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A pilot prospective audit of a prolonged jaundice clinic
PAEDIATRIC RESEARCH SOCIETY ABSTRACTS
to alcohol misuse over a 12-month period between September 2005 and August 2006, comparing these against the current hospital guidelines. Young people were identified using the hospital patient administration systems and ward admission diary. Results: Forty-six patients presented to the hospital (52% being 14–15 years old, and 57% female). A total of 87% of all A&E attendances were admitted to the hospital, 63% had a blood alcohol level of more than 125 mg%, whereas the limit for driving is 80 mg%, and 89% did not know the quantity of the alcohol they had consumed. Of the patients, 22% had a temperature of less than 35°C and 22% admitted misusing other drugs; 45% had urine collected for toxicology, but only 19% of the total were processed. A total of 13% had a Glasgow Coma Score value of less than 10. All admissions were successfully managed in the general wards. Just over half (53%) of young people were asked about recent sexual activity. Referral to the Reiver Project (a local voluntary organisation that works with young people and families with drug and alcohol problems) was made for 87% of the study group, of whom 85% attended. There was a decrease in attendance for alcohol intoxication in 2005–2006 (2005–2006 = 46, 2004–2005 = 55). There was, however, a 53% increase in female attendance. Conclusions: Alcohol misuse remains a problem, with a raised concern of an increase in female attendances. The recording of temperature and other substance misuse, and Reiver Project referral, for all patients was not strictly followed. The management of patients was not affected by the lack of urine toxicology results. Local guidelines are to be redrafted regarding the indications for hospital admission the use of blood alcohol level, and to improve contraceptive advice.
may well be variation within units. Thirty per cent of units routinely electively ventilate a baby on prostin for transfer. In some cases, this is because of anticipated travel time to the regional cardiac unit because of distance or traffic, or because of the mode of transport, e.g. by air. Other units have a more variable policy, citing factors including the duration of prostin infusion prior to transfer and the dose of prostin, with ventilation more likely at higher doses. The primary consideration has to be the safety of the infant during transfer, but elective intubation and ventilation should not be assumed to be the safest option. A pilot prospective audit of a prolonged jaundice clinic O McEleavey1, AR Barclay2, E Chalmers3, JH Simpson1 1Queen Mothers Maternity Hospital, Glasgow 2Department of Child Health, University of Glasgow 3Haematology, Royal Hospital for Sick Children, Glasgow Introduction: Clinically apparent jaundice beyond 14 days of life is common, particularly in term breast-fed infants, where it affects 15–40%. The evaluation of infants with prolonged jaundice is recommended around day 14, primarily to exclude biliary atresia (BA), a rare but potentially catastrophic cause of prolonged jaundice (PJ). Little evidence exits to support extensive laboratory investigations as part of this evaluation process, and much heterogeneity exists in guidelines for the assessment of PJ. Some institutions advocate the delay of laboratory investigation until day 21 in otherwise well term breast-fed infants. To our knowledge, there has been no prospective research on the implications this has for health resources and patient outcomes. Methods: A prospective audit of all infants referred with prolonged jaundice to the Queen Mother’s Hospital, Glasgow, from August 2006 to January 2007. Guidelines implemented included clinical assessment, a PJ proforma questionnaire, a full blood count, Coombs test, thyroid function tests, direct bilirubin, liver function tests and G6PD in ethnically appropriate infants. A consultant paediatrician was available to assist with clinical decisions. Results: Of 1713 deliveries, 38 (2.2%) infants were referred. A total of 97% of infants were receiving breast milk to some degree, and all infants were achieving adequate growth at the time of review. Serum bilirubin ranged from 91 to 325 mm/l, and no infants had cholestatic liver disease. No abnormalities of thyroid function or G6PD were detected. Five infants had neutropenia with no other abnormalities on full blood count, which required further follow-up, and five had isolated elevated alkaline phosphatase. Two infants required repeat total bilirubin investigation for over 300 mmol/l. No infants would have required ongoing medical review on a clinical basis. Conclusions: Many unnecessary blood investigations are taken under the current guidelines, particularly in well-term breast-fed infants. Neutropenia and isolated elevated alkaline phosphatase were self-limiting and required no intervention. Hypothyroidism is screened for on the Guthrie card, and the Coombs test is invariably negative in babies not jaundiced in the first 24 hours of life. BA can be excluded by clinical examination, observation of urine and stools, and with a total and conjugated bilirubin. Much anxiety exists about rationalising approaches to PJ because of concerns of lowering sensitivity for BA detection. Previous prospective study has suggested that assessment by an experienced
Neonatal transfers on prostaglandin E: to ventilate or not to ventilate? C Irving1, SJ Murugan1, S Clarke2, J Thomson1 1Paediatric Cardiology, Leeds General Infirmary 2Neonatal Intensive Care Unit, Jessop Wing, Royal Hallamshire Hospital, Sheffield Introduction: We set out to document current practice in the UK on the transfer of infants with suspected congenital heart disease on prostaglandin E (prostin) infusion to a regional cardiac centre for assessment. Methods: A postal survey of all neonatal units in the UK was undertaken. The questionnaire was sent in November 2004 to the lead clinician in 215 units. The responses were anonymous. Results: A total of 147 responses were received, giving a response rate of 68%; 30% of respondents would electively intubate and ventilate a baby on prostin for transfer. Of those that have a guideline (105 units in all) on the use of prostin, just over a third would ventilate. Ninety-three units (63%) use a starting dose of 5 ng/kg per minute, 31 units (21%) start at 10 ng/kg per minute, and 23 units (16%) use another dose or did not give a dose. Fiftyone units (35%) use Dinoprost (prostaglandin E2), and 80 (54%) use Alprostadil (prostaglandin E1). 11% did not specify. At least 15% of respondents would rely on the advice of the cardiologist. If the baby were being transferred unventilated, 89% would send an escort able to manage an airway. There were six reports of an incidence on which a baby had to be ventilated during transfer. Conclusions: There is variation in practice across the UK. As the information gathered was from one clinician in each unit, there
PAEDIATRICS AND CHILD HEALTH 17:10
415
© 2007 Published by Elsevier Ltd.
PAEDIATRIC RESEARCH SOCIETY ABSTRACTS
clinician is effective in identifying infants with PJ in whom more detailed laboratory investigations are indicated. This pilot study suggests that changes in our PJ policy should be considered, including rationalising laboratory tests to a total and direct bilirubin, haematocrit and/or postponing all investigations to day 21 in well term breast-fed infants. Such changes would need to be monitored prospectively. Little is known of isolated neutropenia in well term breast-fed infants, and further work is needed to characterise this phenomenon’s clinical significance.
symptoms. GPs and general paediatricians infrequently inspect the perianal area in children who do not complain of symptoms, even when CD is suspected. All children in whom CD is a differential diagnosis should have a perianal inspection performed as identifying suggestive perianal findings may shorten the delay in diagnosing this condition. Are we doing too many or too few paediatric endoscopies? J Stojanovic, A Kader, P Dryden, JE Thomas, SK Bunn Department of Paediatric Gastroenterology, RVI, Newcastle upon Tyne
Perianal lesions: a common sign of childhood Crohn’s disease at presentation
Introduction: Diagnostic endoscopy is the standard method of detecting and diagnosing many gastrointestinal disorders. The threshold for examination varies with personal practice and access to endoscopy time and available expertise. An observed 10-fold increase in paediatric endoscopies performed raised the question of whether the threshold for endoscopy had fallen or demand had increased. Our aims were to evaluate the threshold for endoscopy within the paediatric gastroenterology department by assessing positive histological yield, comparing consultants and relating to a previous audit performed in 1991 (in which 65% cases had positive histology). Methods: All children undergoing diagnostic endoscopic procedures from January to May 2006 were identified from the departmental procedure database. A standard proforma was completed on each child, with information collected from the case notes and hospital computer laboratory system. Results: Between January and May 2006, 109 children (62 male) underwent 127 diagnostic endoscopies (some children had oesophogastroduodenoscopy (OGD) and colonoscopy). Indications were recurrent abdominal pain in 27 (34%), altered bowel habit in 16 (20%), persistent vomiting in 12 (15%), lower gastrointestinal bleeding in 10 (12%), upper gastrointestinal bleeding in 7 (9%), dyspepsia I 3 (4%) and failure to thrive in 2 (2%). Histological findings were 77/127 (61%) procedures and 71/109 (65%) children with diagnostic histological findings. The three consultants had very similar diagnostic yields of 62%, 62% and 67% of children undergoing endoscopy.
P Rao, A Kader, P Dryden, SK Bunn Department of Paediatric Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne Introduction: Crohn’s disease (CD) is increasingly common in the paediatric age range. Symptoms may be non-specific and diagnosis is often delayed, even after presentation to secondary care. Some perianal changes are highly suggestive of CD, and identification may expedite diagnosis. Our aims were to assess the perianal symptoms and signs in children presenting with subsequent biopsy-proven CD, determining the pick-up rate of perianal lesions by GPs and secondary-care paediatricians. Methods: All children presenting with subsequent biopsy-proven CD between March 2001 and March 2007 to the Paediatric Gastroenterology Department were identified through the departmental database. A standard proforma was completed for each child by retrospective case note review. Results: Sixty-six children with subsequent biopsy-proven CD presented over this 6-year period, of which 65 notes were available for review. The median age at diagnosis was 12.5 years (range 3.0–15.5 years). Findings on perianal inspection (note that several children had more than one type of lesion) are shown in the table. Number of children with each perianal lesion
With perianal symptoms No perianal symptoms Total
Number of children with perianal lesions
Number of children with no perianal lesions
Infla Skin Abs mmatory tag(s) cess fissure(s)
Fistula(e)
8
7
8
2
17
Nil
9
13
Nil
Nil
21
27
17
20
8
2
38 (58%) 27 (42%)
Procedures
Normal histology Abnormal histology Oesophagitis Gastritis/Helico bacter pylori Coeliac disease Crohn’s disease Colitis Other
Eleven of the 38 children with perianal lesions were referred by GPs and 27 by general paediatricians/paediatric surgeons. There was no difference in the pick-up rate of perianal lesions by GPs and general paediatricians: 5/11 (45%) and 13/27 (48%), respectively. Only 4/21 (19%) of the asymptomatic lesions were identified at primary or secondary care. Conclusions: The majority of children presenting with CD have perianal findings, but only a minority complain of perianal
PAEDIATRICS AND CHILD HEALTH 17:10
OGD = 83
Colonos copy = 37
Sigmoido scopy = 7
Total = 127
34 (41%) 49 (59%) 27 11
11 (30%) 26 (70%)
5 (71%) 2 (29%)
50 (39%) 77 (61%)
11 7 8
1 1
11
Conclusions: The diagnostic yield has not significantly changed from 1991, suggesting that the increased number of paediatric endoscopies performed is due to increased demand rather than 416
© 2007 Published by Elsevier Ltd.
to alcohol misuse over a 12-month period between September 2005 and August 2006, comparing these against the current hospital guidelines. Young people were identified using the hospital patient administration systems and ward admission diary. Results: Forty-six patients presented to the hospital (52% being 14–15 years old, and 57% female). A total of 87% of all A&E attendances were admitted to the hospital, 63% had a blood alcohol level of more than 125 mg%, whereas the limit for driving is 80 mg%, and 89% did not know the quantity of the alcohol they had consumed. Of the patients, 22% had a temperature of less than 35°C and 22% admitted misusing other drugs; 45% had urine collected for toxicology, but only 19% of the total were processed. A total of 13% had a Glasgow Coma Score value of less than 10. All admissions were successfully managed in the general wards. Just over half (53%) of young people were asked about recent sexual activity. Referral to the Reiver Project (a local voluntary organisation that works with young people and families with drug and alcohol problems) was made for 87% of the study group, of whom 85% attended. There was a decrease in attendance for alcohol intoxication in 2005–2006 (2005–2006 = 46, 2004–2005 = 55). There was, however, a 53% increase in female attendance. Conclusions: Alcohol misuse remains a problem, with a raised concern of an increase in female attendances. The recording of temperature and other substance misuse, and Reiver Project referral, for all patients was not strictly followed. The management of patients was not affected by the lack of urine toxicology results. Local guidelines are to be redrafted regarding the indications for hospital admission the use of blood alcohol level, and to improve contraceptive advice.
may well be variation within units. Thirty per cent of units routinely electively ventilate a baby on prostin for transfer. In some cases, this is because of anticipated travel time to the regional cardiac unit because of distance or traffic, or because of the mode of transport, e.g. by air. Other units have a more variable policy, citing factors including the duration of prostin infusion prior to transfer and the dose of prostin, with ventilation more likely at higher doses. The primary consideration has to be the safety of the infant during transfer, but elective intubation and ventilation should not be assumed to be the safest option. A pilot prospective audit of a prolonged jaundice clinic O McEleavey1, AR Barclay2, E Chalmers3, JH Simpson1 1Queen Mothers Maternity Hospital, Glasgow 2Department of Child Health, University of Glasgow 3Haematology, Royal Hospital for Sick Children, Glasgow Introduction: Clinically apparent jaundice beyond 14 days of life is common, particularly in term breast-fed infants, where it affects 15–40%. The evaluation of infants with prolonged jaundice is recommended around day 14, primarily to exclude biliary atresia (BA), a rare but potentially catastrophic cause of prolonged jaundice (PJ). Little evidence exits to support extensive laboratory investigations as part of this evaluation process, and much heterogeneity exists in guidelines for the assessment of PJ. Some institutions advocate the delay of laboratory investigation until day 21 in otherwise well term breast-fed infants. To our knowledge, there has been no prospective research on the implications this has for health resources and patient outcomes. Methods: A prospective audit of all infants referred with prolonged jaundice to the Queen Mother’s Hospital, Glasgow, from August 2006 to January 2007. Guidelines implemented included clinical assessment, a PJ proforma questionnaire, a full blood count, Coombs test, thyroid function tests, direct bilirubin, liver function tests and G6PD in ethnically appropriate infants. A consultant paediatrician was available to assist with clinical decisions. Results: Of 1713 deliveries, 38 (2.2%) infants were referred. A total of 97% of infants were receiving breast milk to some degree, and all infants were achieving adequate growth at the time of review. Serum bilirubin ranged from 91 to 325 mm/l, and no infants had cholestatic liver disease. No abnormalities of thyroid function or G6PD were detected. Five infants had neutropenia with no other abnormalities on full blood count, which required further follow-up, and five had isolated elevated alkaline phosphatase. Two infants required repeat total bilirubin investigation for over 300 mmol/l. No infants would have required ongoing medical review on a clinical basis. Conclusions: Many unnecessary blood investigations are taken under the current guidelines, particularly in well-term breast-fed infants. Neutropenia and isolated elevated alkaline phosphatase were self-limiting and required no intervention. Hypothyroidism is screened for on the Guthrie card, and the Coombs test is invariably negative in babies not jaundiced in the first 24 hours of life. BA can be excluded by clinical examination, observation of urine and stools, and with a total and conjugated bilirubin. Much anxiety exists about rationalising approaches to PJ because of concerns of lowering sensitivity for BA detection. Previous prospective study has suggested that assessment by an experienced
Neonatal transfers on prostaglandin E: to ventilate or not to ventilate? C Irving1, SJ Murugan1, S Clarke2, J Thomson1 1Paediatric Cardiology, Leeds General Infirmary 2Neonatal Intensive Care Unit, Jessop Wing, Royal Hallamshire Hospital, Sheffield Introduction: We set out to document current practice in the UK on the transfer of infants with suspected congenital heart disease on prostaglandin E (prostin) infusion to a regional cardiac centre for assessment. Methods: A postal survey of all neonatal units in the UK was undertaken. The questionnaire was sent in November 2004 to the lead clinician in 215 units. The responses were anonymous. Results: A total of 147 responses were received, giving a response rate of 68%; 30% of respondents would electively intubate and ventilate a baby on prostin for transfer. Of those that have a guideline (105 units in all) on the use of prostin, just over a third would ventilate. Ninety-three units (63%) use a starting dose of 5 ng/kg per minute, 31 units (21%) start at 10 ng/kg per minute, and 23 units (16%) use another dose or did not give a dose. Fiftyone units (35%) use Dinoprost (prostaglandin E2), and 80 (54%) use Alprostadil (prostaglandin E1). 11% did not specify. At least 15% of respondents would rely on the advice of the cardiologist. If the baby were being transferred unventilated, 89% would send an escort able to manage an airway. There were six reports of an incidence on which a baby had to be ventilated during transfer. Conclusions: There is variation in practice across the UK. As the information gathered was from one clinician in each unit, there
PAEDIATRICS AND CHILD HEALTH 17:10
415
© 2007 Published by Elsevier Ltd.
PAEDIATRIC RESEARCH SOCIETY ABSTRACTS
clinician is effective in identifying infants with PJ in whom more detailed laboratory investigations are indicated. This pilot study suggests that changes in our PJ policy should be considered, including rationalising laboratory tests to a total and direct bilirubin, haematocrit and/or postponing all investigations to day 21 in well term breast-fed infants. Such changes would need to be monitored prospectively. Little is known of isolated neutropenia in well term breast-fed infants, and further work is needed to characterise this phenomenon’s clinical significance.
symptoms. GPs and general paediatricians infrequently inspect the perianal area in children who do not complain of symptoms, even when CD is suspected. All children in whom CD is a differential diagnosis should have a perianal inspection performed as identifying suggestive perianal findings may shorten the delay in diagnosing this condition. Are we doing too many or too few paediatric endoscopies? J Stojanovic, A Kader, P Dryden, JE Thomas, SK Bunn Department of Paediatric Gastroenterology, RVI, Newcastle upon Tyne
Perianal lesions: a common sign of childhood Crohn’s disease at presentation
Introduction: Diagnostic endoscopy is the standard method of detecting and diagnosing many gastrointestinal disorders. The threshold for examination varies with personal practice and access to endoscopy time and available expertise. An observed 10-fold increase in paediatric endoscopies performed raised the question of whether the threshold for endoscopy had fallen or demand had increased. Our aims were to evaluate the threshold for endoscopy within the paediatric gastroenterology department by assessing positive histological yield, comparing consultants and relating to a previous audit performed in 1991 (in which 65% cases had positive histology). Methods: All children undergoing diagnostic endoscopic procedures from January to May 2006 were identified from the departmental procedure database. A standard proforma was completed on each child, with information collected from the case notes and hospital computer laboratory system. Results: Between January and May 2006, 109 children (62 male) underwent 127 diagnostic endoscopies (some children had oesophogastroduodenoscopy (OGD) and colonoscopy). Indications were recurrent abdominal pain in 27 (34%), altered bowel habit in 16 (20%), persistent vomiting in 12 (15%), lower gastrointestinal bleeding in 10 (12%), upper gastrointestinal bleeding in 7 (9%), dyspepsia I 3 (4%) and failure to thrive in 2 (2%). Histological findings were 77/127 (61%) procedures and 71/109 (65%) children with diagnostic histological findings. The three consultants had very similar diagnostic yields of 62%, 62% and 67% of children undergoing endoscopy.
P Rao, A Kader, P Dryden, SK Bunn Department of Paediatric Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne Introduction: Crohn’s disease (CD) is increasingly common in the paediatric age range. Symptoms may be non-specific and diagnosis is often delayed, even after presentation to secondary care. Some perianal changes are highly suggestive of CD, and identification may expedite diagnosis. Our aims were to assess the perianal symptoms and signs in children presenting with subsequent biopsy-proven CD, determining the pick-up rate of perianal lesions by GPs and secondary-care paediatricians. Methods: All children presenting with subsequent biopsy-proven CD between March 2001 and March 2007 to the Paediatric Gastroenterology Department were identified through the departmental database. A standard proforma was completed for each child by retrospective case note review. Results: Sixty-six children with subsequent biopsy-proven CD presented over this 6-year period, of which 65 notes were available for review. The median age at diagnosis was 12.5 years (range 3.0–15.5 years). Findings on perianal inspection (note that several children had more than one type of lesion) are shown in the table. Number of children with each perianal lesion
With perianal symptoms No perianal symptoms Total
Number of children with perianal lesions
Number of children with no perianal lesions
Infla Skin Abs mmatory tag(s) cess fissure(s)
Fistula(e)
8
7
8
2
17
Nil
9
13
Nil
Nil
21
27
17
20
8
2
38 (58%) 27 (42%)
Procedures
Normal histology Abnormal histology Oesophagitis Gastritis/Helico bacter pylori Coeliac disease Crohn’s disease Colitis Other
Eleven of the 38 children with perianal lesions were referred by GPs and 27 by general paediatricians/paediatric surgeons. There was no difference in the pick-up rate of perianal lesions by GPs and general paediatricians: 5/11 (45%) and 13/27 (48%), respectively. Only 4/21 (19%) of the asymptomatic lesions were identified at primary or secondary care. Conclusions: The majority of children presenting with CD have perianal findings, but only a minority complain of perianal
PAEDIATRICS AND CHILD HEALTH 17:10
OGD = 83
Colonos copy = 37
Sigmoido scopy = 7
Total = 127
34 (41%) 49 (59%) 27 11
11 (30%) 26 (70%)
5 (71%) 2 (29%)
50 (39%) 77 (61%)
11 7 8
1 1
11
Conclusions: The diagnostic yield has not significantly changed from 1991, suggesting that the increased number of paediatric endoscopies performed is due to increased demand rather than 416
© 2007 Published by Elsevier Ltd.