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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.

The benefits of involving patients and the public in medical education are well documented, however there is a need to further explore how this can be translated to the setting of paediatric medical education. This article aims to identify how organisations can facilitate the involvement of paediatric patients and their parents/carers.While involving children in research can present challenges, we describe examples where organisations have successfully involved young people in clinical research and selection of research topics.Involving paediatric patients and their parents/carers in medical education helps develop a patient centred approach to practice for medical students. Participation of paediatric patients in objective structured clinical examination (OSCE) examinations is employed by many medical schools, however allowing them the ability to provide a ‘global score’ may have the potential to assess skills such as communication and empathy in addition to medical knowledge.The Royal College of Paediatrics and Child Health (RCPCH) have provided a framework on how to involve children in health services, addressing practical considerations such as funding and facilities. This framework could be applied by organisations seeking to actively involve children in paediatric medical education. Potential barriers and facilitators are explored in this article.During the COVID-19 pandemic, involving young people and their families in medical student teaching became challenging. We describe virtual bedside teaching sessions which actively involved paediatric patients and their families, which showed that many patients and parents prefer virtual consultations.Involving paediatric patients and their families in medical education is strongly advocated by the General Medical Council (GMC) and RCPCH. Organisations should actively seek out opportunities to become involved in the development of medical education resources as we describe in this paper.

Introduction: Many children with asthma cannot use their inhalers correctly, resulting in poor symptom control and increased risk of exacerbations. The teach-to-goal method may be used to teach correct inhaler technique by asking the patient to demonstrate how they use their inhaler and providing iterative correction until the patient demonstrates correct technique. Aims and objectives: The aim of this study was to evaluate whether inhaler technique improves after education with the teach-to-goal method in children with asthma. Methods: A pre-post study was designed. Global inhaler technique scores, percentage of correct steps and number of critical errors and were recorded at baseline and then following education using the teach-to-goal method. Understanding of the personalised asthma action plan was also recorded before and after clinic. Data collection took place in outpatient paediatric asthma clinics. Results: Seventy-three patients were assessed. At baseline, 43% of patients demonstrated correct technique on their preventer device and 34% on their reliever which increased to 88% and 84%, respectively, following teach-to-goal education. The median percentage of ‘correct steps’ increased from 83% (preventer) and 75% (reliever) at baseline, to 100% for both devices (p Conclusions: The teach-to-goal method is effective and feasible at improving inhaler technique in children with asthma in an outpatient clinic setting.

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.

Background: Mothers smoking while pregnant is known to increase the offspring risk of subsequent wheezing or asthma. It is less well known whether this phenomenal occurs trans-generationally, which would suggest potential epigenetic transfer. If a link is identified, this would strengthen the need for anti-smoking strategies during pregnancy and would direct further research towards understanding the epigenetic mechanisms. We aim to perform a systematic review and meta-analysis to determine whether or not grandchildren of grandmothers who smoked while pregnant with their mother have a higher risk of childhood wheeze or asthma. Methods: The systematic review will use the Preferred Reporting items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. To identify relevant studies, we will search databases including Medline, PubMed, Embase, Web of Science and Scopus. The exposure being investigated is whether the maternal grandmother smoked in pregnancy and the outcome being measured is recurrent wheeze and/or asthma in the grandchild.Studies will be screened according to inclusion and exclusion criteria to include primary cohort studies of any study design type. Eligible studies will then be evaluated for quality and assessed for bias independently by three reviewers using the “Grading of Recommendations, Assessment, Development and Evaluation” (GRADE) approach. The results of the studies will be extracted into 2x2 outcome tables and a meta-analysis will be carried out. The statistical software used will be StatsDirect.Discussion: This review will help determine whether there is transgenerational inheritance of wheeze and asthma, beyond the risk of direct in utero exposure. Systematic Review Registration: PROSPERO REG: CRD42021234346

Introduction Chronic disease in childhood is becoming more prevalent worldwide. Self-management skills can only be taught with effective communication between the health care worker and the patient or primary care provider. ‘Teach-back’ is one proposed method for providing this education which has yielded success in adult populations but is not yet fully employed in the paediatric setting. Aims To determine whether the ‘teach-back’ technique is effective and feasible at all levels of care (primary, secondary and tertiary) to improve the self-management skills and knowledge required for a young person, or their parent/guardian, to control their chronic illness. Methods We have developed a protocol for a systematic review and meta-analyses in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) statement and have registered it with Prospero [CRD42021229025].

BackgroundIt 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.MethodsThe knowledge of undergraduates and junior paediatric doctors was quantitatively assessed by their performance on a 30-item 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.ResultsThere were a total of 478 participants. Mean examination score was 45.9% for students and 64.2% for doctors (significantly higher [p

Clinical bottom line As a newly appointed Education and Simulation Fellow in a tertiary paediatric hospital, I am interested in using simulation to provide paediatric resuscitation training to staff. I wondered how frequently staff should undergo resuscitation training to ensure optimum retention of cardiopulmonary resuscitation (CPR) skills. Should responders to paediatric arrests ( population ) receive resuscitation training ( intervention ) more frequently than national guidelines recommend ( comparator ) to ensure optimum retention of CPR skills ( outcome )? We searched PubMed using the terms: ‘(frequency OR frequent OR interval OR timing) AND (training OR train OR education OR programme) AND (resuscitation OR CPR OR cardiopulmonary resuscitation OR basic life support training OR chest compression) AND (skills retention OR retain)’. Searches were conducted in September 2020. PubMed yielded 159 results. Studies involving laypeople were excluded. We did not exclude studies that assessed CPR skills on adult manikins given the need for paediatric providers to respond to adolescent emergencies. Thirty-one papers were identified for abstract review and eleven papers underwent …

BackgroundThis study aimed to evaluate how undergraduate students and junior paediatric doctors performed against an examination of knowledge set by non-academic consultants at a “must –know “ level for starting in paediatrics. We named this the Minimum Accepeted Competency (MAC) examination.MethodsExamination (comprised of 30 MCQ questions) was delivered to undergraduates also to new junior paediatric doctors. Results of this examination ascertained if participants had reached a clinician determined MAC, were compared with official university examination results and compared students to junior doctor performance.ResultsTotal of 478 participants. Mean MAC score was 45.9% for students and 64.2% for doctors (significantly higher [p

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, …

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.

Children may present with difficult-to-treat asthma for a number of reasons. Only a small group will have truly severe, therapy-resistant asthma. Using a structured multidisciplinary approach, we describe how the difficult-to-treat asthma clinic delineates children who are symptomatic due to ongoing issues that can be addressed such as poor inhaler technique or adherence, from those children who have true therapy-resistant asthma and in whom biological therapies may be considered. The roles of the relevant multidisciplinary team members are described.

Introduction Time delays in the delivery of emergency treatment in a resuscitation can be detrimental to patient care.1 Multiple factors have been implicated as causes of such delays. These include hospital related factors such as the time taken to access emergency equipment.2 Recommendations have previously been made regarding standardisation of resuscitation trolleys.3 To date there have been no studies evaluating the effect of environmental priming on performance in simulated emergencies. This study aimed to evaluate the effect of environmental priming impact on student performance in a simulated paediatric emergency. Methods Ethical approval for the study was obtained. SimBaby is an inter-professional educational module in which undergraduate nursing and medical students participate in simulated paediatric emergencies. We randomised students participating in SimBaby into primed or un-primed groups. Those in the primed arm received a tour of the sim-suite in advance of the session and had access to an online video tour of the sim-suite. Students then undertook a simulated scenario based on a child with meningococcal septicaemia. The time taken to achieve five of the six key clinical interventions outlined in the Paediatric Sepsis Six protocol were recorded. A selection of groups were then randomly selected to undertake semi-structured interviews with a psychologist. Data was analysed using thematic analysis. Results The primed students were quicker to all five key clinical interventions and significantly quicker to achieving IV access, administration of antibiotics and seeking senior help (p Discussions/Conclusions These findings suggest that familiarity with the clinical environment may improve clinical performance and subsequently impact positively on patient outcomes even if participants are not always aware of the benefit this may confer. This may have implications for considering standardisation of resuscitation areas within healthcare settings. In addition it may highlight the importance of local induction and perhaps helps to promote the use of in-situ-simulation in familiarising staff with the local environment. References Chan P, Krumholz H, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008;358:9–17. Pedley R, Whitehouse A, Hammond S. Improving room layouts for venepuncture, cannulation and ABG equipment on surgical wards. BMJ Quality Improvement Reports 2014; u554.w477 doi: 10.1136/bmjquality.u554.w477 Royal College of Anaesthetists, Royal College of Physicians of London, Intensive Care Society, Resuscitation Council (UK). Cardiopulmonary resuscitation: standards for clinical practice and training. Resuscitation Council (UK).Published October 2004, updated June 2008.

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.

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.

Aims:Some patients with coeliac disease, despite strict adherence to a gluten-free diet, continue to have significant symptoms and/or a severe small intestinal histological lesion. The term “refractory coeliac disease” (rCD) is used to describe this condition. The purpose of this study was to investigate the value of tissue molecular markers reported to help in the diagnosis of rCD.Methods:Details on 61 patients with suspected rCD were collected. The clinical and laboratory findings in these patients were carefully evaluated, in part to determine whether patients were adhering to a strict gluten-free diet. The co-expression of CD3 and CD8 on intraepithelial lymphocytes was investigated by monoclonal antibody staining of small intestinal biopsy tissue; a finding of less than 50% CD3+ cells co-expressing CD8 was defined as an aberrant phenotype. T cell receptor gene rearrangement was assessed when a sufficient tissue sample was available.Results:A diagnosis of rCD was made in 38 patients based on clinical, laboratory and histological data. An aberrant intraepithelial lymphocyte population was found in 20 of these patients and in this group a clonal T cell population was found in five of seven patients tested. In the remaining 18 patients, the CD3/CD8 ratio was normal and two of seven tested had a clonal T cell population. After detailed monitoring, a diagnosis of rCD was excluded in the remaining 23 patients.Conclusions:This study supports the use of phenotypic and T cell clonality investigations in identifying patients with true rCD.

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.

Aims Since inception in 2006 an Inter-professional Education (IPE) project has become embedded within Children’s Nursing and Medical Curricula at an internationally recognised university. Inter-professional high-fidelity simulation teaching using SimBaby® has been developed to provide an integrated approach to student learning and highlights the importance of teamwork, mutual respect and understanding of the roles of other professionals. It aims to assist students in developing the fundamental knowledge and skills required to assess and manage children presenting with common medical emergencies while enhancing student’s use of clinical tools such as the SBAR framework. Methods Fourth year Medical students, undertaking their Child Healthcare module, alongside third year children’s nursing students, each participate in a simulated scenario based on a common paediatric emergency. The student group are observed by both facilitators and their peers, who provide constructive feedback on aspects of performance including patient safety, situational awareness, communication, clinical skills and decision making. Results Students were invited to complete a validated questionnaire composed of Likert-scales to determine their reactions to the simulated learning experience. Focus groups were used to further explore these experiences. The results suggest that students evaluate this learning activity very positively and have stated that they value the opportunity to exercise clinical judgement and decision making skills without endangering the child. Other comments have included: ‘I think we should have much more exposure to SimBaby training’ ‘SimBaby is a very useful, practical and memorable learning tool’. A recent evaluation revealed that 94% of paediatric trainees who helped facilitate at SimBaby® felt it had improved their teaching skills, whilst 82% stated that this project had enhanced their ability to provide constructive feedback. To-date this SimBaby® project has achieved two prestigious prizes, a University Teaching Award in 2008 and a Research award (2009). Conclusion SimBaby® is an important initiative within a portfolio of IPE projects, providing a highly valued learning opportunity for both medical and nursing students and those healthcare professionals involved in facilitating the sessions.

Aims Approximately 240 4th year medical students from Queen’s University Belfast rotate through paediatric units in N. Ireland each year. Paediatric Objective Structured Clinical Examinations revealed poor performance at prescribing paediatric medication despite attendance at an Interprofessional Pharmacy Workshop. The aim of this study is to assess perception of task performance, assess actual task performance and compare. Methods An end of attachment assessment was carried out on 85 students. Students completed a ‘Paediatric Skills Survey’ form, indicating on a 5 point likert scale their perceived competency at 16 various tasks. Students were subsequently assessed on three reciprocal tasks, which included prescribing common paediatric medication, prescribing paediatric intravenous maintenance fluids and plotting growth parameters on an appropriate centile chart. Tasks were marked based on pre-defined criteria and results were subsequently analysed in comparison with perception. Results Results for perception versus performance of skill performance is shown in [Figures 1][1] and [2][2] respectively. Statistical analysis of perception in respect to actuality gave kappa values −0.010, −0.024 and 0.021 for medication prescription, growth chart plotting and intravenous fluid prescription respectively. All confidence intervals contained zero. Therefore, we are unable to regret the null hypothesis that there is no correlation between perception and performance. The Sign Test is highly significant in all 3 areas, with P < 0.001, which indicates clear bias in the direction of more optimistic expectations than reality. ![Abstract G328(P) Figure 1][3] Abstract G328(P) Figure 1 Perception of performance ![Abstract G328(P) Figure 2][3] Abstract G328(P) Figure 2 Actual performance Conclusion The assumption that students are able to indicate assurances in skill performance is disproven. Lack of correlation between perception and performance would put a greater emphasis on continued assessment of medical students and doctors in training. [1]: #F1 [2]: #F2 [3]: pending:yes

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.