BMJ Paediatrics Open

ObjectivesThe objective of this study was to look at whether there is a correlation between urease activity in babies faeces and observed incidence of nappy rash (diaper dermatitis) in a six-infant longitudinal observational study conducted at a university childcare facility over 9 months. MethodsSix babies who met the inclusion criteria and who attended Westwood Nursery, University of Bath were recruited to the study with consent provided by parents following favourable ethical committee opinion from the NHS Regional Ethics Committee. Soiled nappies donated up to twice weekly were analysed for the urease activity in faecal bacteria. At the same time, Nursery staff recorded the skin condition of the nappy area of participating infants. ResultsA clear statistical correlation between urease expression and observed nappy rash incidence and absence of faecal urease and healthy skin was observed using Chi squared analysis (P = <0.0001). ConclusionsUrease expressing bacteria were first implicated in the pathogenesis of nappy rash in the early 20th century. This is the first study to show a population level correlation between nappy rash and faecal enzyme activity, which can be understood in terms of a causal chain: urease catalyses ammonia production, which directly damages skin barrier function and creates a pH environment in which secondary opportunistic micro-organisms can grow at an enhanced rate and increase skin damaging enzyme activity, therefore leading to more severe nappy rash. Key messagesO_ST_ABSWhat is already knownC_ST_ABSthe involvement of urease /ammonia expressing bacteria in the pathogenesis of nappy rash has been suggested for over 100 years. What this study addsThis study shows a clear temporal correlation between faecal urease expression and nappy rash incidence (and vice versa) in a group of six infants followed over 8 months suggesting the key importance of urease in nappy rash pathogenesis in a relevant study population and adds to a previous causal mechanism, where urease converts urea to ammonia, which has been shown to both directly damage skin barrier function and raise skin pH. How this study might affect research, practice or policyThis study raises the possibility that nappy rash can be treated more effectively by direct inhibition of urease. Several urease inhibiting strategies are currently being studied, including watercress extract and probiotic bacteria.

ImportanceChildren of marginalized racial groups have poorer surgical outcomes compared to White children. Clinical communication may contribute to these disparities. ObjectiveWe explore racial differences in parent-clinician communication during initial consultations for elective surgical procedures in children. DesignCross-sectional study of communication during consultations between surgical clinicians and parents of children (age 2-17) referred for initial evaluation for tonsillectomy/adenoidectomy, hernia repair, and circumcision between 2016 and 2023. SettingAcademically affiliated outpatient clinics in the Baltimore, Maryland region. ParticipantsParent-clinician dyads including 22 surgical clinicians and 153 parents. Main Outcome(s) and Measure(s)Visits were audio-recorded and coded using the Roter Interaction Analysis System. Outcomes included visit-level measures (parent versus clinician verbal dominance and patient-centeredness ratio), clinician communication (facilitation/activation statements to encourage parent participation, emotional statements, social chit-chat, and positive affect), and parent communication (emotional statements, social chit-chat, positive affect). We used generalized estimating equations to test associations of parent race with visit communication, accounting for nesting of visits within clinicians and adjusting for parent sociodemographic variables. ResultsOf the 153 parents, 63 (41.2%) were Black and 90 (58.8%) were White. Of the 22 clinicians, 14 (63.6%) were White and 8 (36.4%) reported other or multiple ethnicities. In unadjusted models, visits with Black parents had higher clinician verbal dominance but no difference in overall patient-centeredness scores relative to visits with White parents. However, visits with Black parents had fewer clinician chit-chat statements, fewer total parent statements, fewer parent emotional statements, fewer parent chit-chat statements, and lower parent positive affect. After adjusting for parent sociodemographic variables, clinician verbal dominance remained significantly higher, with clinicians making 0.4 more statements per parent statement (95% CI: 0.1 to 0.7). Conclusions and RelevanceIn this cohort study of communication during pediatric surgical consultations, parent race was associated with differences in clinician, parent, and interactive visit communication, although some differences appeared to be mediated by sociodemographic factors and most were due to differences in parent rather than clinician communication. Application of patient-centered communication and engagement strategies may help to bridge social distance in pediatric surgical care. Key PointsO_ST_ABSQuestionC_ST_ABSHow does parent-clinician communication differ by parent race during initial pediatric surgery consultations? FindingsIn this cohort study, consultations with Black parents had higher clinician verbal dominance, less parent emotional expression, and less social chit-chat (both parent and clinician) relative to visits with White parents. MeaningOur findings reveal opportunities to mitigate racial differences in communication and bridge social distance in pediatric surgical care, including through improved clinician elicitation of patient and family concerns and intentional attempts to build rapport.

UK Lockdown measures introduced in March 2020 aimed to mitigate the spread of Covid-19. Although seeking healthcare was still permitted within restrictions, paediatric emergency department attendances reduced dramatically and led to concern over risks caused by delayed presentation. Our aim was to gain insight into healthcare decisions faced by parents during the first wave of the Covid-19 pandemic and to understand if use of urgent healthcare, self-care, and information needs differed during lockdown as well as how parents perceived risks of Covid-19. We undertook qualitative telephone interviews with a purposive sample of parents living in the North East of England recruited through online advertising. We used a semi-structured topic guide to explore past and current healthcare use, perceptions of risk and the impact of the pandemic on healthcare decisions. Interviews were transcribed and analysed using Thematic Analysis. Three major themes were identified which concerned (i) how parents made sense of risks posed to, and by their children, (ii) understanding information regarding health services and (iii) attempting to make the right decision. These themes contribute to the understanding of the initial impact of Covid-19 and associated restrictions on parental decisions about urgent healthcare for children. These findings are important to consider when planning for potential future public health emergencies but also in the wider context of encouraging appropriate use of urgent healthcare.

Care-experienced children - also referred to as children in out-of-home care, children in foster care, or looked after children - face additional barriers to good physical health compared to those without care experience. Despite good health in early years being vital to long-term quality of life, there is little research on physical health outcomes in young care-experienced children. This scoping review aimed to collate and review peer-reviewed published literature to identify gaps and inform future research and policy. Standard rigorous scoping review methods were applied. Studies were included if they reported on physical health outcomes affecting children under seven years in high-income countries with care experience. MEDLINE, CINAHL, and Web of Science Core Collection databases were searched. Searches yielded 17,363 results, and 36 articles were included. Studies took place in kinship, foster, residential, and adoptive care settings. Synthesis of results identified poor physical development in terms of height and weight, poor dental health, dermatological conditions, anaemia, and low immunisation rates as substantial health problems among young care-experienced children. However, strong conclusions about the causes and relative prevalence of most conditions could not be drawn. This was often due to a lack of comparator groups, failure to adjust for socioeconomic variables, insufficient reporting about care context, and heterogeneity in study methods. Future work would benefit from relevant comparator groups, clear reporting of participant socioeconomic characteristics and care settings, and limiting focus to specific developmental stages.

Objective.To explore parents experiences following receipt of positive newborn screening for sickle cell disease (SCD) test results at a teaching hospital in Ghana. Methods.Using purposive sampling, data were collected using semi-structured individual guides to interview parents of newborns attending the paediatric SCD clinic at Korle Bu Teaching Hospital (KBTH), the major referral health facility in Ghana. Questions were categorized into 3 main areas: parents reactions to initial positive results, parents responses to in-clinic counselling, and parents attitudes towards follow-up clinic care. Interviews were conducted face to face either in English or a local dialect (Twi) after which they were transcribed verbatim. Data were analyzed using NVivo software to identify relevant codes which were organized into themes and sub-themes. Results.Twenty-four mothers and one father were interviewed between 2nd November 2021 and 28th January 2022. The ages of their children ranged from 7 months to 3 years 9 months. Seventeen (68%) of the parents were married, 5 (20%) had more than one child enrolled in the clinic, and 10 (40%) reported that they or their partners had SCD. The 5 themes identified were: (i) emotional response after disclosure, (ii) decision to share results, (iii) care and management of newborns at home, (iv) knowledge of genetics of SCD, and (v) adherence to routine follow-up. Positive test results elicited worry, surprise, or shock in the majority, especially those with no previous knowledge of or experience with SCD. Most parents had received counselling and educational information on caring for their positive newborns at home and the danger signs of SCD. The decision to share test results with others was influenced by fear of stigmatization. While desiring to see their babies remain healthy, parents defaulted on clinic visits due to financial difficulties and the COVID-19 pandemic. Conclusion.Knowledge of SCD and personal experience influenced parents reaction to initial positive newborn screening for SCD test results. There is a need for more education about SCD among the general population and institutions of strategies to provide psychological and socioeconomic support for families attending the KBTH clinic.

BackgroundPublic health restrictions are an essential strategy to prevent the spread of COVID-19; however, unintended consequences of these interventions may have led to significant delays, deferrals and disruptions in medical care. This study explores clinical cases where the care of children was perceived to have been negatively impacted as a result of public health measures and changes in healthcare delivery and access due to the COVID-19 pandemic. MethodsThis study used a qualitative multiple case study design with descriptive thematic analysis of clinician-reported consequences of the COVID-19 pandemic on care provided at a childrens hospital. A quantitative analysis of overall hospital activity data during the study period was performed. ResultsThe COVID-19 pandemic has resulted in significant change to hospital activity at our tertiary care hospital, including an initial reduction in Emergency Department attendance by 38% and an increase in ambulatory virtual care from 4% before COVID-19, to 67% in August, 2020. Two hundred and twelve clinicians reported a total of 116 unique cases. Themes including (1) timeliness of care, (2) disruption of patient-centered care, (3) new pressures in the provision of safe and efficient care and (4) inequity in the experience of the COVID-19 pandemic emerged, each impacting patients, their families and healthcare providers. ConclusionBeing aware of the breadth of the impact of the COVID-19 pandemic across all of the identified themes is important to enable the delivery of timely, safe, high-quality, family-centred pediatric care moving forward. Whats newCOVID-19 disrupted typical paediatric care delivery. This study demonstrates the breadth of its impact on the delivery of timely, safe, equitable and patient and family centered care, highlighting considerations for paediatric providers as we move forward.

BACKGROUNDAnorectal Malformations (ARM) are congenital defects where the anus and rectum do not form correctly, presenting a range of complexities that often necessitate intricate surgical interventionist global incidence of ARM is approximately 1 in 2000 to 5000 live births. In developing countries like Tanzania, managing ARMs poses significant challenges due to late presentations, shortage of trained pediatric surgeons and inadequate diagnostic facilities. This study aimed to evaluate the prevalence and treatment outcomes of ARM at Mnazi Mmoja Hospital (MMH) over five years 2018 to 2022 OBJECTIVESincluding analyzing patient demographics (age and sex), the prevalence of ARMs, common types, surgical procedure used and associated complications. A retrospective, descriptive cross-sectional study was conducted using data from structed questionnaire, which were analyzed with SPSS software. RESULTSrevealed that the sex distribution of patients was nearly equal, with ARM cases increasing from 8 (9.9%) in 2018 to 33(40.7%) in 2022. The majority of cases were in Urban Wes (49.9%), and most patients (90.1%) had major ARMs. Surgical treatments included three-stage procedures (65.4%) and one-stage procedures (13.6%), with a postoperative complication rate of 17.2%. survival was high, with 90.1% survival rate and low mortality rate of 9.9% CONCLUSIONARM remains a prevalent and challenging surgical issue in Zanzibar, constituting 35% 0f pediatric gastrointestinal surgeries. Implementing modern single-stage surgical approaches could potentially improve patient outcomes and reduces complications

BackgroundThere is limited available published information regarding surgical diagnoses and post-operative outcomes of intestinal obstruction among adult patients in East African hospitals. The observation is despite available anecdotal evidence of the condition to be among the commonest surgical emergencies in the area. ObjectiveTo assess the surgical diagnoses and outcomes of intestinal obstruction among adult patients treated at the regional referral hospitals in Dar-es-salaam - Tanzania. Methods & FindingsThis was a prospective, observational, hospital-based study. Data were collected using a pre-validated Clinical Research Form (CRF). All adult patients with post-operative surgical diagnoses of intestinal obstruction at Amana, Mwananyamala and Temeke hospitals in Dar es Salaam were the target population. Data were analyzed using a generalized linear model via SAS version 9.7. Multivariable logistic regression model was the final fitted model. Intra-operative findings (surgical diagnoses) of intestinal obstruction was an outcome variable. Unless otherwise stated, an -level of 5% was used as a limit of type 1 error in findings. The study analysed an average of 1411 patients-days of follow-up. Participants median age and duration of hospital stay were 47 (IQR: 35-67) years and 4 (IQR: 3-6) days respectively. Intra-operative findings included adhesions (aOR=5.66), abdominal tumors (aOR=1.028), hernia (aOR=2.04) and volvulus (aOR=4.2). Moreover, 12 (5.26%) clients died and 20 (9%) had surgical sites infection. No statistically significant difference of hospital on surgical outcomes ({chi}2 test value = 4.992; df = 10). ConclusionAdhesions was the commonest intraoperative cause of intestinal obstruction in this study population. One-in-twenty of all followed-up clients died. Significant proportion of patients had evidence of post-operative complications.

BackgroundCOVID-19 has changed the practice of surgery vividly all over the world. Pediatric surgery is not an exception. Prioritization protocols allowing us to provide emergency surgical care to the children in need while controlling the pandemic spread. The aim of this study is to share our experiences with the outcome of children with COVID-19 who had a co-existing surgical emergency. MethodsThis is a retrospective observational study. We reviewed the epidemiological, clinical, and laboratory data of all patients admitted in our surgery department through the emergency department and later diagnosed to have COVID-19 by RT-PCR. The study duration was 3 months (April 2020 - June 2020). A nasopharyngeal swab was taken from all patients irrespective of symptoms to detect SARS CoV 2 by RT-PCR with the purpose of detecting asymptomatic patients and patients with atypical symptoms. Emergency surgical services were provided immediately without delay and patients with positive test results were isolated according to the hospital protocol. We divided the test positive patients into 4 age groups for the convenience of data analysis. Data were retrieved from hospital records and analyzed using SPSS (version 25) software. Ethical permission was taken from the hospital ethical review board. ResultsTotal patients were 32. Seven (21.9%) of them were neonates. Twenty-four (75%) patients were male. The predominant diagnosis was acute abdomen followed by infantile hypertrophic pyloric stenosis (IHPS), myelomeningocele, and intussusception. Only two patients had mild respiratory symptoms (dry cough). Fever was present in 13 (40.6%) patients. Fourteen (43.8%) patients required surgical treatment. The mean duration of hospital stay was 5.5 days. One neonate with ARM died in the post-operative ward due to cardiac arrest. No patient had hypoxemia or organ failure. Seven health care workers (5.51%) including doctors & nurses got infected with SARS Co V2 during this period. ConclusionOur study has revealed a milder course of COVID-19 in children with minimal infectivity even when present in association with emergency surgical conditions. This might encourage a gradual restart to mitigate the impact of COVID-19 on childrens surgery.

BackgroundThe burden of surgical diseases in children and perioperative complications in sub-Saharan Africa remains high. The assessment of the pattern and the determinants of perioperative mortality plays an invaluable role in identifying indicators of poor outcomes in order to improve overall outcomes in childrens surgery, thus necessitating this study. MethodsA retrospective review of medical records of patients aged 15 years and below, who had general pediatric, oncological, and urological surgeries under general anesthesia between January 2014 and December 2023, with complete records up to at least post-surgery or died within 30 days of surgery, was carried out. Information extracted included biodata, diagnosis, ASA classification of physical status, time of death after surgery, cause of death, and duration of surgery. Data were collated and analyzed using univariate and multivariate statistical tools. ResultsA total of 1621 patients were analyzed. The 30-day perioperative mortality rate in this study was 2.96% (296 per 10,000 patients); jejuno-ileal atresia, gastrochisis and bladder exstrophy are the conditions associated with the highest mortality rates, well above 50%. Furthermore, logistic regression model identified neonatal age group, ASA class greater than II and repeated surgical procedures as the significant predictors of mortality, while sepsis and intestinal/anastomosis failure were identified as the most common direct cause of death. ConclusionNeonatal age group, ASA class greater than II, and repeated surgery are the significant predictors of mortality in childrens surgery in our practice. Efforts should be made to combat sepsis and provide physiologic support and intensive care to improve outcomes. Key messagesWhat is already known about this subject: O_LIPerioperative mortality rate in pediatric surgery in sub-Saharan Africa remains high. C_LIO_LIOnly a few studies in the region have attempted to identify predictors of POM in children. C_LI What this study addsO_LIThis study revealed the real burden of POM in our practice and identified the determinants of poor outcomes C_LIO_LINeonatal age group, high ASA classification and repeated surgeries are significant predictors of mortality in this study C_LIO_LIJejuno-ileal atresia and gastrochisis are associated with a high case fatality rate. C_LI How this study might affect research, practice or policyO_LIFindings from this study provide potential tools to improve outcomes in pediatric surgery in the region. C_LI

BackgroundSurgical conditions are responsible for up to 15% of total DALY lost globally. Worldwide estimates have found that approximately 4.8 billion people have no access to surgical care. Within South Asia, greater than 95% of the population does not have access to care for conditions that require surgical management. Considering that greater than 50% of the population in the least developed regions worldwide is children, the surgical burden amongst children in LMICs is immense. In this study we use the SOSAS and PediPIPES in TMK district to assess the surgical needs of children under-5, quality of health facilities, and care seeking behavior in the community. Material and MethodsThe research was reviewed and approved by the Aga Khan University (AKU) Ethical Review Committee (ERC) and the National Bioethics Committee (NBC). Confidentiality of all collected data was assigned high priority at each stage of data handling. Data was collected through the SOSAS and PediPIPES survey tools between November 2019 and February 2020 from a total of 3,643 households in the TMK, Sindh, Pakistan. The SOSAS survey was conducted by research associates trained for data collection. Household mothers provided information about their children and data was recorded electronically. Health facilities were assessed using PediPIPES survey form. Information was collected on hard copies from all 39 health care facilities in the district, including RHCs, BHUs, DCDs, and DHQ. Data was collected by core team and entered onto an excel sheet. ResultsA total of 3,643 households participated and information of 6,371 children was collected. A total of 1,794 children were identified to have 3,072 lesions that required surgical attention. We categorized the lesions requiring surgical care according to six regions of the body. Head and neck accounted for the greatest number of lesions (n = 1,697) and the most significant unmet surgical need (16.6%). The chest region had 102 lesions and the least unmet surgical need of 5.9%. The back accounted for 87 lesions with an unmet surgical need of 6.9%. The abdomen had 493 lesions and an unmet surgical need of 13.4%. A total of 169 lesions were found on buttocks/groin/genitalia region with an unmet surgical need of 14.8%, while extremities presented with 296 lesions amounting to 11.8% unmet surgical need. A total of 39 health facilities, consisting of one DHQ, three RHCs, 14 BHUs and 21 DCDs, were surveyed. Trained staff were only present at the DHQ. Basic procedures such as suturing, wound debridement, I&D were performed more commonly than the more complex procedures. Most hospitals were found to have a good availability of equipment and supplies. PediPIPES scores and indices were calculated for the 39 health facilities in the area. The DHQ was found to have the highest score. ConclusionsThis study holds great significance for evaluation of pediatric surgical burden in Pakistan. It provides important insight into the burden of childrens operative disease in Pakistans rural district of TMK. The results show a significant need for provision of surgical care and has important implications for the global operative community as well as for strengthening the local health system in Pakistan. This data is useful preliminary evidence that emphasizes the need to further evaluate interventions for strengthening surgical systems in rural Pakistan.

ObjectiveAs paediatric and adolescent gynaecology (PAG) falls within the remit of paediatrics and gynaecology, training in both specialties is underdeveloped. There is a paucity of research investigating trainee knowledge of PAG, while postgraduate paediatric training demonstrates little focus in the field. Compounding this, a finite number of PAG specialists means clinical training is limited. We hypothesize that knowledge deficits exist among paediatric and GP trainees and that this has future implications for increased morbidity in girls. Design, Setting and ParticipantsA structured questionnaire assessing PAG was distributed to forty paediatric and GP trainees in October 2019 in a tertiary paediatric hospital. Results60% (24) incorrectly identified vulvovaginitis as candidal infection. 80% (32) were unable to identify labial adhesions. 62% (25) were unable to define menorrhagia. 100% (9) of GP trainees said they would prescribe the OCP compared with 51% (16) of paediatric trainees. 52% (21) did not consider STI screening when appropriate. 75% (30) believed genital warts invariably warrant referral to child sexual assault clinic. 70% (28) could not identify female genital mutilation. 60% (24) did not consider imperforate hymen as a cause of primary amenorrhoea. 67% (27) misdiagnosed lichen sclerosis. ConclusionsA knowledge deficit among trainees was evident in relation to PAG conditions. Misdiagnosis and delayed treatment could lead to considerable increased morbidity for girls and we postulate that a key intervention which may prove effective in improving trainee competency in PAG lies in the introduction of a structured training curriculum for all clinicians involved in PAG practice.

BackgroundMore than 100,000 cleft lip and palate patients have benefited from reconstructive surgeries in Africa because of surgical support from non-governmental organizations such as Smile Train. The Smile Train Express is the largest cleft-centered patient registry with over a million records of clinical records, globally. In this study, we reviewed data from the east African patient registry to analyze and understand the clinical profiles of cleft lip and palate patients operated at Smile Train partner hospitals in East Africa. MethodA retrospective database review was conducted in all East African cleft lip and palate surgeries documented in the Smile Train database from November 2001 to November 2019. Results86,683 patient records from 14 East African countries were included in this study. The mean age was 9.1 years, the mean weight was 20.2kg and 19kg for males and females, respectively, and 61.8% of the surgeries were performed on male patients. Left cleft lip only (n=22,548, 28.4 %) and right cleft lip only (n=17862, 22.5%) were the most common types of clefts, with bilateral cleft lip only (n= 5712, 7.2%) being the least frequent. Complete right cleft lip with complete right alveolus was the most frequent cleft combination observed (n = 16,385) and Cleft lip to cleft lip and palate to cleft palate ratio (CL:CLP: CP) was 6.7:3.3:1. Unilateral primary lip-nose repairs were the most common surgeries (69%). General anesthesia was used for 74.6 % (52847) of the procedures. ConclusionMost children with cleft lip and/or palate were underweight, possibly due to malnutrition or related to socioeconomic status. There were more male patients compared to females, which could be related to gender disparities. Access to surgical care for children born with congenital defects needs to be improved, and inequities need to be addressed via more evidence-based collaborative intervention strategies. Highlights- More than 80,000 patient records from fourteen East African countries were analyzed in this study to describe orofacial clefts. - Orofacial clefts were found most commonly in males, accounting for over 62% of all cases. - To improve cleft care in East Africa, there is a greater need for evidence-based implementation of programs, research collaboration, and data-centric advocacy efforts.

Studies of quality of life (QoL) routinely exclude children with complex needs. These children struggle to access leisure activities, particularly those with severe communication needs or challenging behaviour. Sparkle provides specialised leisure services to children and young people (0-17 years) with complex needs in South Wales, UK. We aimed to evaluate previously validated tools to measure QoL with this population. Three tools were assessed over a 6-year period - PedsQL, KINDLR and QI-Disability. PedsQL (41) and KINDLR (10) were attempted by the children attending the clubs (5-17 years old), and QI-Disability by caregivers (96). The majority of child participants had a neurodevelopmental diagnosis, a proportion of whom were non-verbal. Neither KINDLR nor PedsQL were appropriate for the population, with children unable to understand the questions and answers. The QI-Disability scores showed a statistically significant improvement in parents estimate of their childs positive emotions, but results were severely limited by drop off. Existing validated QoL tools cannot be meaningfully used by children with complex needs. While the caregiver tool showed some benefit of specialist leisure provision, it is recognised that caregivers may perceive a childs QoL differently to the child themselves, and caregivers clearly found repeat measurements onerous.

ObjectiveDespite the emergence of telemedicine as an important model for healthcare delivery, there is a lack of evidence-based telemedicine guidelines, especially for resource-limited settings. We sought to develop and evaluate a guideline for a pediatric telemedicine and medication delivery service (TMDS). MethodsA prospective cohort study was conducted at a TMDS in Haiti; children [&le;]10 years were enrolled. Among non-severe cases, paired virtual and in-person exams were conducted at the call center and household; severe cases were referred to the hospital. The primary outcome was the performance of the virtual exam compared to the in-person exam (reference standard). FindingsA total of 391 cases were enrolled. Among 320 cases with paired exams, no general World Health Organization (WHO) danger signs were identified at the household; problem-specific danger signs were identified in 6 cases (2%). Cohens kappa for the designation of mild cases was 0.78 (95%CI 0.69-0.87). Among components of the virtual exam, the sensitivity and specificity of a reported fever were 91% (87%-96%) and 69% (62%-74%), respectively; the sensitivity and specificity of fast breathing were 47% (21%-72%) and 89% (85%-94%), respectively. Kappa for dehydration assessments indicated moderate congruence (0.69; 95%CI 0.41-0.98). At 10 days, 95% (273) of the 287 cases reached were better/recovered. ConclusionThis study, and resulting guideline, represents a formative step towards an evidence-based pediatric telemedicine guideline built on WHO clinical principles. In-person exams for select cases were important to address limitations with virtual exams and identify cases for escalation.

BackgroundChildren and Young People (CYP) with acute illness require routine assessment of their physiological observations. There is no agreement as to what the standard reference ranges of vital signs in children and young people are. Existing reference ranges of vital signs that are currently used in clinical practice are minimally supported by empirical evidence. They are also sometimes conflicting. MethodsWe conducted a cross-sectional study using 66356 admission episodes to analyze routinely collected age-specific respiratory rate, heart rate, and blood pressure observations of CYP aged 0-19 years old at hospital discharge. Quantile regression with Restricted Cubic Splines was used to model age-specific centiles. These were then compared with standard reference ranges and literature. ResultsNew centile charts for vital signs are presented. Advanced Paediatric Life Support (APLS, 6th Ed.) reference ranges for respiratory rate and blood pressure poorly aligned to the centiles derived in this study although the centiles for heart rate align well. Variance was also demonstrated between the study centiles and those from the clinical papers, with the greatest differences seen in the upper centiles. Similarly, in comparison with APLS reference ranges, heart rate showed best alignment. ConclusionsThis is the first-time physiological observations of CYP in a UK Childrens hospital have been described and centile charts developed. Current widely used reference ranges especially those for Heart Rate and Respiratory Rate are not fit for purpose when evaluating whether the vital signs of a child are normal or otherwise.

IntroductionThis study explores UK Paediatric Intensive Care (PIC) trainees thoughts and feelings about high-profile end-of-life cases recently featured in the press and social media and the impact on their career intentions. MethodsSemi-structured interviews were conducted with nine PIC-GRID trainees (Apr-Aug 2021). Interview transcripts were analysed using thematic analysis. ResultsSix main themes were identified: (i) All participants wished to do what was best for the child, feeling conflicted if this meant disagreeing with parents. (ii) Interviewees felt unprepared and expressed deep concern about the effect of high-profile cases on their future career. (iii) They highlighted too often being shielded from involvement in challenging discussions. (iv) Working in a supportive environment is crucial, underscoring the importance of clear and unified team communication, but specific training on the ethical and legal nuances of such cases is required. (vi) All had purposefully minimised their social media presence. (vi) All had reconsidered training in PIC due to concerns about future high-profile end-of-life disputes; despite describing this as a cause of concern and anxiety, all were still in training. ConclusionUK PIC trainees feel unprepared and anxious about future high-profile cases. A parallel can be drawn to child protection improvements following significant educational investment after Government reports into preventable child abuse deaths. Models for supporting trainees and establishing formal PIC training are required to improve trainees confidence and skills in managing high-profile cases. Further research with other professional groups, the families involved, and other stakeholders would provide a more rounded picture. O_LIWhat is already known on this topic - PIC trainees report high levels of distress associated to childrens death and disagreements with the families. C_LIO_LIWhat this study adds - PIC doctors are extremely concerned about future high-profile end-of-life disputes, the effect on themselves and their career. They feel unprepared to manage them and require more training, experience and recognition of this. C_LIO_LIHow this study might affect research, practice or policy - PIC trainee curriculum and training scheme should prepare doctors to deal with high-profile end-of-life cases to ensure children and families receive appropriate care and avoid PIC-induced moral injury and workforce burdens. C_LI

BackgroundPhysical symptoms without an identified organic cause are frequently observed in adolescents. These symptoms are often linked to psychiatric comorbidities, posing diagnostic and management challenges for healthcare professionals. ObjectiveTo assess the proportion of pediatric emergency room visits for physical symptoms without organic etiology among adolescents with Patient Health Questionnaire-13 (PHQ-13) somatic symptoms. To assess the proportion of patients with somatic symptoms who received a psychosocial history, and describe the socio-demographic and clinical characteristics of these adolescents. MethodsQuantitative cross-sectional descriptive study of adolescents consulting the pediatric emergency department in Martinique from February 1, 2023 to April 30, 2024. Inclusion criteria were patients aged 11 to 17 years consulting with a somatic symptom of the PHQ-13 questionnaire. Medical management in the emergency department was considered satisfactory if a psychosocial history based on the HEADSSS questionnaire was taken. Results2398 emergency room visits were included. Analysis revealed that 42.2% of pediatric emergency consultations were related to symptoms without etiology. The majority of these consultations concerned girls (69.1 %, p[&le;] 0. 05). The HEADSSS questionnaire was used in only 6.4 % of cases (p[&le;] 0. 05). In our study, the most frequent physical symptoms without organic etiology were abdominal pain (35.7 %), chest pain (24.7 %) and malaise (24.7 %). ConclusionThis study shows that consultations related to physical symptoms without an identified organic cause found in adolescents are frequent in pediatric emergency departments in Martinique. Their management appears to be sub-optimal, and prospects for improvement should be considered, such as setting up a management protocol, training doctors in this area and carrying out further prospective and interventional studies.

ObjectiveTo investigate strategies used by cleft surgeons to manage post-palatoplasty haemorrhage. DesignOnline cross-sectional survey SettingGreat Britain and Ireland Participants23 of 36 Cleft Surgeons (64% response rate) Results16% of respondents indicated having a protocol for managing post-operative bleeds. There was an emphasis on the importance of preventative strategies to reduce the risk of post-operative bleeds occurring. Amongst the variety of non-surgical management options, systemic tranexamic acid and direct pressure were considered the most important. The tendency to prescribe antibiotics for secondary bleeds indicates a perceived difference in the nature or risk associated with these compared to primary bleeds. There was agreement that once identified, the management of post-operative bleeds should be proactive with a low threshold to return to theatre in the presence of an active intra-oral bleed. ConclusionsWe suggest a template with considerations that can be adapted into a local haemorrhage protocol for individual cleft units.

BackgroundVulnerable children from poor communities with high HIV and Tuberculosis(TB) burdens were impacted by COVID-19 lockdowns. Concern was raised about the extent of this impact and anticipated post-pandemic surges in mortality. MethodsInterrupted time series segmented regression analyses were done using routinely collected facility-level data of children admitted for medical conditions at four South African referral hospitals. Monthly admission and mortality data over a 60-month period from 01 April 2018 to 31 January 2023 was analysed using models which included dummy lockdown level variables, a dummy post-COVID period variable, Fourier terms to account for seasonality, and excess mortality as a proxy for healthcare burden. ResultsOf the 45 015 admissions analysed, 1237(2{middle dot}75%) demised with significant decreases in admissions during all the lockdown levels, with the most significant mean monthly decrease of 450(95%, CI=657{middle dot}3, -244{middle dot}3) p<0{middle dot}001 in level 5 (the most severe) lockdown. There was evidence of loss of seasonality on a six-month scale during the COVID periods for all admissions (p=0{middle dot}002), including under-one-year-olds (p=0{middle dot}034) and under-five-year-olds (p=0{middle dot}004). No decreases in mortality accompanied decreased admissions. Post-pandemic surges in admissions or mortality were not identified in children with acute gastroenteritis, acute pneumonia and severe acute malnutrition. ConclusionDuring the COVID-19 pandemic, paediatric admissions in 4 hospitals serving communities with high levels of HIV, TB and poverty decreased similar to global experiences however there was no change in in-hospital mortality. No post-pandemic surge in admissions or mortality were documented. Differences in the impact of pandemic control measures on transmission of childhood infections and access to health care may account for differing outcomes seen in our setting compared to the global experiences. Further studies are needed to understand the impact of pandemic control measures on healthcare provision and transmission dynamics and to better inform future responses amongst vulnerable child populations.