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Urine pads for routine metabolic and biochemistry tests in paediatrics
PAEDIATRIC RESEARCH SOCIETY ABSTRACTS
Probiotics for necrotising enterocolitis (NEC): a systematic review
definitive multicentre RCT is required to resolve these outstanding issues. Future research into the benefits of such nutritional therapies in infants and children should consider the long-term and short-term effects on health and observe recommendations on the conduct of multicentre trials by the ESPGHAN Committee on Nutrition (JPGN 2001; 32: 255–8).
AR Barclay1, B Stenson2, JH Simpson3, LT Weaver1, DC Wilson4 1University of Glasgow 2University of Edinburgh 3Queen Mother’s Maternity Hospital, Glasgow and Neonatal Unit 4Royal Infirmary of Edinburgh
Staff noise exposure during neonatal transportation
Introduction: Probiotics have been shown to reduce NEC in experimental rat models and have been used in clinical trials. We aim to review existing data on oral probiotics for the prevention of NEC in very low-low birthweight (VLBW) infants. Methods: We used a systematic review of randomised controlled trials (RCT) and quasi-RCTs involving the administration of probiotics to less than 33-week and VLBW infants. Outcome measures sought were, and the incidence of NEC, NEC ≥ 2 (stage 2 or above), NEC 3 (need for surgery) and mortality in NEC. Electronic searches were performed on MEDLINE and CINAHL using keyword and subject heading (MeSH), employing combinations of the terms infant, preterm; infant, VLBW; enterocolitis, necrotising; probiotic. Hand searches from the ESPR/SPR from the past 10 years were performed. In addition, citation searches were performed for all potential studies. The QUORUM checklist (Lancet 1999; 354: 1896) for methodology and reporting was observed. Results: Six potential RCTs, but no systematic or Cochrane reviews, were identified for inclusion. One study was discounted owing to its use of historical controls. Five studies were selected for analysis. Cumulatively, 640 infants were treated with probiotics and 627 were used as controls. All studies showed a trend toward less NEC in the treatment group. The heterogeneity of probiotic formulations and the timing and methods of intervention in the identified studies made the synthesis and comparison of data inappropriate. Study
Treatment/ Control
NEC
NEC ≥ 2
NEC 3
NEC mor tality
Dani et al. Costalos et al. Lin et al. Bin Nun et al. Manzoni et al. Cumulative
298/290 51/36
4 vs 8 5 vs 6
4 vs 8 –
– –
0 vs 2 – – –
180/187 72/73
2 vs 10 3 vs 12
2 vs 10 0 vs 6 1 vs 10 0 vs 3
– 7 vs 20 0 vs 3 3 vs 8
39/41
1 vs 2
1 vs 2
–
640/627
15 vs 45 8 vs 30 0 vs 10 0 vs 5 15 vs 34
0 vs 1
S Guthrie, D Maclean, I Dale, J Jack, P Booth, L Jackson Neonatal Transport Service (West) Introduction: Interhospital patient transfers are undertaken internationally by dedicated teams of specifically trained personnel performing many transfers per shift. The West of Scotland Neonatal Transport Service undertakes 700 transfers per annum using ambulances, helicopters and aeroplanes. There has been concern that such transfers were significantly noisy, and recent European legislative changes have decreased the permitted sound level that staff may be exposed to. This study aimed to assess the sound level staff were exposed to during neonatal transport. Methods: Personal sound level meters (CR:110A) were worn by staff throughout their shift. Thirty staff days were measured to assess the daily difference in workload. Staff recorded times, direction, mode of transport, location in the ambulance, whether the baby was on board and siren usage. Data were analysed for the whole shift, including daily personal noise level ‘Lex,8h’ dB(A) and maximum sound pressure level ‘Peak’ dB(C), with individual journeys analysed including equivalent continuous sound pressure level ‘Leq’ dB(A) and Peak dB(C). These data were compared with legislative standards (The Control of Noise at Work Regulations UK 2005). Results: Thirty-one staff shifts were measured. One shift excluded for Peak and another for LEX due to collection error, leaving 29 shifts for LEX and Peak. A total of 112 journeys were performed (median three per day); 20% of shifts exceeded the LEX lower exposure action level, and 3% exceeded the LEX upper exposure action level. Mean LEX was 76.1 dB. A total of 73% of shifts exceeded Peak lower exposure action levels, 47% of shifts exceeded peak upper exposure action level, and 23% shifts exceeded Peak exposure limit value. The Leq values of individual journeys ranged from 70.6 to 86.3 dB (median 78.9 dB). Journeys in the back of the ambulance averaged 2.7 dB louder, and journeys with the baby on board averaged 2.5 dB louder. Journeys involving intermittent siren use averaged 3.2 dB louder. Conclusions: The majority of shifts exceed legal limits for Peak sound level, but LEX was only rarely exceeded. This prompted an ambulance review, hearing protection provision and an annual surveillance of hearing. Our transport network has been alerted to this risk, and we believe that these data evidence a risk for patient transport teams worldwide.
Overall mor tality
5 vs 6
Conclusions: The data appear to lend support to the use of oral probiotics for the prevention of NEC in VLBW and preterm infants. However, the data are insufficient to comment on the short- and long-term safety of such treatments. Types of probiotic used, timing and dosage are still to be optimised. Bacteria that have been genetically characterised, with known mechanisms of action, should be used. Further understanding of the pathogenesis of NEC and the mechanisms by which probiotics prevent it may lead to evidence-based treatment strategies. A
PAEDIATRICS AND CHILD HEALTH 17:10
Urine pads for routine metabolic and biochemistry tests in paediatrics P Crofton, P Henderson, N Squires, S Taheri Royal Hospital for Sick Children, Edinburgh 411
© 2007 Published by Elsevier Ltd.
PAEDIATRIC RESEARCH SOCIETY ABSTRACTS
Introduction: It is often difficult to collect urine from infants. The use of specifically designed urine collection pads gives reliable results for routine biochemistry tests of adult urine. Paediatric urine may have a different composition, and whether these pads give reliable results for metabolic investigations is unknown. Our aim was to evaluate whether the pads give reliable results for routine and metabolic biochemistry tests in paediatric urine. Methods: Urine collected by bag or clean-catch from infants under 2 years of age without metabolic disorders was divided into two aliquots, one of which was added to a collection pad, incubated for 15 minutes at 37 °C and then recovered by aspiration. Routine and metabolic analyses were performed on pad/ non-pad aliquots. Additionally, selected metabolic analyses were performed on pad/non-pad urine from patients with diagnosed inborn errors and urine spiked to simulate metabolic disorders. For quantitative analyses, pad/non-pad results were compared using Bland–Altman bias plots, Passing and Bablok regression and paired t-tests. Results: Routine tests (urea, electrolytes, creatinine, osmolality, calcium:creatinine, phosphate:creatinine, magnesium: creatinine, urate:creatinine; n = 32) showed close concordance with no clinically significant pad/non-pad differences. In infants without metabolic disorders, amino acids (n = 10), organic acids (n = 12) and mucopolysaccharides (n = 8), and in patients with metabolic disorders – phenylketonuria (n = 1), mucopolysaccharidoses II (n = 2) and III (n = 1), inborn errors of organic acid metabolism (n = 6) and cystinuria (n = 3) – all showed excellent pad/non-pad concordance. Sugar chromatography showed identical staining intensity in pad/non-pad samples. Conclusions: Urine collection pads give reliable results for a wide range of routine and metabolic tests in paediatric urine.
8.7–13.0 years). There were 33 patients with Crohn’s disease, 5 with ulcerative colitis and 10 with indeterminate colitis. All were referrals to our regional paediatric gastroenterology service between 2000 and 2006. IBD was diagnosed by standard criteria. Calprotectin was measured using a commercially available kit (PhiCal Test), and 47/48 patients had comparative blood results available at diagnosis. Statistics were performed using Minitab software v.13. Results: A total of 46/48 (95.8%) IBD patients had a positive faecal calprotectin (>50 μg/g) at diagnosis, with a median value of 750 μg/g (interquartile range 235.8–1251 μg/g). In comparison, 32/45 (71.1%) had an abnormal erythrocyte sedimentation rate (>20 mm per hour), 19/38 (50.0%) had an abnormal C-reactive protein level, 29/46 (63.0%) had abnormal platelets (>400 × 109/l), and 12/45 (26.7%) had abnormal albumin (35 g/l); 38/47 (80.9%) of patients had at least one abnormal result in the blood test panel. Using chi-square analysis, calprotectin was more likely to be abnormal in comparison to all of the individual blood tests (P ≤ 0.001 for all). We identified 9/47 (19.1%) patients with raised calprotectin at diagnosis who did not have abnormalities detected in the blood tests performed at diagnosis. All 48 patients (100%) had at least one abnormal blood test and/or raised calprotectin at diagnosis. Conclusions: A raised faecal calprotectin level is present in the majority of children with IBD at diagnosis in this study. It is significantly more likely to be raised than any of the commonly employed blood tests, and used in combination with these bloods tests an abnormality was demonstrated in one or both tests in all patients at diagnosis in this study. The measurement of faecal calprotectin is a significant advance when used contemporaneously and in addition to a routine panel of blood tests in the diagnosis of paediatric IBD.
Faecal calprotectin – a significant advance in the diagnosis of inflammatory bowel disease in childhood
Audit on the use of magnesium sulphate in asthma K Jones, S Jakka, A Monaco, D Das, O Rackham Department of Paediatrics, Arrowe Park Hospital
MA Quail1, RK Russell1, JE Van Limbergen2, P Rogers1, H Drummond2, DC Wilson3, PM Gillett1 1Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children 2Gastrointestinal Unit, Western General Hospital 3Child life and Health, University of Edinburgh
Introduction: Arrowe Park Hospital is a large district general hospital in the North West of England serving a population of 400 000. Our asthma protocol was introduced in June 2006 based on British guidelines and current evidence that intravenous (IV) magnesium sulphate is effective in children with moderate-tosevere asthma unresponsive to initial bronchodilator treatment. Our objectives were to assess the impact of introducing the routine use of IV magnesium sulphate and to audit our practice in the management of children presenting with wheeze over the age of 1 year. We monitored for any adverse events and assessed the need for admission to the high-dependency unit (HDU) for the administration of magnesium. Methods: One hundred consecutive children over the age of 1 year presenting with wheeze were included in the audit between September and November 2006. Children’s asthma was categorised as mild, moderate or severe according to our protocol. Intravenous magnesium was administered to children in the severe group and to those in the moderate group not responding to initial bronchodilator treatment. Data were collected by three investigators using a standard proforma.
Introduction: Scotland has one of the highest rates of paediatric inflammatory bowel disease (IBD) in the world. Despite advances in diagnosis, the median time to diagnosis remains longer than 6 months. A simple panel of blood tests (full blood count, erythrocyte sedimentation rate, C-reactive protein, liver function tests) will be abnormal in most but not all children with IBD. Faecal calprotectin is a neutrophil cytosolic protein whose concentration will rise in the stool in the presence of luminal inflammation, including in patients with IBD. We aimed to study faecal calprotectin at IBD diagnosis in 48 Scottish children with IBD and compare its diagnostic accuracy in comparison and combination with the IBD blood test panel. Methods: Stool samples from 48 Scottish children (29 males, 19 females) had calprotectin measured at diagnosis of their IBD. The median age at diagnosis was 11.2 years (interquartile range
PAEDIATRICS AND CHILD HEALTH 17:10
412
© 2007 Published by Elsevier Ltd.
Probiotics for necrotising enterocolitis (NEC): a systematic review
definitive multicentre RCT is required to resolve these outstanding issues. Future research into the benefits of such nutritional therapies in infants and children should consider the long-term and short-term effects on health and observe recommendations on the conduct of multicentre trials by the ESPGHAN Committee on Nutrition (JPGN 2001; 32: 255–8).
AR Barclay1, B Stenson2, JH Simpson3, LT Weaver1, DC Wilson4 1University of Glasgow 2University of Edinburgh 3Queen Mother’s Maternity Hospital, Glasgow and Neonatal Unit 4Royal Infirmary of Edinburgh
Staff noise exposure during neonatal transportation
Introduction: Probiotics have been shown to reduce NEC in experimental rat models and have been used in clinical trials. We aim to review existing data on oral probiotics for the prevention of NEC in very low-low birthweight (VLBW) infants. Methods: We used a systematic review of randomised controlled trials (RCT) and quasi-RCTs involving the administration of probiotics to less than 33-week and VLBW infants. Outcome measures sought were, and the incidence of NEC, NEC ≥ 2 (stage 2 or above), NEC 3 (need for surgery) and mortality in NEC. Electronic searches were performed on MEDLINE and CINAHL using keyword and subject heading (MeSH), employing combinations of the terms infant, preterm; infant, VLBW; enterocolitis, necrotising; probiotic. Hand searches from the ESPR/SPR from the past 10 years were performed. In addition, citation searches were performed for all potential studies. The QUORUM checklist (Lancet 1999; 354: 1896) for methodology and reporting was observed. Results: Six potential RCTs, but no systematic or Cochrane reviews, were identified for inclusion. One study was discounted owing to its use of historical controls. Five studies were selected for analysis. Cumulatively, 640 infants were treated with probiotics and 627 were used as controls. All studies showed a trend toward less NEC in the treatment group. The heterogeneity of probiotic formulations and the timing and methods of intervention in the identified studies made the synthesis and comparison of data inappropriate. Study
Treatment/ Control
NEC
NEC ≥ 2
NEC 3
NEC mor tality
Dani et al. Costalos et al. Lin et al. Bin Nun et al. Manzoni et al. Cumulative
298/290 51/36
4 vs 8 5 vs 6
4 vs 8 –
– –
0 vs 2 – – –
180/187 72/73
2 vs 10 3 vs 12
2 vs 10 0 vs 6 1 vs 10 0 vs 3
– 7 vs 20 0 vs 3 3 vs 8
39/41
1 vs 2
1 vs 2
–
640/627
15 vs 45 8 vs 30 0 vs 10 0 vs 5 15 vs 34
0 vs 1
S Guthrie, D Maclean, I Dale, J Jack, P Booth, L Jackson Neonatal Transport Service (West) Introduction: Interhospital patient transfers are undertaken internationally by dedicated teams of specifically trained personnel performing many transfers per shift. The West of Scotland Neonatal Transport Service undertakes 700 transfers per annum using ambulances, helicopters and aeroplanes. There has been concern that such transfers were significantly noisy, and recent European legislative changes have decreased the permitted sound level that staff may be exposed to. This study aimed to assess the sound level staff were exposed to during neonatal transport. Methods: Personal sound level meters (CR:110A) were worn by staff throughout their shift. Thirty staff days were measured to assess the daily difference in workload. Staff recorded times, direction, mode of transport, location in the ambulance, whether the baby was on board and siren usage. Data were analysed for the whole shift, including daily personal noise level ‘Lex,8h’ dB(A) and maximum sound pressure level ‘Peak’ dB(C), with individual journeys analysed including equivalent continuous sound pressure level ‘Leq’ dB(A) and Peak dB(C). These data were compared with legislative standards (The Control of Noise at Work Regulations UK 2005). Results: Thirty-one staff shifts were measured. One shift excluded for Peak and another for LEX due to collection error, leaving 29 shifts for LEX and Peak. A total of 112 journeys were performed (median three per day); 20% of shifts exceeded the LEX lower exposure action level, and 3% exceeded the LEX upper exposure action level. Mean LEX was 76.1 dB. A total of 73% of shifts exceeded Peak lower exposure action levels, 47% of shifts exceeded peak upper exposure action level, and 23% shifts exceeded Peak exposure limit value. The Leq values of individual journeys ranged from 70.6 to 86.3 dB (median 78.9 dB). Journeys in the back of the ambulance averaged 2.7 dB louder, and journeys with the baby on board averaged 2.5 dB louder. Journeys involving intermittent siren use averaged 3.2 dB louder. Conclusions: The majority of shifts exceed legal limits for Peak sound level, but LEX was only rarely exceeded. This prompted an ambulance review, hearing protection provision and an annual surveillance of hearing. Our transport network has been alerted to this risk, and we believe that these data evidence a risk for patient transport teams worldwide.
Overall mor tality
5 vs 6
Conclusions: The data appear to lend support to the use of oral probiotics for the prevention of NEC in VLBW and preterm infants. However, the data are insufficient to comment on the short- and long-term safety of such treatments. Types of probiotic used, timing and dosage are still to be optimised. Bacteria that have been genetically characterised, with known mechanisms of action, should be used. Further understanding of the pathogenesis of NEC and the mechanisms by which probiotics prevent it may lead to evidence-based treatment strategies. A
PAEDIATRICS AND CHILD HEALTH 17:10
Urine pads for routine metabolic and biochemistry tests in paediatrics P Crofton, P Henderson, N Squires, S Taheri Royal Hospital for Sick Children, Edinburgh 411
© 2007 Published by Elsevier Ltd.
PAEDIATRIC RESEARCH SOCIETY ABSTRACTS
Introduction: It is often difficult to collect urine from infants. The use of specifically designed urine collection pads gives reliable results for routine biochemistry tests of adult urine. Paediatric urine may have a different composition, and whether these pads give reliable results for metabolic investigations is unknown. Our aim was to evaluate whether the pads give reliable results for routine and metabolic biochemistry tests in paediatric urine. Methods: Urine collected by bag or clean-catch from infants under 2 years of age without metabolic disorders was divided into two aliquots, one of which was added to a collection pad, incubated for 15 minutes at 37 °C and then recovered by aspiration. Routine and metabolic analyses were performed on pad/ non-pad aliquots. Additionally, selected metabolic analyses were performed on pad/non-pad urine from patients with diagnosed inborn errors and urine spiked to simulate metabolic disorders. For quantitative analyses, pad/non-pad results were compared using Bland–Altman bias plots, Passing and Bablok regression and paired t-tests. Results: Routine tests (urea, electrolytes, creatinine, osmolality, calcium:creatinine, phosphate:creatinine, magnesium: creatinine, urate:creatinine; n = 32) showed close concordance with no clinically significant pad/non-pad differences. In infants without metabolic disorders, amino acids (n = 10), organic acids (n = 12) and mucopolysaccharides (n = 8), and in patients with metabolic disorders – phenylketonuria (n = 1), mucopolysaccharidoses II (n = 2) and III (n = 1), inborn errors of organic acid metabolism (n = 6) and cystinuria (n = 3) – all showed excellent pad/non-pad concordance. Sugar chromatography showed identical staining intensity in pad/non-pad samples. Conclusions: Urine collection pads give reliable results for a wide range of routine and metabolic tests in paediatric urine.
8.7–13.0 years). There were 33 patients with Crohn’s disease, 5 with ulcerative colitis and 10 with indeterminate colitis. All were referrals to our regional paediatric gastroenterology service between 2000 and 2006. IBD was diagnosed by standard criteria. Calprotectin was measured using a commercially available kit (PhiCal Test), and 47/48 patients had comparative blood results available at diagnosis. Statistics were performed using Minitab software v.13. Results: A total of 46/48 (95.8%) IBD patients had a positive faecal calprotectin (>50 μg/g) at diagnosis, with a median value of 750 μg/g (interquartile range 235.8–1251 μg/g). In comparison, 32/45 (71.1%) had an abnormal erythrocyte sedimentation rate (>20 mm per hour), 19/38 (50.0%) had an abnormal C-reactive protein level, 29/46 (63.0%) had abnormal platelets (>400 × 109/l), and 12/45 (26.7%) had abnormal albumin (35 g/l); 38/47 (80.9%) of patients had at least one abnormal result in the blood test panel. Using chi-square analysis, calprotectin was more likely to be abnormal in comparison to all of the individual blood tests (P ≤ 0.001 for all). We identified 9/47 (19.1%) patients with raised calprotectin at diagnosis who did not have abnormalities detected in the blood tests performed at diagnosis. All 48 patients (100%) had at least one abnormal blood test and/or raised calprotectin at diagnosis. Conclusions: A raised faecal calprotectin level is present in the majority of children with IBD at diagnosis in this study. It is significantly more likely to be raised than any of the commonly employed blood tests, and used in combination with these bloods tests an abnormality was demonstrated in one or both tests in all patients at diagnosis in this study. The measurement of faecal calprotectin is a significant advance when used contemporaneously and in addition to a routine panel of blood tests in the diagnosis of paediatric IBD.
Faecal calprotectin – a significant advance in the diagnosis of inflammatory bowel disease in childhood
Audit on the use of magnesium sulphate in asthma K Jones, S Jakka, A Monaco, D Das, O Rackham Department of Paediatrics, Arrowe Park Hospital
MA Quail1, RK Russell1, JE Van Limbergen2, P Rogers1, H Drummond2, DC Wilson3, PM Gillett1 1Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children 2Gastrointestinal Unit, Western General Hospital 3Child life and Health, University of Edinburgh
Introduction: Arrowe Park Hospital is a large district general hospital in the North West of England serving a population of 400 000. Our asthma protocol was introduced in June 2006 based on British guidelines and current evidence that intravenous (IV) magnesium sulphate is effective in children with moderate-tosevere asthma unresponsive to initial bronchodilator treatment. Our objectives were to assess the impact of introducing the routine use of IV magnesium sulphate and to audit our practice in the management of children presenting with wheeze over the age of 1 year. We monitored for any adverse events and assessed the need for admission to the high-dependency unit (HDU) for the administration of magnesium. Methods: One hundred consecutive children over the age of 1 year presenting with wheeze were included in the audit between September and November 2006. Children’s asthma was categorised as mild, moderate or severe according to our protocol. Intravenous magnesium was administered to children in the severe group and to those in the moderate group not responding to initial bronchodilator treatment. Data were collected by three investigators using a standard proforma.
Introduction: Scotland has one of the highest rates of paediatric inflammatory bowel disease (IBD) in the world. Despite advances in diagnosis, the median time to diagnosis remains longer than 6 months. A simple panel of blood tests (full blood count, erythrocyte sedimentation rate, C-reactive protein, liver function tests) will be abnormal in most but not all children with IBD. Faecal calprotectin is a neutrophil cytosolic protein whose concentration will rise in the stool in the presence of luminal inflammation, including in patients with IBD. We aimed to study faecal calprotectin at IBD diagnosis in 48 Scottish children with IBD and compare its diagnostic accuracy in comparison and combination with the IBD blood test panel. Methods: Stool samples from 48 Scottish children (29 males, 19 females) had calprotectin measured at diagnosis of their IBD. The median age at diagnosis was 11.2 years (interquartile range
PAEDIATRICS AND CHILD HEALTH 17:10
412
© 2007 Published by Elsevier Ltd.