Ethical advice in paediatric care

The need for local ethics advice during the COVID-19 pandemic has put a spotlight on clinical ethics committees (CECs) and services. In this review, we focus on paediatric CECs that raise both generic questions and specific issues. In doing this, we acknowledge the broader roles of education, research and staff support some bioethics teams have developed but focus on the main areas of clinical ethics support to clinical teams. We raise 12 questions about the role, remit and responsibilities of CECs, provide preliminary answers to these and set out the next steps for the development of ethics support both in paediatric practice and more generally.

COVID-19-associated multisystem inflammatory syndrome in children: Experiences of three centres in Turkey

ABSTRACT Background The pathogenesis and clinical manifestations of the multisystem inflammatory syndrome in children (MIS-C) has not yet been fully elucidated and there is no clear consensus on its treatment yet. Objectives To evaluate our patients diagnosed with MIS-C and present them to the literature in order to contribute to the better understanding of this new disease, which entered paediatric practice with the SARS-CoV-2 peak. Methods In this study, 17 MIS-C cases diagnosed according to the Centers for Disease Control and Prevention criteria were included. Results Of the patients, 7 (41.2%) had a comorbidity. Gastrointestinal system involvement was the most prominent in the patients (70.6%). Laparotomy was performed in 3 patients due to acute abdomen. Two patients had neurological involvement. Of the patients, 15 (88.2%) received intravenous immunoglobulin and 13 (76.5%) received both intravenous immunoglobulin and methylprednisolone. Two patients received invasive mechanical ventilation and 4 patients received high flow rate nasal cannula oxygen therapy. One of our patients who needed invasive mechanical ventilation and high vasoactive-inotrope support died despite all supportive treatments including plasmapheresis and extracorporeal membrane oxygenation. Conclusions MIS-C picture can have a fatal course and may present with severe gastrointestinal and neurological signs. Unnecessary laparotomy should be avoided.

Lost but not missing: factors associated with loss of follow-up in a paediatric cardiology clinic

Background: Loss of follow-up is a barrier to providing adequate care to paediatric cardiac patients. The purpose of this study was to determine variables associated with loss of appropriate paediatric cardiology follow-up, including potentially modifiable factors. We hypothesised having earlier recommend follow-up intervals was associated with less likelihood of loss of follow-up. Methods: We performed a retrospective cohort study of patients >5 years old seen in a large, outpatient paediatric practice from 2013 to 2016. Subjects were considered to be lost to follow-up if they did not have a subsequent outpatient encounter by 6 months after their recommend follow-up time interval. Results: Of the 8940 eligible patients, 45.9% were lost to follow-up. Recommended follow-up interval of 1 year was associated with less loss of follow-up (41.4%) as compared to 2-year intervals (51.6%) and 3 years (55.7%) (p < 0.001 for both). Other significant predictors of loss of follow-up included less severe heart disease, older age, and non-Hispanic Black race/ethnicity. Sex and payor type were not significant predictors. In the stratified analyses by severity of disease and age, longer recommended follow-up time was associated with greater loss of follow-up among all severity and age categories. Conclusions: Almost half of the patients in our cohort did not return to clinic within the recommended timeline. Shorter follow-up time was associated with less loss of follow-up among all categories of disease severity and age groups. Recommending shorter follow-up intervals may be one initiative for paediatric cardiologists to improve rates of follow-up.

Evaluation of an Algorithm for the Diagnosis and Therapy of Lyme Neuroborreliosis: A Follow-up Study

Background: Although Lyme Neuroborreliosis (LNB) is often seen in paediatric practice, diagnostic criteria for LNB in children are not clearly defined. The guidelines for LNB in adults are based on a combination of clinical picture, CSF pleocytosis and the detection of specific antibodies against Borrelia burgdorferi in CSF and serum. Diagnostic procedure takes several days, thus it isn´t useful in deciding for the need of prompt antibiotic treatment. Aim of study was a retrospective evaluation of an algorithm for the diagnosis and therapy of lyme’s disease, which is used since 2005 at the paediatric department of Innsbruck. Patients and Methods: All patients presenting with acute peripheral facial palsy from January 2006 to December 2014 were reviewed. The patients were diagnosed according to the algorithm, based on the criteria of the German Society of Neurology. The focus lay on evaluation of diagnosis and therapy according to the algorithm and whether overtreatment and underdiagnosis could therefore be avoided. Results: 120 patients were enrolled with peripheral facial palsy. 65 (54%) were handled as bell´s palsy and 55 (46 %) as B. burgdorferi s.l. infection. 19 cases were classified as confirmed LNB, 10 as probable and 26 as possible LNB. A total of 69 patients (58 %) were treated correctly according to the algorithm, 16 (13%) were over treated and 14 (11%) under treated with antibiotics. 21 (18%) could not be classified, according to the algorithm, due to the lack of CSF results. Although receiving proper treatment, 3 cases had a persistent defect after recovery. Conclusions: The algorithm is an appropriate diagnostic tool for the diagnosis and therapy of LNB, particularly with regard to the necessity of a prompt antibiotic treatment, and therefore helpful to avoid underdiagnosis and overtreatment.

Neonatal administration of a subanaesthetic dose of JM-1232(−) in mice results in no behavioural deficits in adulthood

In animal models, neonatal exposure of general anaesthetics significantly increases apoptosis in the brain, resulting in persistent behavioural deficits later in adulthood. Consequently, there is growing concern about the use of general anaesthetics in obstetric and paediatric practice. JM-1232(−) has been developed as a novel intravenous anaesthetic, but the effects of JM-1232(−) on the developing brain are not understood. Here we show that neonatal administration of JM-1232(−) does not lead to detectable behavioural deficits in adulthood, contrarily to other widely-used intravenous anaesthetics. At postnatal day 6 (P6), mice were injected intraperitoneally with a sedative-equivalent dose of JM-1232(−), propofol, or midazolam. Western blot analysis of forebrain extracts using cleaved poly-(adenosine diphosphate-ribose) polymerase antibody showed that JM-1232(−) is accompanied by slight but measurable apoptosis 6 h after administration, but it was relatively small compared to those of propofol and midazolam. Behavioural studies were performed in adulthood, long after the neonatal anaesthesia, to evaluate the long-term effects on cognitive, social, and affective functions. P6 administration to JM-1232(−) was not accompanied by detectable long-term behavioural deficits in adulthood. However, animals receiving propofol or midazolam had impaired social and/or cognitive functions. These data suggest that JM-1232(−) has prospects for use in obstetric and paediatric practice.

Metabolic infant nephropathies: a systematic review

Background. Metabolic diseases are growing, also in paediatric practice. Metabolic nephropathy is becoming more prevalent comprising 27–64% total paediatric nephrological cases, according to various published evidence. In this concern, the correct diagnosis, dietary and drug therapy acquire particular importance.Objectives. An overview of current methods for laboratory and instrumental diagnosis and treatment of metabolic nephropathies in children.Methods. National and foreign literature sources were mined in the RSCI, VAK, Scopus, Web of Science, PubMed, Cochrane Library and eLibrary databases at a search depth limited to seven years. The query keywords were: metabolic nephropathy [обменная нефропатия], children [дети], calcium oxalate crystalluria [оксалатно-кальциевая кристаллурия], therapy [терапия]. Content and descriptive analyses were used as research tools.Results. The review surveyed 74 literature sources, with 50 selected for further analysis.Discussion. Modern views on metabolic nephropathies are highlighted in terms of classification, clinical progression, methods of diagnosis, treatment and prevention. A current trend in these diseases is earlier-age morbidity. The most studied metabolic nephropathy is calcium oxalate crystalluria. The article also discusses the role of Oxalobacter formigenes bacteria in secondary oxalate nephropathy.Conclusion. Therapies for metabolic nephropathies as polyaetiologic diseases are multicomponent to target both a causal factor and lithogenesis-contributing mechanisms. Current treatment approaches to metabolic nephropathies in children are highlighted in the light of published knowledge.

Implementation and evaluation of a curriculum on the assessment and treatment of disruptive behaviour disorders

Disruptive behaviour disorders (DBDs)—which can include or be comorbid with disorders such as attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder and disruptive mood dysregulation disorder—are commonly seen in paediatric practice. Given increases in the prescribing of atypical antipsychotics for children and youth, it is imperative that paediatric trainees in Canada receive adequate education on the optimal treatment of DBDs. We describe the development, dissemination, and evaluation of a novel paediatric resident curriculum for the assessment and treatment of DBDs in children and adolescents. Pre–post-evaluation of the curriculum showed improved knowledge in participants.

Chronic rhinitis in children is not a local problem

Allergic rhinitis is the most common pathology among all allergic diseases. The article presents the epidemiologic and pathogenetic issues of the allergic rhinitis. The underdiagnosis of allergic rhinitis and its underestimation as a systemic pathology were observed in various countries. The importance of allergic rhinitis in paediatric practice, its impact on the quality of life, studies, and cognitive abilities is considered. The extranasal manifestations of the disease, as well as the role of allergic rhinitis in the development of increased respiratory viral morbidity are assessed. The differences between allergic and vasomotor rhinitis (non-allergic non-infectious rhinopathy) are analysed. Frequent interdependence and interaction of the allergic and vasomotor rhinitis are stressed. The signs of nonspecific hyperreactivity of the upper respiratory tract affected by the allergic rhinitis are presented. The role and importance of decongestants in the treatment of both allergic and vasomotor rhinitis are discussed in detail. Vasoconstrictors would help reduce hyperemia and nasal mucosa oedema, reduce the level of mucus secretion, improve the drainage of paranasal sinuses, normalizing the pressure in them. The use of a combination drug – a sympathomimetic combined with a local antihistamine agent would be the most appropriate treatment for patients with AR. The use of intranasal combination therapy for allergic rhinitis is justified: a sympathomimetic phenylephrine combined with a blocker of H1-histamine receptors dimethindene. The insights into the safety and efficacy of above drug combination in paediatric practice are presented. The use of a combination intranasal drug based on phenylephrine and dimethindene in patients with allergic rhinitis is justified in paediatric practice as both symptomatic and pathogenetic treatment. It is also advisable to administer it to treat acute respiratory viral diseases, in the post-viral period with situational exacerbations of the vasomotor component.