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What are the indications for probiotics in children
The health benefits of probiotics have been the subject of extensive research although it is not always clear to the practicing clinician if, when, which and for how long they should be used. Hania Szejewska reviews the evidence providing guidance for the clinician. Probiotics are ‘live micro-organisms' that when prescribed in adequate amounts confer a health benefit to the host. Probiotics can be administered as a dietary supplement, food product or a drug. It is important to remember that not all probiotics are equal and for specific indications to consider the evidence for specific probiotics strains. The review works through different potential indications. The best documented efficacy is for acute gastroenteritis, prevention of antibiotic associated diarrhoea, prevention of nosocomial diarrhoea and the prevention of necrotising enterocolitis. There is some evidence for the treatment of infantile colic, treatment of helicobacter pylori, prevention of atopic eczema and treatment of ulcerative colitis. There is less evidence for efficacy for the treatment of abdominal pain and other functional gastrointestinal disorders, constipation and Crohn's disease. Dose, quality and safety are discussed. The review starts with Probiotics: myth or miracle? Are probiotics really that good for your health? Probiotics: panacea or just a big ‘fad’? The author uses published evidence to help answer this important question. (See page 394)
Systematic review of the toxicity of short-course oral corticosteroids in children
Short courses of oral corticosteroids are widely used in children to treat conditions such as asthma. The long term adverse effects are well known. Aljiebab and colleagues review the toxicity of steroids used short term (less than 14 days)—38 studies, 22 randomised controlled trials, 3200 children, 850 adverse drug reactions (ADRs) were reported. The most common ADRs were vomiting (5.4%), behaviour change (4.7%), sleep disturbance (4.3%), nausea (1.9%), increased appetite (1.7%), abdominal pain (1.3%) and infection (0.9%—including one death from varicella infection) of patients assessed for these ADRs. When measured, 144 of 369 patients showed increased blood pressure; 21 of 75 patients showed weight gain; and biochemical hypothalamic–pituitary–adrenal axis suppression was detected in 43 of 53 patients. Corticosteroids are highly efficacious and widely prescribed—it is important for the clinician to be aware of the side effects even when used short term. (See page 361)
The duties of candour—what do they mean for paediatricians
The duty of candour is the duty to be open and honest—new professional and statutory obligations have strengthened the requirement for candour for doctors and their organisations following the Mid Staffordshire Inquiry. Reynolds and Kelly discuss the detail. Guidance on the professional duty of candour (June 2015) aims to support doctors, nurses and midwives to be open and honest about mistakes and adverse events. In essence individuals must offer information on what has happened, make a meaningful apology (remember an apology is not an admission of guilt), report the incidents to prevent them happening again, and for clinical leaders they must encourage a culture of reporting and learning. The new statutory duty (April 2015) sets out specific requirements for how and when a patient must be informed of a ‘notifiable safety event'. The authors explore what the duties mean for doctors and their organisations, what the duties mean for patients, parents and their organisations and what the duties mean in practice. The implication is that for implementation there needs to be a culture of transparency and openness which avoids blame and punishment. The authors summarise the GMC guidance and provide case studies to work through. The authors highlight that being open and apologising for mistakes may also be beneficial if there are disciplinary procedures. The GMC is likely to consider that a doctor's failure to apologise when their actions or omissions have harmed a patient is evidence that they lack insight, and this may be a key factor in whether a medical fitness to practice panel will find the doctor's fitness to practice to be impaired. (See page 300)
Biomechanical characteristics of head injuries in children less than 48 months
Head injury is a frequent cause of hospital admission in young children, most commonly due to falls. Most are minor. A fall height threshold is important when evaluating the likelihood of a structural head injury or abusive head trauma. Hughes and colleagues report a case controlled study to correlate the fall characteristics (witnessed falls) with the extent of injury—47 skull fractures/intracranial injury, 416 minor head injuries. No child had a serious head injury who fell from less than 0.6 metres (2 feet) based on the head centre of gravity. Risk factors for skull fracture/intracranial injury were age less than 12 months, fall from greater than 0.6 metres, impact to temporal/parietal/occipital bone, fall from carer's arms, impact onto wood. There is useful additional information regarding fall height in the paper with a plot of all values (figure two). The data set helps in the evaluation of risk when patients present with head injury—the importance of a careful history is highlighted and all the above factors should be included in it. (See page 310)
In E&P this month
Doing more for mental health
Mental health is an integral part of child health and as such a vital part of paediatric practice. Max Davie works through some of the key issues including just how common mental health disorders are in children and young people—850,000 have serious mental health disorders, suicide is the second commonest cause of death in adolescence (male and female), more than 50% of adult mental health is apparent by age 15 years. Many children and young people with physical symptoms/physical disorders have mental health problems. The article summarises what can be done to help and the paediatricians role in advocacy and health promotion. There are useful sections on the clinical approach, detection and referral and educational opportunities including signposting to some e learning opportunities. It is important for paediatricians to be up to date with these issues in order to deliver the best care to children and young people who present unwell whatever the presenting complaint.
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