is a major risk factor for the development of type 2 diabetes but its relationship with diabetic kidney disease (DKD) remains unclear. Some studies have suggested that the metabolic syndrome (including obesity) may be associated with DKD in type 1 diabetes. Aim: To investigate the association between obesity and DKD. Design: Retrospective cross-sectional study. Methods: National Diabetes Audit data were available for the 2007–08 cycle. Type 1 and 2 diabetes patients with both a valid serum creatinine and urinary albumin:creatinine ratio were included. DKD was defined as an estimated glomerular filtration rate (eGFR)

There is a need for reproducible and effective models of pediatric bronchial epithelium to study disease states such as asthma. We aimed to develop, characterize, and differentiate an effective, an efficient, and a reliable three-dimensional model of pediatric bronchial epithelium to test the hypothesis that children with asthma differ in their epithelial morphologic phenotype when compared with nonasthmatic children. Primary cell cultures from both asthmatic and nonasthmatic children were grown and differentiated at the air-liquid interface for 28 d. Tight junction formation, MUC5AC secretion, IL-8, IL-6, prostaglandin E2 production, and the percentage of goblet and ciliated cells in culture were assessed. Well-differentiated, multilayered, columnar epithelium containing both ciliated and goblet cells from asthmatic and nonasthmatic subjects were generated. All cultures demonstrated tight junction formation at the apical surface and exhibited mucus production and secretion. Asthmatic and nonasthmatic cultures secreted similar quantities of IL-8, IL-6, and prostaglandin E2. Cultures developed from asthmatic children contained considerably more goblet cells and fewer ciliated cells compared with those from nonasthmatic children. A well-differentiated model of pediatric epithelium has been developed that will be useful for more in vivo like study of the mechanisms at play during asthma.

Background Human respiratory syncytial virus (RSV) causes severe respiratory disease in infants. Airway epithelial cells are the principle targets of RSV infection. However, the mechanisms by which it causes disease are poorly understood. Most RSV pathogenesis data are derived using laboratory-adapted prototypic strains. We hypothesized that such strains may be poorly representative of recent clinical isolates in terms of virus/host interactions in primary human bronchial epithelial cells (PBECs). Methods To address this hypothesis, we isolated three RSV strains from infants hospitalized with bronchiolitis and compared them with the prototypic RSV A2 in terms of cytopathology, virus growth kinetics and chemokine secretion in infected PBEC monolayers. Results RSV A2 rapidly obliterated the PBECs, whereas the clinical isolates caused much less cytopathology. Concomitantly, RSV A2 also grew faster and to higher titers in PBECs. Furthermore, dramatically increased secretion of IP-10 and RANTES was evident following A2 infection compared with the clinical isolates. Conclusions The prototypic RSV strain A2 is poorly representative of recent clinical isolates in terms of cytopathogenicity, viral growth kinetics and pro-inflammatory responses induced following infection of PBEC monolayers. Thus, the choice of RSV strain may have important implications for future RSV pathogenesis studies.