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AimThe early administration of antibiotics in sepsis reduces mortality and improves outcomes. This randomised control trial evaluated the effect of environmental priming (EP) on healthcare student performance in a simulated paediatric sepsis scenario.MethodsMedical and nursing students were randomised into primed and unprimed groups. Primed groups received both direct and virtual priming. Each group completed a standardised simulated sepsis scenario. Time to achieve five key clinical interventions was recorded. Mini focus groups were conducted to explore perceptions of EP.ResultsThere were 26 primed and 26 unprimed groups. The primed students were quicker to complete all five interventions and statistically significantly quicker to achieving intravenous (IV) access (median 350 s vs 373 s, p=0.02), administering IV antibiotics (median 648 s vs 760 s, p=0.045) and seeking senior help (median 703 s vs 780 s, p=0.02). Primed students did not feel that they had gained any specific advantage from being primed.ConclusionsEP can improve clinical performance. Implications for practice include incorporating EP of key clinical areas into local induction, standardisation of resuscitation areas and regular use of in situ simulation.

No examination of a child’s abdomen or gastrointestinal system is complete without an examination of the ’backside' or perineum, however there is often reluctance among paediatricians to perform this examination routinely. This article aims to describe how to use perineal examination in infants and children. It discusses the indications and stepwise approach to performing a per-rectal examination and interpretation of the findings one could expect to encounter. We include four cases encompassing the major conditions, both congenital and acquired, that paediatricians should be aware of and how they were managed in our institution.

Background In the UK, the proportion of places available in medical school, the total number of foundation doctors, and the number of trainees applying to Paediatrics are falling. The NHS is at ‘breaking point’, exacerbated by workforce shortages, chronic underfunding, increasing service demand and poor job satisfaction within healthcare workers. Paediatrics in is in the midst of this crisis. Issues in recruitment and retention of paediatricians ‘threaten the safety of our children’s health’ according to the Royal College of Paediatrics and Child Health. In 2019, the RCPCH Executive Committee has prioritised a new recruitment and retention campaign as their key strategic priority for the next three years. Aim The aim of this study is to explore what strategies have been described in the literature that have been used to enhance recruitment and retention in Paediatrics. This is the first-known scoping review of the literature exploring specific strategies used globally to enhance recruitment and retention in Paediatrics. Methods A scoping review methodology was conducted, employing a qualitative approach to review the literature on strategies used to improve recruitment and retention in Paediatrics. The studies included were English-language studies. 38 full-text articles were reviewed and analysed by the research team. Study Findings Despite the importance of this issue, there is a paucity of data in the literature that describes evidence-based approaches to improving retention and recruitment in Paediatrics. The most important strategies employed to help are identified and collated using validated PRISMA criteria for systematic reviews. The findings were grouped into six main themes of professional advocacy, workforce diversity, mentorship, improving working conditions, career flexibility and enhancing educational opportunities. The authors propose a strategic modified ‘Paediatric Pipeline’ paradigm of ‘Identify, Engage, Recruit, Retain and Champion.’ Conclusions There appear to be three main elements that are key to recruitment and retention of Paediatricians: personal, professional and systemic factors. Whilst some of the issues encountered share similarities with other medical specialities in difficulty, much of the context and potential remedies within Paediatrics are distinct. A strategic, multi-agency international collaborative approach is required urgently to address the significant issues that face both Paediatrics and the healthcare system itself.

You are the paediatric registrar at an epilepsy clinic. A mother of a 9-year-old patient with childhood absence epilepsy asks if he should be taking vitamin D. He is currently prescribed sodium valproate. You wonder if you should prescribe vitamin D supplementation alongside his antiepileptic medication. In children with a clinical diagnosis of epilepsy on antiepileptic drugs (AED) (population), is there evidence to suggest that they should receive supplemental vitamin D (intervention) to improve their bone health (outcome)? We searched OVID MEDLINE in June 2020 with the keywords (Child OR Paediatrics OR Pediatrics) AND (Vitamin D OR Vitamin D Deficiency OR Cholecalciferol OR Calcitriol) AND (Anti-Epileptic Drug OR Anti-Epileptic Medication OR Anti-Convulsant Drug). The search was limited to articles in English from the year 2000. Sixty-five articles were identified. Twenty articles were included after initial scrutiny and four were selected for full-text review. One further study was identified on review of article references. These were graded according to the Oxford level of evidence (table 1).1 View this table: Table 1 Summary of included studies Vitamin D deficiency is common worldwide. Vitamin D is protective for musculoskeletal health. Children treated with AED are known to have problems with bone metabolism and bone mineral density (BMD) loss. Enzyme-inducing AEDs (phenytoin, carbamazepine, primidone and phenytoin) increase vitamin D metabolism due to induction of cytochrome P450. Newer, non-enzyme-inducing antiepileptic drugs (NEIAEDs) can affect bone metabolism in a variety of ways, including stimulation of osteoclast activity, direct action on bone cells, parathyroid hormone resistance, inhibition of calcitonin secretion …

BackgroundIn the UK, the number of junior doctors completing foundation programme, and the number of trainees applying to paediatrics has been in decline in recent years. The NHS is at ‘breaking point’, exacerbated by workforce shortages, chronic underfunding, increasing service demand and poor job satisfaction within healthcare workers. Issues in recruitment and retention of paediatricians ‘threaten the safety of our children’s health’, according to the Royal College of Paediatrics and Child Health.AimTo explore what strategies have been described in the literature to enhance recruitment and retention in paediatrics.MethodsA scoping review methodology was conducted, employing a qualitative approach to review the literature. The studies included were English-language studies. 16 full-text articles were reviewed and analysed.Study findingsThere is a paucity of data in the literature that describes evidence-based approaches to enhancing retention and recruitment in paediatrics. The most important strategies employed to help are identified and grouped into six main themes. These include professional advocacy, workforce diversity, mentorship, improving working conditions, career flexibility and enhancing educational opportunities. The authors have created a ‘paediatric pipeline’ paradigm of ‘identify, engage, recruit, retain and champion’, which allow us to present these themes in a pragmatic way for paediatricians and policymakers.ConclusionsWhile some issues share similarities with other specialties in difficulty, much of the context and potential remedies within paediatrics are distinct. A strategic, multi-agency collaborative approach is required urgently to address the significant issues that face both paediatrics and the healthcare system.

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p

In paediatric practice feeding, eating, drinking and swallowing difficulties are present in up to 1% of children. Dysphagia is any disruption to the swallow sequence that results in compromise to the safety, efficiency or adequacy of nutritional intake. Swallowing difficulties may lead to pharyngeal aspiration, respiratory compromise or poor nutritional intake. It causes sensory and motor dysfunction impacting on a child’s ability to experience normal feeding. Incoordination can result in oral pharyngeal aspiration where fluid or food is misdirected and enters the airway, or choking where food physically blocks the airway The incidence is much higher in some clinical populations, including children with neuromuscular disease, traumatic brain injury and airway malformations. The prevalence of dysphagia and aspiration-related disease is increasing secondary to the better survival of children with highly complex medical and surgical needs. This article aims to outline the indications for performing videofluoroscopy swallow (VFS). This includes the technical aspects of the study, how to interrupt a VFS report and some of the limitations to the study.

A 2-year-old boy attends outpatient clinic with a history of persistent, intermittent non-bilious vomiting from birth. An upper gastrointestinal (UGI) contrast study was arranged, and the radiology report has stated that the duodenal-jejunal flexure is midline and lower than the gastric outlet, suggesting malrotation without volvulus. Should (patient) children with non-bilious vomiting and radiological evidence of malrotation (intervention) undergo a Ladd’s procedure or (comparison) be managed conservatively (outcome) to reduce the risk of volvulus? We performed an online literature search in March 2019 using PubMed. The key terms were ‘malrotation’ and ‘asymptomatic’. The search was limited to full articles written in English and yielded 109 results. On review of titles and abstracts, we excluded all case reports, studies not including children and papers focusing on heterotaxy syndromes. Nine studies were identified along with an expert consensus review commissioned by the American Pediatric Surgical Association (APSA). These articles are outlined in table 1 and are graded according to the Oxford levels of evidence. View this table: Table 1: Summary of included articles During normal fetal development, the bowel undergoes a 270° counter-clockwise turn, resulting in the duodenal-jejunal flexure (DJF) positioning itself to the left of the midline and at the level of the gastric outlet. It is fixed in position by the ligament of Trietz. From there, the remainder of the small bowel continues …

Introduction In September 2015, the UK became the first country in the world to introduce the 4-component meningococcal B vaccine(4CMenB) into the routine vaccine schedule for infants. 4CMenB is known to cause fever in infants. Infants presenting with fever, particularly those under 3 months, have a significant risk of serious bacterial infection(SBI). Method Between September 2015 and January 2016, we performed a prospective audit of management of infants between 30 and 180 days attending the regional paediatric emergency department(ED) in Northern Ireland, within 4 days of receiving 4CMenB. Results 35 ED attendances in infants aged 30–180 days were due to symptoms occurring after primary vaccinations including 4CMenB, representing an estimated 0.8% of the vaccinated population in the catchment area. 86% of infants presented after the first vaccine and parents reported giving paracetamol to 94% of infants. 80% of infants presented with fever. Blood tests were performed in 62% of infants and leucocytosis was present in 73%. All cultures taken were negative and 51% were admitted to hospital. 100% of final diagnoses were vaccine related (diagnosis made by exclusion). Discussion In this study, an estimated 0.8% of the vaccinated population in the catchment area attended ED with symptoms occurring after primary vaccinations including 4CMenB. Infants with fever have a higher risk of SBI, but infants with fever in the post-vaccination period may not have the same risk. Further data are essential to inform national guidelines on investigation and management of fever in infants following vaccination with 4CMenB, possibly incorporating a less-invasive approach.

Acute bronchiolitis is the most common respiratory condition under 1 year of age. In the UK and Ireland, approximately one in three infants will develop bronchiolitis in the first year of life and ~2%–3% of all infants require hospitalisation.1 In severe cases, children are admitted to paediatric intensive care (PICU) for ventilation and supportive treatment. An admission to a critical care unit is an extremely stressful time for children and their families. It also has significant implications on workload and resources. High-flow nasal cannula oxygen (HFNCO) is a treatment where oxygen is delivered at high rates via a tight-fitting nasal mask. This treatment has recently been increasingly used to manage bronchiolitis. Recent evidence has suggested that this may have a role as rescue therapy to reduce the proportion of children requiring high-cost intensive care.2 Prior to this initiative, this treatment option was only available in PICU in our trust. In 2016, our team acquired one HFNCO unit in a bid to introduce this treatment at ward level. These attempts to do so, prior to developing an introductory simulation-based collaborative teaching event, …

Paediatric traumatic brain injury (TBI) is a non-degenerative, acquired brain insult. Following a blow or penetrating trauma to the head, normal brain function is disrupted. If it occurs during the early stages of development, deficits may not immediately become apparent but unfold and evolve over time. We address the difficulties that arise when treating a child with severe TBI.

Background Simulation-based education is now a well-established part of undergraduate and postgraduate healthcare education. However, many healthcare teams still experience challenges with providing this due to limited staff engagement. ‘Play is the highest form of research’ is a well-known quote that has been attributed to Albert Einstein. However, concerns about performing in ‘make-belief’ simulations & peer-critique inhibit participation and impede sim-based education credentials. Summary of project We conceived, designed, facilitated and evaluated N. Ireland’s inaugural ‘Sim-off competition’. This was devised as a fun, educational opportunity to improve knowledge of Paediatric conditions, to aid networking, and act as an inter-speciality and multi-professional event. It was the first national sim-off competition in any speciality across the UK & Ireland. The contest ran as an informal ‘round robin’ competition with 10 competing teams representing hospitals from all 5 NI Healthcare trusts, a University APNP team and a Paediatric EM team from Dublin. Our prestigious judging panel comprised of 5 experienced paediatric clinicians with expertise in clinical education. Several moderate complexity scenarios were designed. Team marks were awarded for both technical and non-technical skills. Summary of results 114 people attended this inaugural event in QUB Riddel Hall on Friday 15th June 2018. There were 44 Paediatric ST1-8 trainees as well as 70 other attendee’s. 26 doctors & 20 nurses formed the 10 competing teams. Feedback was received from 21 participants and 11 observers. 85% of those (27 people) felt that performing simulation as a competition enhanced the educational experience. Some comments included: ‘Extremely enjoyable day- competitive side of sim added to the experience’, and ‘An exemplary day of education. Well done to all involved on an excellent concept!’ Discussion This inaugural ‘sim-off’ contest has provided trainees and sim-enthusiasts an ideal opportunity to engage in an informal competition, enhance perceptions of sim-based education & generate region-wide enthusiasm. It is hoped this will be used as a platform for further similar events in undergraduate intervarsity competitions, and at a postgraduate level within various specialities (such as Anaesthetics, Emergency Medicine) as well as potentially run as a biennial event in Paediatrics.

Background Paediatrics, like many specialties, is experiencing a decline in applications for specialty training.1 Reasons include perceptions of poor flexibility; arduous training programme and lack of adequate career guidance and support.2 The RCPCH suggest strategies to increase recruitment should include exposure to educational opportunities. 2 In the UK, the transition between foundation level training and specialty training is an uncertain and stressful time. We believe that allowing access to high fidelity simulation training affords a unique opportunity to showcase our specialty. Summary of project We designed, delivered and evaluated ‘A Foundation in Acute Paediatrics Simulation’ (FAPS) course aimed at offering junior doctors an introduction into the management of common paediatric conditions. This initiative was approved by the Northern Ireland Medical & Dental Training Agency (NIMDTA). A highly experienced inter-professional faculty provide an insight into a career in paediatrics, their own career perspectives and an opportunity for group discussion and tailored personal career advice. Clinically relevant interactive simulation scenarios offer the candidates an opportunity to work alongside colleagues and encounter common paediatric conditions, potentially developing their clinical acumen and enhancing non-technical skills. Summary of results Since its inception in 2017, 32 Junior doctors (FY1-FY3) have taken part in the annual course. Prior to the course, 22/32 (69%) candidates were unsure whether they would apply to Paediatrics. After the course, all 32 candidates indicated that that they were more likely to apply [mean score- 2.7 before vs 3.9 after; 1-very unlikely, 3-undecided, 5-Very likely to apply]. Subsequently, 31/32 candidates (97%) felt more confident in the assessment of the unwell child. All candidates (100%) recommend this course to peers. Qualitative comments included ‘Excellent concept, relevant scenarios and useful course’ and ‘First exposure to Paediatrics since 4th year medical school. Thoroughly enjoyable.’ Discussion This is the first use of high-fidelity simulation to enhance specialty recruitment that has been reported. It has now become an established part of the academic calendar in Northern Ireland and runs on an annual basis each November. It is endorsed by both the Northern Ireland Foundation School & NIMDTA. This course affords an opportunity to gain access to motivated clinicians while experiencing common paediatric conditions in a safe, simulated learning environment. The tailored career advice may be of use for their future speciality direction. This course actively helps in addressing the current plight of low trainee recruitment and retention in Paediatrics and could be easily replicated in other areas. References Royal College of Paediatrics and Child Health. ST1 Paediatric Deanery/LETB Competition ratios and fill rate 2016. London, 2016. http://www.rcpch.ac.uk/ Jacob H, Shanmugalingam S and Kingdon C. Recruitment and retention in paediatrics. Arch Dis Child December 2 016. doi:10.1136/archdischild-2016-311390

Background Paediatrics, like many specialties in the UK, is experiencing a decline in applications for specialty training1. Reasons include perceptions of poor flexibility, arduous training programme and lack of adequate career guidance and support2. Transition between foundation level training and specialty training is an uncertain and stressful time3.In 2016, only 50% of FY2 doctors reported that they would enter directly into speciality training4. We believe that offering access to high-fidelity simulation course affords a unique opportunity to showcase our specialty, as encouraged by the RCPCH2. Methods We designed, delivered and evaluated ‘A Foundation in Acute Paediatrics Simulation’ (FAPS) course aimed at offering junior doctors an introduction into the management of common paediatric conditions. A highly experienced inter-professional faculty provided an insight into a career in paediatrics and an opportunity for group discussion and tailored personal career advice. This initiative was approved by the Foundation programme director of the Northern Ireland Medical and Dental Training Agency (NIMDTA). This course was specially designed to run in the weeks prior to the opening of the national speciality application process. Results 16 Foundation doctor candidates took part in the pilot FAPS course in November 2017. Prior to the course 11/16 (69%) candidates were unsure whether they were going to apply for paediatrics. After the course all 11 candidates indicated that that they were more likely to apply [mean score- 2.9 before vs 4.0 after; 1-very unlikely, 3-undecided, 5-Very likely to apply]. Subsequently, 15/16 candidates (94%) felt more confident in the assessment of the unwell child. This course will run annually and is now oversubscribed for the next course in November 2018. Conclusions This was the first known use of a high-fidelity simulation recruiter course to enhance specialty recruitment within the UK. This course provides an opportunity to gain access to motivated junior trainees in a safe, simulated learning environment. It was extremely well received by the candidates, the faculty, and the regional training agency. This course actively helps in addressing the current plight of low trainee recruitment and retention in Paediatrics and could be easily replicated in other areas. References Royal College of Paediatrics and Child Health. ST1 Paediatric Deanery/LETB Competition ratios and fill rate 2016. London, 2016. http://www.rcpch.ac.uk/ Jacob H, Shanmugalingam S and Kingdon C. Recruitment and retention in paediatrics. Arch Dis ChildDecember2016. doi:10.1136/archdischild-2016–311390 Pinnock R, Reed P, Wright M. The learning environment of paediatric trainees in New Zealand. J Paediatr Child Health2009;45:529–34 British Medical Association. The state of pre and post-graduate medical recruitment in England September 2017. https://www.bma.org.uk/collective-voice/policy-and-research/education-training-and-workforce/state-of-medical-recruitment

Aims The objective of this quality improvement project was to increase CSF interpretability by 50% in a 5 month period using an Lumbar Puncture (LP) simulator to enhance trainee technique. LP is a core practical procedure of level 1 RCPCH training. Lack of opportunity, experience and low procedural confidence can make it difficult to achieve this competency. Traumatic punctures causing blood stained CSF can lead to difficulties with interpretation. Methods Prospective data was collected during August 2017 to December 2017 for general paediatric admissions (patient demographics, trainee grade, number of attempts, microscopy results and interpretability). Three half-day simulated procedural training days practicing LP technique, discussing appropriate sedation and clinical cases occurred during this time and their impact was measured. Results 58 LPs were performed during the study period. Participation of junior trainees increased from 8% to 40% in the first 4 months but then decreased to 15% in December. Encouragingly after the second LP course CSF interpretability increased from 47% to 92%. LPs carried out in theatre under general anaesthetic (4 patients) were mostly atraumatic (RBC 0–23). The number of LP attempts also impacted on CSF quality and likelihood of achieving interpretable CSF microscopy Conclusions Simulation-based training is beneficial for trainees to gain experience of procedural skills. This project shows that when trainees are given the opportunity to gain hands-on experience using high-fidelity models it translates to enhanced user confidence, willingness to participate in the clinical setting and increased procedural competence (table 1). During the 5 months CSF interpretability increased from 47% to 69%, nearly achieving our overall project aim.

Aims Time delays in the delivery of emergency treatment can be detrimental to patient care. Multiple factors have been implicated as causes of such delays including the time taken to access emergency equipment. This randomised control trial aimed to evaluate the impact of environmental priming on student performance in a simulated paediatric emergency. Methods We randomised medical and nursing students into primed or un-primed groups. The groups then undertook a standardised simulated scenario based on a child with meningococcal septicaemia. Those in the primed arm had received a tour of the sim-suite in advance of the session and had access to an online video tour. The time taken to achieve five of the six key clinical interventions outlined in the Paediatric Sepsis Six protocol were recorded. Groups from each arm were then randomly selected to undertake focus groups with a psychologist. Results The primed students were quicker to all five key clinical interventions and significantly quicker to administration of the first fluid bolus, administration of antibiotics and seeking senior help (p Interestingly students participating in the focus groups suggested that they did not feel that they had gained any specific advantage from being primed, perhaps displaying a degree of cognitive dissonance. Un-primed students did not feel disadvantaged by not being primed. Conclusions This study suggests that familiarity with the clinical environment improves clinical performance. It may be possible to address this through standardising the layout of resuscitation areas, by ensuring familiarisation with key areas during local induction and through the use of in-situ simulation in clinical settings.

Bronchiolitis is a seasonal viral lower respiratory tract illness common in infancy and a major cause of hospitalisation in this age group. The course is often self-limiting. Mainstay of management is supportive care to maintain oxygenation and hydration. We developed local guidelines for the management of bronchiolitis based on recommendations from NICE and Bronchiolitis of Infancy Discharge Study (BIDS). Key messages being: minimal handling and suctioning, rare pharmacological treatment in selected cases and permissive approach to patients with saturations>90% (BIDS). This guidance was implemented using a robust teaching program for all staff including nurses and junior doctors. We aimed to audit current management of bronchiolitis and compliance with new guideline. We also compared outcomes with practice before implementation of new guideline. Methods An audit proforma was designed and the new trust guideline – 2015/2016 was used as gold standard. Data was collected using clinical coding, case notes, electronic case records. Data on 30 patients admitted with bronchiolitis between October 2014 to December 2014 was collected. The new guideline was implemented in December 2015. We collected data on infants admitted with bronchiolitis between 1st January and 31st March 2016 in RBHSC. A total of 29 patients were included in this cohurt. Results Suctioning was reduced from 83% to 34%, so as the use of hypertonic saline nebulisers. There was a slight increase in the use of antibiotics. No change was seen with regards to duration of stay. 1 patient was readmitted in 2016 compared with 5 patients in 2014. Conclusion Compliance to the new guideline was good and minimal handling and suctioning did not prolong the stay or readmission.

­ A 9-month-old boy presented to the emergency department with acute wheeze. He had a background of cleft lip repair at 4 months and was awaiting palatoplasty. He had mild eczema but had never had a previous wheezy episode, and was awaiting cardiology follow-up for a small patent ductus arteriosus (PDA). He had been at the child minder when symptoms began abruptly with no witnessed event. On assessment, the wheeze had resolved, saturations were 98% breathing air, respiratory rate was 34 breaths per minute and he was afebrile. He was discharged home with safety net advice. He represented 2 days later with cough, wheeze and shortness of breath. On examination, he had subcostal recession and there was reduced air entry on the right. There was no wheeze, crepitations or obvious organomegaly. Oxygen saturations were 98% breathing air, respiratory rate was 38 breaths per minute and he was afebrile. Oral amoxicillin was given. Questions Given the history what is the likely diagnosis? Bronchiolitis Congestive heart failure Foreign body aspiration Pneumonia Reactive airways disease Which investigation would be most useful at this stage? Bronchoscopy Chest X-ray CT chest Echocardiogram Point-of-care respiratory strip What is the next step in the management? Intravenous ceftriaxone/clarithromycin Intravenous diuretics Needle thoracocentesis Oral steroids and inhaled bronchodilator Rigid bronchoscopy What are the long term complications of an undiagnosed foreign body? Answers can be found on page 2.

A healthy 15-month-old girl presented to the emergency department with a 24-hour history of fever and rash. The initial blanching rash developed into non-blanching areas with associated leg swelling. She had received no recent medications, had no known drug allergies and no unwell contacts.On examination, she was feverish at 38.6°C, capillary refill time was2 s with warm peripheries, heart rate 169 bpm and blood pressure 94/59 mm Hg. A palpable purpuric rash was evident on all four limbs and face (figure 1) although the trunk was spared. Her legs were tense and oedematous to the knee.edpract;103/1/25/EDPRACT2016311782F1F1EDPRACT2016311782F1Figure 1Rash at presentation.Initial investigations: Haemoglobin level: 131 g/L, white cell count: 16.6×10What is the diagnosis? Henoch-Schonlein purpura (HSP)Meningococcal septicaemiaAcute haemorrhagic oedema of infancy (AHOI)Vasculitic urticariaGianotti-Crosti syndromeWhat further investigation is required? Check viral serology including Epstein-Barr virus and hepatitis B virusComplement levels and autoimmune screenSkin biopsyLumbar puncture and audiologyNo further investigationHow should this child be managed? Complete 7 days of ceftriaxone treatmentOral aciclovirOral steroidsRegular follow-up with urinalysis and blood pressure monitoringStop antibiotics if cultures were negative at 48 hours and discharge

Needle cricothyroidotomy is a simple but potentially life-saving emergency airway manoeuvre used to provide oxygenation during a ‘cannot intubate, cannot ventilate’ (CICV) emergency.1 ,2 The procedure involves inserting a large bore cannula through the cricothyroid membrane and can be performed in patients of all ages.3 It is, however, only a short-term oxygenation solution prior to insertion of a definitive airway.1 The procedure is taught on Advanced Paediatric Life Support (APLS) courses where focus is on needle cricothyroidotomy insertion and not subsequent airway utilisation.3 This along with the rarity of this emergency means practical experience is lacking. Problems, such as equipment availability and poor assembly, would likely arise when the manoeuvre is required, which could be disastrous during this time-critical emergency. In this study, we show that introduction of a simulation-based training bundle improves: 1. Successful simulated patient oxygenation 2. Time taken to oxygenation 3. APLS provider confidence Invited APLS providers within a tertiary paediatric hospital were given the same hypothetical CICV scenario where a simulated patient has a needle cricothyroidotomy airway in situ. The project was registered with the local trust governance department. Candidates were asked, within a maximum time of 10 min, to collect and assemble suitable equipment to oxygenate or ventilate the patient. Candidates were then shown a standardised video tutorial on needle cricothyroidotomy and introduced to a procedure pack containing all necessary equipment used within the …

A 10-year-old boy presented with a 1-week history of crampy abdominal pain and haematuria. He complained of flank tenderness and the abdominal X-ray and ultrasound of his abdomen suggested a left renal stone. This was confirmed on CT scan as 3 mm in size. At a handover meeting, it was suggested that alpha-antagonists, which are often used in adult patients, could be used in the treatment of this child. You wonder whether these are better than conservative medical management. In children with renal stones (population) does treatment with an alpha blocker (intervention) compared with conservative medical management with analgesia alone (comparison) increase stone expulsion rate (outcome)? We searched PubMed on 14 March 2018 using the terms (paediatric OR pediatric OR child) AND (renal calculi OR renal stone OR nephrolithiasis OR urolithiasis OR ureteric stone OR ureteric calculi) AND (alpha blocker OR doxazosin OR tamsulosin). Non-paediatric studies and those which looked at the use of alpha-antagonists after shock wave lithotripsy were excluded. Twenty-one papers were found and assessed and 17 qualified for further review. Nine were found to be relevant on abstract review, of which four were systematic reviews. Five of these relevant papers were not included as they had been included in the systematic review articles. A total of four systematic reviews were subsequently analysed (table 1). View this table: Table 1 Summary of included articles See table 1. The incidence of renal stones in children is increasing.1–5 In adult patients, the use of medical expulsive therapy is well established to …

Summary Background Diagnosis of meningococcal disease relies on recognition of clinical signs and symptoms that are notoriously non-specific, variable, and often absent in the early stages of the disease. Loop-mediated isothermal amplification (LAMP) has previously been shown to be fast and effective for the molecular detection of meningococcal DNA in clinical specimens. We aimed to assess the diagnostic accuracy of meningococcal LAMP as a near-patient test in the emergency department. Methods For this observational cohort study of diagnostic accuracy, children aged 0–13 years presenting to the emergency department of the Royal Belfast Hospital for Sick Children (Belfast, UK) with suspected meningococcal disease were eligible for inclusion. Patients underwent a standard meningococcal pack of investigations testing for meningococcal disease. Respiratory (nasopharyngeal swab) and blood specimens were collected from patients and tested with near-patient meningococcal LAMP and the results were compared with those obtained by reference laboratory tests (culture and PCR of blood and cerebrospinal fluid). Findings Between Nov 1, 2009, and Jan 31, 2012, 161 eligible children presenting at the hospital underwent the meningococcal pack of investigations and were tested for meningococcal disease, of whom 148 consented and were enrolled in the study. Combined testing of respiratory and blood specimens with use of LAMP was accurate (sensitivity 89% [95% CI 72–96], specificity 100% [97–100], positive predictive value 100% [85–100]; negative predictive value 98% [93–99]) and diagnostically useful (positive likelihood ratio 213 [95% CI 13–infinity] and negative likelihood ratio 0·11 [0·04–0·32]). The median time required for near-patient testing from sample to result was 1 h 26 min (IQR 1 h 20 min–1 h 32 min). Interpretation Meningococcal LAMP is straightforward enough for use in any hospital with basic laboratory facilities, and near-patient testing with this method is both feasible and effective. By contrast with existing UK National Institute of Health and Care Excellence guidelines, we showed that molecular testing of non-invasive respiratory specimens from children is diagnostically accurate and clinically useful. Funding Health and Social Care Research and Development, Public Health Agency, Northern Ireland.

INTRODUCTIONWe report an extremely rare and challenging combination of congenital anomalies. Only five similar cases have been described in the English language medical literature to date.PRESENTATION OF CASEA male infant was born at 30+5 weeks gestation by emergency caesarian section. Cervical spine rachischisis, shortened oesophagus, intrathoracic stomach, atretic duodenum and absent spleen were noted, in addition to respiratory insufficiency. Gastrointestinal re-anastomosis, particularly oesophageal lengthening, was not feasible at the initial thoracotomy. Surgical stabilization of the cervical spine was unlikely to be successful until two years of age. Asplenia predisposed the infant to sepsis from encapsulated organisms, and recurrent respiratory infections occurred.DISCUSSIONA close relationship exists between the upper gastrointestinal tract and cervical spine during embryonic development. An embryonic aberration at this level could account for all the deformities present in this infant. Tethering of the embryonic cervical oesophagus to the somites in the first trimester, preventing foregut elongation, and producing ischaemia at the coeliac axis, is suggested as the aetiology.CONCLUSIONThis case presented a challenge to the multi-disciplinary team involved in his management and prompted extensive consultation with international experts. After considerable counseling of the parents, care was directed towards palliation.

Children may be admitted and treated for MD ‘just in case’, with treatment being discontinued 48 h later if cultures are negative. Further dif-ficulty arises after 48 h of treatment, when the attending clinician must decide whether it is safe to discontinue treatment on the basis of a negative culture result that has a low sensitivity.Polymerase chain reaction using Taqman

Paediatric Intensive Care, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom Paediatrics, Royal Belfast Hospital for Sick Children, 180–184 Falls Rd, Belfast BT12 6BE, United Kingdom Department of Epidemiology and Public Health, Queen’s University, Belfast BT9 5EE, United Kingdom Paediatric Intensive Care, Royal Belfast Hospital for Sick Children, 180–184 Falls Rd, Belfast BT12 6BE, United Kingdom

Bell J.M.1, Shields M.1, Angus A.2, Dunlop K.3, Bourke T.1, Kee F.1, Lynn F.A.1 1Queen’s University Belfast, Belfast, UK, 2Belfast Health & Social Care Trust, Belfast, UK, 3South Eastern Health and Social Care Trust, Belfast, UK OBJECTIVES: To establish if the procalcitonin (PCT) test’s diagnostic performance is more clinically and cost-effective than C reactive protein (CRP) and White Cell Count (WCC) tests for suspicion of prodomal stage Meningococcal disease (MD) in children presenting at emergency department (ED) with a fever without source. METHODS: A decision analytic model was designed to reflect realistic clinical pathways for a child presenting with non-specific fever to ED. Test accuracy was evaluated using data from independent studies carried out in developed countries identified through a systematic literature search. Studies were combined to determine the optimal cut-off value for the PCT, CRP and WCC tests, each as an indicator of MD. Summary Receiver Operator Curve (SROC) analysis was used to determine the inter-study and overall diagnostic performance of each test from the areas under the curve (AUC), with 95% confidence intervals (CIs). Components of each clinical pathway were costed in UK sterling using the National Schedule of Reference Costs 2010-2011. Hospital stays were costed using the appropriate Health Resource Group code. RESULTS: Seven studies involving 881 children with non-specific fever provided data for inclusion. The PCT test was more accurate (sensitivity= 89%, 95%CI= 75-96; specificity= 71%, 95%CI= 37-91) for early MD compared to CRP (sensitivity= 84%, 95%CI= 74-90; specificity= 60%, 95%CI= 44-74) and WCC (sensitivity= 50%, 95%CI= 39-60; specificity= 68%, 95%CI= 54-79). PCT had the best PLR (3.0, 95%CI= 1.8-7.8) to be viable as a rule-in test for MD and a borderline NLR as a rule-out test, making it a better option to either CRP (2.1, 95%CI= 1.4-3.1) or WCC (1.5, 95%CI= 1.0-2.3). Outcomes from the decision analytic model indicated that the PCT test was the most cost-effective (£2547 per patient treated), followed by the combined CRP and WCC test (£3069 per patient treated). CONCLUSIONS: The improved sensitivity and specificity of the PCT test provides a more cost-effective test than the currently recommended CRP and WCC tests.

A 5-week-old male infant was admitted to the paediatric intensive care unit with small bowel obstruction secondary to an inguinal hernia. His postoperative course was complicated by suspected migration of his left internal jugular central venous catheter into branches of the inferior thyroid artery and mediastinum. This resulted in bilateral pleural effusions which were biochemically and visually similar to the total parenteral nutrition he was receiving. After drainage of the pleural effusions he made an uneventful recovery.

Distinguishing viral illness from serious bacterial infection is notoriously difficult. Many of the symptoms currently recommended as “screening” questions for A/H1N1 flu such as fever, coryza, sore throat, headache, muscle aches, vomiting, and diarrhoea may also be present …