The paediatric research society. Scientific abstracts

ARTICLE IN PRESS Current Paediatrics (2004) 14, 178–189

www.elsevierhealth.com/journals/cuoe

THE PAEDIATRIC RESEARCH SOCIETY Scientific Abstracts University of Birmingham 26–27 September 2003 The Paediatric Research Society (PRS), established in 1962, is a forum for young researchers in paediatrics to present their work. Meetings are held each Spring and Autumn, with oral presentations, guest lectures and research seminars.

doi:10.1016/j.cupe.2003.11.001

For details of future meetings, abstract forms and travel grants go to the PRS websiteFwww. paediatric-research-society.org.uk

ARTICLE IN PRESS Scientific Abstracts

Braking the accelerator hypothesis J.R. Porter and T.G. Barrett Department of Endocrinology and Diabetes, Birmingham Children’s Hospital The accelerator hypothesis suggests that diabetes is due to three accelerators: insulin resistance, autoimmunity and genetic susceptibility (Wilkin T (2001) The accelerator hypothesis: weight gain as the missing link between Type I and Type II diabetes. Diabetologia 44:914–922). The theory predicts that type 1 diabetes will present earlier if body mass index, and thus insulin resistance is higher. Our aim was to test this hypothesis in our diabetes population. Our secondary aim was to test whether the relationship was more evident in South Asian children, who are more insulin resistant than white UK children. In our population, we compared age of onset of diabetes with standardized body mass index standard deviation score (BMI SDS) at first clinic after diagnosis, and 1 year later. Inclusion criteria were type 1 diabetes; age o16 years; ethnic origin white UK or South Asian. We analysed the data with Spearman’s rank correlation. 131 children fulfilled our criteria. We had data on 24 South Asian (10 female) and 71 white UK children (40 female). The mean ages at diagnosis were 9.3 years (range 1.4–15.5) South Asian, 7.3 years (range 1.28–14) white UK, a significant difference ðp ¼ 0:04Þ: Mean BMI SDS were 0.4 (95% confidence interval 0.17–0.63) white UK and 0.36 (95% confidence interval 0.32–1.04) South Asian. There was no significant correlation between age at onset of diabetes and BMI SDS in 24 South Asian (r ¼ 0:3 p40:1), and 71 white UK children (r ¼ 0:038 p40:5) at diagnosis or 1 year after diagnosis Asian (r ¼ 0:235; p40:1), white UK children (r ¼ 0:2; p40:1). We found no link between age at presentation and body mass index in our population of children with type 1 diabetes. It is possible that other factors have a larger influence on age of onset of type 1 diabetes in our cohort than obesity. Development of an assessment tool to select children at risk of Type 2 diabetes for oral glucose tolerance testing S. Ehtisham and T.G. Barrett Department of Endocrinology and Diabetes, Birmingham Children’s Hospital

179

Background: Children are increasingly being referred to paediatric clinics with obesity. It is not clear which of these children are at risk of glucose intolerance, and it is not practical to undertake oral glucose tolerance tests on all referrals. Aims: We aimed to audit our own practice of oral glucose tolerance testing in children referred to clinic with obesity, acanthosis or suspected diabetes secondary to insulin resistance. We then aimed to refine our selection criteria for testing to minimize unnecessary tests. Methods: We undertook a case note review of all children who had undergone an oral glucose tolerance test (OGTT) during a 4-year period. Data collected included sex, ethnicity, age, reason for referral, family history of diabetes, height and weight, examination findings and laboratory results. Results: Of 66 OGTTs undertaken during the time period, 53 were normal and 13 (20%) were abnormal (four children had diabetes, eight had impaired glucose tolerance and one had impaired fasting glycaemia). Factors that predicted abnormal results were: age greater than 11 years, female sex, higher body mass index standard deviation score, ethnic minority origin, strong family history of Type 2 diabetes and signs of insulin resistance. Conclusions: On the basis of these results, we have revised our selection process for OGTT by developing an assessment tool, which uses clinical features to categorize children into low and high risk of having an abnormal OGTT. Testing only those children who fall into the high-risk category picks up all 13 of the abnormal results but reduces the overall number of OGTTs undertaken to 36, giving a sensitivity of 100%, specificity of 57% and a positive predictive value of 36%, i.e. that three children need to be tested to identify one abnormal result. Risk factors for hospital admission in infancy J.M. Leonard and C.M. Wright Department of Child Health, University of Glasgow Aim: To determine the main causes and covariates of hospital admission in infancy, particularly the potential influence of breast-feeding. Method: Data were taken from the Millennium Baby Study, which recruited 1029 babies in a geographically defined urban area. Four postal questionnaires completed by parents included reports of all hospital admissions. Data were analysed on the babies for whom we had at least two completed questionnaires. This number was 782 (76%). For

ARTICLE IN PRESS 180

each admission, the date, length of stay and reason for admission were recorded. These data were collated, the reasons coded into condition categories and merged with available demographic data. Results: The causes of admission to hospital were respiratory (35.1%), systemic illness (20.1%), minor infection (3.2%), gastrointestinal illness (7.8%), non-infectious medical, (11.0%), surgical including accidents (15.6%), and others (7.1%). 58% of admissions had infective aetiology. 128 (16.4%) were admitted at least once, totalling 154 admissions. 54.9% were admitted for less than 24 hours, 8.5% for more than a week. 31.8% of cohort were breastfed for more than 6 weeks. 19.3% (77) of boys were admitted as were 13.4% (51) of girls. 10.4% of the cohort were SCBU graduates, but constituted 25% of the admissions. Twins, (3.5%) of the cohort, were 2.44 times more likely to be admitted than singletons. Male gender remained independently predictive of admission (OR 1.49 p ¼ 0:03) even after adjusting for confounding effects of birth weight and prematurity in logistic regression. Twinning was no longer significant. Mode of feeding and measures of deprivation were unrelated to whether admitted or not, or to the severity or type of admission. Conclusion: Neither deprivation nor breast-feeding proved to be risk factors for admission in the first year of life, whereas being male gender was associated with a 50% increased rate of admission. Use of the T maze to test cognitive function in rats following fluid percussion traumatic brain injury B. Hameeda, P. Grundyb, M. Harbuzc, S. Lightmanc and P.M. Sharplesa a

Department of Paediatric Neurology, Frenchay Hospital, Bristol; b Department of Neurosurgery, Frenchay Hospital, Bristol; c University Research Centre for Neuroendocrinology, University of Bristol Background: Traumatic brain injury (TBI) is a major cause of death and acquired disability in children. It produces a cascade of autodestructive molecular events which cause delayed neuronal loss, particularly involving the hippocampus. Neuroprotective agents may therefore improve outcome. To investigate putative neuroprotective agents, animal models of TBI are needed which exhibit the cognitive and histological effects seen in patients. The T maze test is forced alternation task which

Scientific Abstracts

tests working memory and is associated with hippocampal damage in rats. It has not previously been used in TBI. Aim: To investigate whether rats subjected to TBI perform less well on the T maze test than rats subjected to sham injury. Methods: All memory testing was carried out in a purpose-built modifiable T maze. Adult male Wistar rats were food deprived, habituated and pretrained in the maze over 2 days using food pellets as reward, after which they were subjected to fluid percussion injury (FPI) or sham injury. The acquisition sessions (six trials each), were performed on the day before surgery and on days 1 and 2 after surgery. The animals were then sacrificed for histological studies. The mean score on T maze testing on days 1 and 2 following surgery was calculated (minimum 0, maximum 6) and ANOVA performed to examine differences between the groups. Results: Mean (7) force delivered at the time of FPI was 2.270.1 atms. The mean (7SEM) T maze score for sham injured controls ðn ¼ 6Þ was 5.770.17. Animals sustaining FPI ðn ¼ 5Þ scored significantly worse than the controls, with a mean of 4.570.27 ðp ¼ 0:03Þ: Histological staining (haematoxylin and eosin) showed that the total number of neurons with normal histological appearance was significantly lower in the ipsilateral (sham mean 31.371.5, FPI mean 20.471.5) and contralateral (sham mean 31.071.5, FPI mean 22.471.2) dentate hilar regions of the hippocampus of animals undergoing FPI compared with sham surgery ðpo0:0001Þ: Conclusion: The T maze test differentiates between FPI and sham injured rats with respect to cognitive function. The differences correlate with histological evidence of hippocampal neuronal loss. Relationship between the King’s Outcome Scale for Childhood Head Injury (KOSCHI) at hospital discharge, injury severity and detailed measures of early outcome in children with traumatic brain injury (TBI) S.E. Calvert, H.E. Miller, A.L. Curran, R.J. McCarter, L. Hunt and P.M. Sharples The Kids’ Head Injury Study Group, Frenchay Hospital, Bristol Background: TBI is the most common cause of hospital admission in children and of acquired neurological morbidity. The KOSCHI has been proposed as a short hand description of outcome following childhood TBI which can provide a tool for

ARTICLE IN PRESS Scientific Abstracts

documenting recovery, service planning, and evaluating interventions and research. To date, however, it has not been validated against other outcome measures. Aim: To relate the KOSCHI category at hospital discharge to injury severity and to detailed measures of early outcome. Methods: Prospective cohort study. TBI severity was classed by admission Glasgow Coma Score (GCS). Cognition was assessed by the Wechsler Intelligence Scales for Children (WISC)-III, Test of Everyday Attention in Children (TEA-ch) and the Tower of London (TOL) test of executive function. Behaviour was assessed by the Child Behaviour Checklist (CBCL). Quality of life was assessed by the Pediatric Quality of Life Scale (PedsQL) and the Health Utilities Index Mark 3 (HUI-3). The KOSCHI at hospital discharge was scored retrospectively from the case notes by a researcher blinded to the detailed outcome data. Results: Up to date 50 TBI subjects (23 severe, 11 moderate, 16 mild) have been recruited. The mean length of hospital stay (LOS) was 23 days, range 1–142. The mean time between injury and assessment was 60 days (range 18–120 days). KOSCHI categories assigned at discharge were good (5) ðn ¼ 16Þ; moderate (4) ðn ¼ 30Þ and severe disability (3) ðn ¼ 4Þ: There was a significant correlation between KOSCHI category and GCS ðpo0:0001Þ and LOS ðpo0:001Þ: There was a significant correlation between KOSCHI and verbal IQ ðp ¼ 0:017Þ; performance IQ ðp ¼ 0:016Þ; PedsQL school ðp ¼ 0:004Þ and PedsQL physical, ðp ¼ 0:04Þ: No significant correlation was found between KOSCHI and measures of attention (TEA-ch, p ¼ 0:26), executive function (Tower of London, p ¼ 0:8), behaviour (total problem CBCL, p ¼ 0:9; externalizing CBCL, p ¼ 0:9) or other measures of quality of life (PedsQL emotion p ¼ 0:33; PedsQL social, p ¼ 0:19; HUI total p ¼ 0:11). An updated analysis will be presented. Conclusion: The KOSCHI correlates well with injury severity and certain measures of intellectual impairment. However, the lack of relationship between the KOSCHI and measures of attention, behaviour and quality of life calls into question its value as a summary outcome measure.

181 b

Cytogenetic Laboratory, Birmingham Women’s Hospital, Metchley Park Road, Edgbaston, Birmingham Background: The gold standard for diagnosis of Down’s syndrome is karyotype analysis. However, clinical suspicion usually prompts the initiation of this test. The accuracy of clinical diagnosis has been shown to be relatively low. Aim: The aim of this study is to analyse results of karyotyping of clinically suspected Down’s syndrome in the West Midland region and at Birmingham Women’s Hospital (BWH) in particular. Methods: A retrospective analysis of all clinically suspected cases of Down’s syndrome during the period from June ’00 to Dec ’02 was made. These were identified from the database at Regional Cytogenetic Laboratory. A retrospective case note study of the cases identified from BWH was also undertaken. Positivity of karyotyping from the West Midland region and from BWH was then compared with published national and regional data. Results: In the West Midland region, a specimen for karyotype analysis was sent from 233 suspected cases of Down’s syndrome. 29 of these were from BWH. Positivity of karyotype from the West Midland region as a whole was 63%. However, positivity from BWH was 86%. Previous published figures indicate a National positivity rate of 68% and 64% from the Manchester area. Of the 29 samples sent from BWH, only four suspected cases had normal karyotype and two of those were not seen by a consultant. We are unaware of any missed cases from BWH during that period although diagnosis was delayed in two preterm babies (3–4 weeks after delivery). Conclusion: Data from BWH showed a favourable positivity rate compared with other published data. Assessment by senior paediatricians before testing may minimize the risk of negative results. There may be difficult in diagnosing Down’s syndrome in preterm babies who may take sometime to manifest classical features. Validation of SNAP in an overseas NICU K.V. Mulay and J.A. Mondkar

Accuracy of clinical diagnosis in Down’s syndrome S. Sivakumara, S. Larkinsb and A.K. Ewera a

Regional Neonatal Unit, Birmingham Women’s Hospital, Metchley Park Road, Edgbaston, Birmingham;

Lokamanya Tilak Municipal Medical School and Teaching Hospital, Sion, Bombay, India Aims: This study was undertaken to validate the performance of SNAP in an overseas NICU. This was to correlate illness severity measured by SNAP on

ARTICLE IN PRESS 182

D1, D3 and D7 to neonatal mortality, to correlate illness severity as measured by SNAP on D1 to length of NICU stay amongst survivors, to compare illness severity as measured by SNAP on D1 to Physician’s estimation of mortality risk and to compare Physician’s estimation of mortality risk, birth weight and SNAP in predicting neonatal mortality. Methods: Prospective analytical study of randomly selected 100 neonates admitted to a tertiary neonatal unit over 9 months period. The SNAP score was recorded prospectively in these neonates on the day of admission (D1), on D3, and D7 of admission. Physician’s estimation of mortality risk was recorded on D1 using five-point Likert scale. Multiple logistic regression analysis was used to compare physician’s estimation of mortality risk, birth weight and SNAP score in predicting neonatal mortality. Results: Moderate to high correlation was observed (Cramer’s v ¼ 0:53) between SNAP on D1 and mortality. Positive predictive value of SNAP in predicting mortality on D3 and D7 was found to be 100%. SNAP score showed moderate to high correlation with other indicators of illness severity including physician’s estimate of mortality risk (Cramer’s v ¼ 0:5) and length of NICU stay amongst survivors (t ¼ 5:1). Conclusion: The SNAP score over 20 are associated with higher mortality. SNAP showed highly significant correlation with Physician’s estimate of mortality risk and length of stay. Serial recording of SNAP scores (D1, D3 and D7) are a better indicator of effectiveness of therapeutic response and better predictor of outcome. The SNAP with fewer variables may be more practical in assessing illness severity.

Scientific Abstracts

surgical or cardiological intervention. Data were collected from SCBU Annual Statistics and Microbiology database. We considered only positive blood cultures as criteria for the diagnosis of neonatal sepsis. The microbiological profile, antibiotic sensitivity pattern and relation to the presence of peripheral venous long lines were reviewed. Results: 1189 blood cultures were sent from the SCBU during the 5-year period and the incidence of positive blood culture was 9.6%. An average of almost one blood culture per baby was sent (1.1/ baby). Staphylococcus epidermidis (SE) was the predominant organism grown in blood cultures (69%) followed by Staphylococcus aureus (5.2%) and Group B Streptococcus (4.3%). The microbiological profile was similar in all the years studied. Most SE was sensitive to gentamycin (75.3%) and erythromicin (60.5%) but all were resistant to penicillin. Almost 80% of SE infection was in babies with long lines. Conclusion: The pattern of organisms causing blood culture positive neonatal sepsis in our DGH was similar to published data from tertiary neonatal units. Our data do not support the idea that neonatal sepsis or antibiotic resistance is more of a problem in tertiary centres than in DGHs. We emphasize that the choice of antibiotics in neonates with suspected sepsis should be made with SE in mind, especially where a long line is in place. Education is needed to improve neonatal parenteral nutrition practice M. Ahmeda, S. Irwinb and D.P. Tuthilla a

Neonatal sepsis: do DGHs have less of a problem than tertiary centres?

Department of Neonatal Medicine Llandough Hospital, Cardiff; b Pharmacy Department University Hospital of Wales, Cardiff

R. Mittal and B. Harrington Wrexham Maelor Hospital, Wales Aims: Neonatal sepsis continues to haunt neonatologists all over the world. There is little published literature concerning its incidence in district general hospitals (DGHs). The aim of this study was to produce one such profile. Methods: All blood cultures sent from the Special Care Baby Unit of Wrexham Maelor Hospital from January 1997 to December 2001 were reviewed. There were 11 392 deliveries over the period and 1085 were admitted to the Unit. The Unit cares for all inborn babies except those requiring neonatal

Introduction: Parenteral nutrition is an essential component of neonatal care for those infants who are unable to tolerate adequate enteral feeding. Its use is not without complications such as biochemical derangements, sepsis, thrombosis, extravasation of fluid and death. Such complications can be reduced by meticulous management of PN in response to biochemical abnormalities, nutrition teams, policies to reduce sepsis and staff training to be more aware of pericardial and pleural effusions. Objective: To ascertain the current practices in parenteral nutrition (PN) administration and management of complications in all Neonatal Units

ARTICLE IN PRESS Scientific Abstracts

(NNU) with six or more intensive care cots in England, Scotland and Wales. Methods: Telephone survey of Specialist Registrars working in all 57 neonatal units was conducted using a standard questionnaire. The questions were focused around practical issues and problems that are commonly encountered with PN practice including composition, complications, training and nutrition support. Results: A response was obtained from 95% of the units contacted and a wide range of practice observed. Only 16% of units delay addition of sodium until 448 hours after birth with 33% delaying protein till then. Lipid infusions are stopped in proven or suspected sepsis in just over half of all units. In hyperglycaemic preterm infants 25 units decrease their glucose infusion, 21 commence insulin and 8 have no policy. Two-thirds of SpRs had no idea of the amount of protein to prescribe for these infants and only one-third involve a pharmacist in the PN prescribing. Conclusion: In conclusion, few units practice delayed sodium administration despite this having the potential to improve oxygenation and reduce chronic lung disease. There is an urgent need for further SpR training in prescribing of PN and the involvement of pharmacists to ensure safety. The management of common complications such as sepsis and hyperglycaemia are highly variable. We suggest that the involvement of nutrition teams in all neonatal units would help reduce PN complications. Improved staff training is urgently required. Current sedation and neuromuscular blockade practice in PICUs in the UK S.D. Playfor For the Paediatric Intensive Care Society Sedation Working Group To clarify sedation and neuromuscular blockade practice in Paediatric Intensive Care Units (PICUs) in the UK, the Paediatric Intensive Care Society Sedation Working Group has conducted a postal survey of 21 units. Data were returned for 364 patients. A total of 296 children were intubated and required sedation and analgesia of whom 106 children (36%) were administered neuromuscular blocking agents. Sixtynine children (23%) had undergone cardiac surgery. Excluding simple analgesics, 24 different sedative and analgesic agents were used and four different neuromuscular blocking agents. Morphine was administered to 260 patients (88%) and midazolam

183

was administered to 203 patients (69%). The most commonly used enteral sedative agents were chloral hydrate in 93 patients (31%), triclofos in 72 patients (24%) and trimeprazine in 61 patients (21%). Propofol was used for sedation in 16 patients (5%) whose ages ranged from 4 to 15years. Vecuronium was the most commonly prescribed neuromuscular blocking agent being used in 80 patients (27%). Physical restraints were used in nine patients (3%). Features of withdrawal were observed in 30 children (10%) and one child suffered prolonged neuromuscular weakness following prolonged administration of vecuronium. This study has shown a surprisingly high level of variation in sedation and neuromuscular blockade practice in UK PICUs. Evidence in the medical literature to support sedation and neuromuscular blockade practice is of a low level and therefore the group is also in the process of generating a set of consensus guidelines in these areas using a modified Delphi process. Surfactant treatment in paediatric ARDS V.K.T. Nootigattu and S.D. Playfor Paediatric Intensive Care Unit, Royal Manchester Children’s Hospital Background: The success of exogenous surfactant replacement in premature neonates is well established. There is quantitative and qualitative deterioration of surfactant in acute respiratory distress syndrome (ARDS), which contributes to lung dysfunction. There is no good data to support the routine use of surfactant replacement, an expensive treatment option in respiratory failure beyond the neonatal period. Aim: To determine the effect of surfactant on oxygenation index (OI) in respiratory failure and whether subsequent doses provide further benefit in terms of OI. Methods: Three patients diagnosed as ARDS in our Paediatric Intensive Care Unit were treated with the natural surfactant Curosurf. ARDS was secondary to aspiration and infection. OI was calculated for at least 72 hours after the first dose of surfactant. In two cases the dose of Curosurf was 200 mg/kg followed by 100 mg/kg at þ 12 and þ 24 hours. The third case received one dose of Curosurf of 60 mg/kg. Results: In two cases, the response to the first dose of surfactant (OI improved by 30% and 58%) was significantly greater than with subsequent doses. The third case received only one dose and the OI improved by only 9% after 4 hours. However, the

ARTICLE IN PRESS 184

Scientific Abstracts Variations in oxygenation index following surfactant adminstration

55 50 Oxygenation Index

45 40 35 30 25 20 15 10 71

66

61

56

51

46

41

36

31

26

21

16

6

11

1

5 Time in hrs Surfactant

Patient 1

Patient 2

Patient 3

oxygenation index improved by 12 (23%) when the next dose was due. Conclusion: Whilst there is insufficient evidence to support the routine use of surfactant in paediatric ARDS, its administration is associated with improvements in oxygenation. Our data support the suggestion that surfactant should be considered as a rescue therapy in paediatric ARDS and should probably be limited to one dose of 200 mg/kg. Audit of protocol Doppler ultrasound scans after paediatric liver transplantation S. Harave, S.M. Davison, P. McClean and M.D. Stringer PaediatricLiver and GI Unit, St James’ University Hospital, Leeds Background: The early detection of post-operative complications (particularly Hepatic Artery Thrombosis, HAT) after liver transplantation (LT) allows prompt institution of appropriate therapeutic measures. Doppler Ultrasound Scan of Liver (DUSL) is the initial imaging study of choice in the screening of surgical complications after transplantation. The current policy of our unit is to perform DUSL routinely on days 1, 2, 3, 5 and 7 post-LT. Additional DUSL are performed according to clinical need. Aims: To ascertain (1) the value of protocol DUSL in the early post-operative period by evaluating the detection rate of abnormalities and the correlation with clinical findings and (2) the number of additional DUSL in the first 2 weeks post-LT. Methods: The case notes of 35 consecutive children who underwent 41 LT at The Children’s Liver Unit, St. James’s University Hospital from 11/00 to 05/03

were reviewed retrospectively. DUSL results were reviewed and abnormal findings noted. The clinical status and presence of biochemical abnormalities were noted. Results: Abnormalities were detected on DUSL in five children (12.%). There was no clinical deterioration or biochemical abnormality in any of these children. 3/5 required intervention: two with HAT, one with hepatic artery stenosis. The other two abnormalities were parvus tardus waveforms (repeat scans were normal). Additional scans were performed in 17 children (41%) based on either clinical suspicion or biochemical abnormality. Three of these (17.6%) had an US abnormality, (fluid collection, ascites, haematoma). A further five underwent scans to exclude an abnormality prior to liver biopsy for suspected acute rejection. Conclusions 1. Protocol DUSL suggested abnormalities in three patients in the absence of clinical deterioration and facilitated early intervention. 2. Additional DUSL performed in 41% of children detected significant abnormality in 17.6%. 3. Protocol DUSL are of significant clinical value in the immediate post-operative care of children after LT. Junior medical staff’s knowledge of common legal situations C.S. Ashtekar, M. Alfaham, A. Hande, E. Stallard and D. Tuthill Department of Paediatrics, Llandough Hospital, Cardiff Aim: To determine junior paediatric medical staff’s knowledge of common legal situations. Methods: A standardized structured interview was developed exploring common issues with legal implications for paediatric practice. It focused on areas such as: medical responsibility/ accountability, child protection powers and important legal principles such as ‘Bolam’ for good medical practice and ‘Gillick’ for consent and legal training. We attempted to contact all paediatric SHOs and SpRs in Wales by telephone. Responses were analysed against the answers shown in italics. Results: There are 56 SpRs in Wales and 124 SHOs. 119 doctors (66%) were contacted, 46 SpRs (82%) and 73 SHOs (59%). Conclusion: Few junior staff have adequate knowledge of basic legal principles and practice as they

ARTICLE IN PRESS Scientific Abstracts

185

Question with acceptable answers in italics

Correct answers% SHO

(1) Which organization is responsible for good medical practice in the UK? GMC (2) What is the ‘Bolam’ principle in medico-legal situations? A Dr’s action must be in accordance with a responsible body of medical opinion to avoid negligence (3) What is the legal age of consent for medical procedures in the UK? 16 years (4) Can a 14-year-old girl with cystic fibrosis refuse intravenous antibiotics for her chest infection? Yes initially if she is ‘Gillick’ competent. (5) A 2-year-old girl is admitted with suspicious facial and pinna bruising. You suspect NAI. The father removes the child from the ward against your wishes. Who has the legal power to protect the child and under what legislation? Police or social services under the Children’s Act (6) Have you ever received any form of training in legal procedures?

relate to children. Training opportunities are limited. Explaining unlicensed medications to children: how effective is the RCPCH leaflet? C. Vandevelde and C.P.J. Chariton Department of Paediatric Gastroenterology, Queen’s Medical Centre, Nottingham Introduction: Manufacturers are required to include a drug information insert with their medicines. The leaflet will include the indications for use and the patients age range, which will have been approved by the medicine control agency when the company applied for a license to promote the medicine. A recent study showed that 36% of children during admission received at least one drug that was unlicensed or outside license during their stay.1 The Royal College Committee on Medicines, sent a letter round to the Chief Executives with a patient information leaflet for parents and a separate one for older children, to explain licensing and reassure patients and parents that unlicensed drugs are safe, if prescribed by their doctor.2 Our aim was to evaluate the effectiveness of the leaflet for older children. Method: Head teachers of a Nottingham and Liverpool Comprehensive School were approached, and agreed to present the leaflet as a class activity

SpR

71

83

0

11

77

85

54

85

Only police 36

50

Only social services 30

48

Both 14 21

26 46

in comprehension, to two classes of mixed ability. The children were given sufficient time to read and reread the leaflets and fill in a short questionnaire with the leaflet still at hand. They were judged to have understood the leaflet if they indicated the following: 1. Not all drugs have licenses 2. Unlicensed drugs are safe to take if prescribed by your doctor Subjects: 21 children in a Nottingham School and 29 children in a Liverpool School took part. The response rate was 100%. The authors evaluated the anonymous questionnaires. Results: According to the above criteria, six out of 50 children understood the leaflet, with sample comments reflecting the problems in understanding were: ‘What is it trying to say?’ ‘Be careful with unlicensed medicines’ and ‘Are they (unlicensed medicines) dangerous?’ The children were well motivated to complete the procedure and interestingly 14 made positive comments saying that the leaflet was interesting. Twelve commented that the leaflet was difficult to understand. Conclusion: The children failed to understand the key message of the leaflet that unlicensed medicines are safe to take if prescribed by your doctor. This could lead to problems in compliance with unlicensed medications. The RCPCH need to review

ARTICLE IN PRESS 186

Scientific Abstracts

1. Turner S, Longworth A, Nurm AJ, Choonara 1. Unlicensed and off label drug use in paediatric wards: prospective study. Br Medl J 1998;316: 343–5. 2. Stevenson T. Letter to all chief executives of NHS trusts from the chairman of the joint RCPCH/NPPG standing committee on medicines. October 2000.

disappeared into abdomen was seen in 16 (16.2%) children. In nine (9.1%) children orchiopexy was delayed because of parents failing to keep appointment and children getting lost to follow-up. Two children were diagnosed early, but were referred to surgeons late. Despite implementation of aggressive screening, majority of undescended testis is getting operated at much later age than recommended. The causes of delayed orchiopexy is multifactorial and is not just a failure of screening.

Delayed orchiopexy: failure of screening or ascending testis

Reference

S. Thayyil, M. Shenoy and K.N. Agrawal

1. Health for all children, 4th ed. Hall & Hillman: 2003.

the production of leaflets aimed for children and young people.

References

North Tees and Hartlepool NHS Trust Undescended testis is a common condition with an incidence of 6% at birth and 1.6% at 3 months of age. Current guidelines recommends that infant boys thought to have incomplete descent of testis should be referred for surgical opinion by 12 months of age and operated before 2 years of age.1 A retrospective audit conducted in 1996 showed that the 88.8% of orchiopexies were done after the age of 2 years and the median age of orchiopexy was 7.8 year. A joint guidelines between paediatricians, general practitioners and surgeons on management of orchiopexy was introduced following this. This involved screening for undescended testis at birth, 6–8 weeks by general practitioner, 6–9 months and 12–15 months by health visitor and during preschool check by a doctor. A re-audit was done after a 5 year period on 99 children who underwent orchidopexy between January 2001 and January 2003. Median age (range) at diagnosis of undescended testis was 17 months (1 day–12.4 year) and median age (range) at orchiopexy was 5.2 year (15 months– 14.6 year). 41.4% of undescended testis was diagnosed after the age of 2 years. Only 14.1% of children were operated before the age of 2 years. Majority (54.5%) of the children had orchiopexy between the age of 5 and 15 years. In 23 children (23.2%), testis was initially thought to be retractile testis, but later testis was not found at all. In 22 (22.2%) children, the initial diagnosis was delayed (i.e. diagnosed after 2 years). Thirteen (13.1%) children were referred to surgeons before 2 years of age; however, orchiopexy was still delayed due to various surgical and administrative reasons. Ascending testis where testis was clearly documented a descended into scrotum, but later

Diagnostic value of chest radiography in the assessment of children with heart murmurs H.P. Satish, D. Deekollu, G. Tudor and A. Goodwin Department of Child Health and Department of Radiology; Princess of Wales Hospital, Bridgend, South Wales Objectives: To assess the usefulness of chest radiographs in diagnosing heart defects in children with heart murmurs. Methods: Sixty-seven patients who were referred to the paediatric cardiology clinics for assessment of heart murmurs between January 2002 and December 2002 were included in this study. Data were collected by retrospective case notes analysis using a structured proforma. Based on the clinical assessment, patients were categorized into one of the two groups namely, no heart disease or probable heart disease. Then their chest radiographs were independently assessed by a radiologist, categorizing them into one of the above two groups. These assessments were compared to the final diagnosis made by the cardiologist following echocardiography. Results: Forty-seven out of the 67 patients were clinically diagnosed to have probable heart defects. Following echocardiography 43 of these patients were confirmed to have heart defects and 4 were normal. Twenty patients were clinically normal and all these patients except for one were normal on echocardiography. Clinical assessment had a sensitivity of 98%, specificity of 83%, positive predictive value of 92% and negative predictive value of 95% for the detection of heart defects in this group of patients. Nine had abnormal radiological features and all these were confirmed to have heart defects. However, these nine patients

ARTICLE IN PRESS Scientific Abstracts

were diagnosed to have probable heart defects on clinical assessment as well. Fifty-eight had normal radiological features. Twenty-three of these were normal on echocardiography and 35 had heart defects. Radiological evaluation had a sensitivity of 20%, specificity of 100%, positive predictive value of 100% and negative predictive value 40% for the detection of heart defects in this group of patients. Conclusions: Chest radiographs had low sensitivity in the detection of heart defects in children with heart murmurs and did not provide additional information to the clinical assessment. A study of emergency appendicectomies in children in Shropshire V.K.T. Nootigattu, G. Meena, N. Vrahimis, J.E.H. Brice and S.D. Playfor Royal Shrewsbury Hospital, Shrewsbury and Princess Royal Hospital, Telford Introduction: Appendicectomy is the most common emergency operation. Misdiagnosis (often referred as negative appendicectomy) rate more than zero is accepted as perforation rate is thought to be inversely proportionate to negative appendicectomy rate. Children with appendicitis are quite often admitted and cared by paediatric physicians initially and then surgeons in most of hospitals. Aims: To determine the rate of ‘negative appendicectomy’ and predictors of histologically inflamed appendix in children undergoing emergency appendicectomy. Methods: We searched Shropshire’s hospital episodes database to obtain a cohort of children under 16 years of age undergoing emergency appendicectomy during a 12-month period. Results: Seventy-seven children (mean age, 11.6 years) underwent emergency appendicectomy during this period. The overall mean time to surgery from admission was 16.1 hours, being 30.9 hours for children with diagnostic uncertainty. The mean time from decision to surgery was 3.7 hours. Only three (4%) children were operated between midnight and 8 a.m. Appendix was considered to be inflamed, clinically at surgery in 88% but histopathologically in 76%. Eight of 14 histopathologically normal appendices were considered clinically inflamed. The rate of perforation and gangrene was 11.7%. White cell count of 15 or more [OR (95% CI), 24.6 (3.7 -.)], neutrophil count 412 [OR (95% CI), 31.5 (4.7 -)], and CRP420 [OR (95% CI), 10.9 (1.6 - .)] were

187

significantly associated with histopathologically inflamed appendix. Conclusions: Normal appendicectomy and perforation rates in our cohort are comparable to national figures. Leucocytosis (415), neutrophilia (412) and raised CRP (420) are good indicators of histologically inflamed appendix. Variation in the management of coeliac disease in Wales M. Ahmed and H.R. Jenkins Department of Paediatric Gastroenterology, University Hospital of Wales, Cardiff Introduction: Coeliac disease1 (CD) is a life-long immune-mediated enteropathy that affects the small intestine in genetically susceptible individuals. There are established guidelines in adult gastroenterology elucidating the management of patients with coeliac disease. In the absence of paediatric guidelines, there is thought to be variation in the management of childhood CD different hospitals/NHS trusts across the country. Objective: To explore the current management practices of children with CD amongst Consultant Paediatricians in Wales. Methods: All the Consultant Paediatricians working in different NHS Hospitals/Community Trusts in Wales were electronically sent a standardized questionnaire. The questions were focused around practical issues and overall management of children with CD including initial screening, diagnosis, follow-up, annual assessment, dietetic involvement and gluten challenge. Results: 84% (92/110) consultants returned the questionnaire. 20/92 consultants are not involved in the diagnosis and management of children with CD. Results analysed from remaining 72 questionnaires are summarized below. Majority (67) always request coeliac antibodies in suspected cases of CD, which includes antitissue transglutaminase antibodies (TTG) alone or in combination with other antibodies in 46 cases. Four consultants are continuing to obtain small intestinal biopsies using Crosby capsule and additional five utilize both Crosby capsule or endoscopic duodenal biopsy (depending upon the availability). Coeliac antibody screening test is performed in children with faltering growth/short stature (65), unexplained anaemia (54), first-degree relatives of children with CD (35), insulin-dependent diabetes mellitus (IDDM) (34), Down’s syndrome (29), other autoimmune conditions (22) and Turner’s syndrome (10). Prevalence of CD in Wales (in

ARTICLE IN PRESS 188

centres screening for the disease) in IDDM is 2.3% (28/1208) and 1.06% (3/282) in cases of Down’s syndrome. Thirty-one consultants replied ‘yes’ to annual assessment of these children in their hospital and 51 consultants regularly involve dieticians in their clinics. Conclusion: We strongly feel that guidelines need to be developed for the management of childhood CD, based on evidence and recent literature. This will help and guide both General Paediatricians and General Practitioners and create opportunities for future audits.

Reference 1. Ciclitira P. Guidelines for the management of patients with coeliac disease. British Society of Gastroenterology, 2002. http://www.bsg.org.uk/clinical prac/guidelines/ coeliac.htm

Scientific Abstracts

and recording of these problems at that consultation. Results: A total of 429 children aged 1.18–17.5 years were included in this study. 429 k-326 normal or low BMI 103-overweight /obese (24%) k-7 notes unavailable 96 -4/62 overweight recognition (6.5%) -13/34 obesity recognition (38%) Conclusions: The prevalence of obesity and overweight was in concordance with national data. Physician recognition and recording was low. We suggest that BMI should be plotted routinely along with weight and height for every child attending paediatric outpatient clinics. Improved recognition is perhaps the first step of their management.

Physician recognition of obesity/overweight amongst children attending outpatient clinics

Review of the effect of starting insulin/repaglinide on lung function and body mass index in children with cystic fibrosis and diabetes

M. Elemraid, S. Ashteka, C. Sadlier and D. Tuthill

S.M. Korada, M. Desai and T.G. Barrett

Department of Child Health, Llandough Hospital, Cardiff Background: The prevalence of obesity/overweight among children is increasing worldwide. In 1998, the World Health Organisation designated obesity as a global epidemic. The UK is rated the eighth most obese nation in the world with one in five children obese/overweight. Up to 26–41% of obese preschoolers and 42–63% of school age children will become obese adults. In contrast to adults BMI varies throughout childhood and so a standard cutoff cannot be used, making recognition more difficult. Aims: To assess physician recognition and recording of obesity/overweight in OPD. Method: All children over 1 year of age attending outpatient clinics over a 7-week period were included. Two nurses recorded weight and height on a SECA electronic scales and a Leicester stadiometer. Body mass index (BMI), weight (kg)/ height (m)2, was calculated and plotted on BMI centile charts. Overweight and obesity were defined according to the International Obesity Task Force guidelines: Overweight 41.04 SD above the 85th centile (B91st centile) Obese 41.64 SD above the 95th centile (B99th centile) Clinic notes and letters of obese/overweight children were reviewed for physician recognition

a

Department of Endocrinology, Birmingham Children’s Hospital; b Diabetes and Respiratory Medicine, Birmingham Children’s Hospital Background: Diabetes mellitus affects up to 20% of children with cystic fibrosis. Treatment with insulin or oral hypoglycaemic agent is thought to improve lung function, body mass index and decrease respiratory infections. However, the evidence for the beneficial effect of glucose-lowering treatment is conflicting. Aims: We aimed to review the effect of glucoselowering treatment on lung function (FEV1 SDS and FVC SDS) and body mass index (BMI SDS) for children with cystic fibrosis and diabetes. Methods: We undertook a retrospective study on 11 children with cystic fibrosis and diabetes presenting to Birmingham Children’s Hospital between 1996 and 2003. Diabetes mellitus was diagnosed using WHO criteria. We calculated SDS scores based on national paediatric data for FEV1 and FVC (Rosenthal 1993) and BMI (British Growth Reference 1990). We collected data from 1 year before diagnosis, to 6 months after treatment was commenced. Results: There were 11 children with diabetes who presented to our hospital between 1996 and 2003. The median age at diagnosis of diabetes was 11.77 years (range, 6.5–15.3 years). The range in FEV1 SDS was 13.1229 to þ 6.325 and FVC SDS was

ARTICLE IN PRESS Scientific Abstracts

9.4431 to þ 1.5667. In the 10 patients with available data from 1 year before diagnosis to 6 months, the median change in FEV1 SDS was 1.7835 (13.1229 to þ 0.6201) and FVC was 1.2262 (range, 9.4431 to þ 1.5667). For BMI SDS the median change was 0.0091 (range, 0.03858 to 1.36). Conclusion: There was great patient variability, but no clear improvement in the indices after treatment of diabetes. We conclude that the reasons we did not see a measurable benefit in lung function and BMI in our patients may include: intercurrent illness, steroid treatment, delayed diagnosis, inadequate treatment. Children with cystic fibrosis need to have diabetes diagnosed promptly and adequate treatment instituted in order to maintain lung function and BMI. Insulin-resistant diabetes in children without obesity: an association with bone marrow transplantation S. Iyer, J. Kirk, N. Shaw, A. Toogood and T. Barrett Department of Endocrinology and Diabetes, Birmingham Children’s Hospital Aims: Type 2 diabetes has been recognized in children in association with obesity and insulin resistance. Diabetes is also recognized as one of the long-term sequelae of bone marrow transplantation. We aimed to characterize the nature of diabetes in a series of children presenting to our unit after bone marrow transplantation.

189

Methods: Children were identified from the diabetes database (1995–2002) of Birmingham Children’s Hospital. Criteria for inclusion were: diabetes according to the WHO criteria and previous bone marrow transplantation. The data were then collected on a standard proforma and analyzed. Results: We identified five children aged 2.5–14 years. All patients were female and four were from ethnic minority groups. The median age of the children at transplant was 8 years; indications were: beta thalassaemia ðn ¼ 2Þ; acute myeloid leukaemia ðn ¼ 1Þ; acute lymphoblastic leukaemia ðn ¼ 1Þ; and myelodysplasia ðn ¼ 1Þ: Ablative radiation doses included total body irradiation (8–14 Gy). Cyclosporin was used in four of the five cases for Graft vs host disease prophylaxis. The median time from transplantation to diagnosis of diabetes was less than a year for the thalassaemia patients and 7 years (range 5–9.5 years) for the leukaemia group. None was obese (BMI 4 þ 2SDS). The median body mass index standard deviation score was 1.34 (range 1.97 to þ 1.25) Insulin resistance was present in four of the five cases: four had acanthosis nigricans; of these, two had raised fasting insulin (210 and 911 pmol/l) and one had a raised C-peptide (1470 pmol/l). Conclusion: Diabetes mellitus in four of the five children, following bone marrow transplantation, showed features of insulin resistance without obesity. These children constitute a special group with multisystem problems who have different needs from children with type 1 or type 2 diabetes.