Acute treatment of paediatric migraine: a meta-analysis of efficacy

Aim:   To undertake a meta-analysis of all randomised controlled trials (RCTs) on the acute pharmacologic treatment of children and adolescents with migraine headache.
Methods:   In total, 139 abstracts of clinical trials specific to the acute treatment of paediatric migraine were appraised. Inclusion criteria required clinical trials to be randomised, blinded, placebo-controlled studies with comparable endpoints. Non- English language publications were excluded. 11 clinical trials qualified for inclusion in the final meta-analysis. Two endpoints were analysed: the proportion of patients with (1) headache relief, and (2) complete pain relief, 2 h post-treatment.
Results:   The following medications were included in the analysis: acetaminophen ( n  = 1), ibuprofen ( n  = 2), sumatriptan ( n  = 5), zolmitriptan ( n  = 1), rizatriptan ( n  = 2) and dihydroergotamine ( n  = 1). Results are expressed as a relative benefit (RB) conferred over placebo and the number needed to treat (NNT). Only ibuprofen and sumatriptan provided a statistically significant relative efficacy in comparison with placebo. Two hours post-treatment, ibuprofen was associated with an RB 1.50 (95% CI 1.15–1.95) in the generation of headache relief (NNT 2.4) and RB 1.92 (95% CI 1.28–2.86) in the production of complete pain relief (NNT 4.9). Sumatriptan rendered an RB 1.26 (95% CI 1.13–1.41) in headache relief (NNT 7.4) and an RB 1.56 (95% CI 1.26–1.93) in the production of complete pain relief (NNT 6.9).
Conclusion:   Despite the pharmacological options for the management of acute migraine, few RCTs in the paediatric population exist. Composite data demonstrate that only ibuprofen and sumatriptan are significantly more effective than placebo in the generation of headache relief in children and adolescents.     

The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting

Aims:   To identify the prevalence of constipation in children with nocturnal enuresis presenting to a tertiary paediatric outpatient service and to assess parental and clinician recognition of constipation.
Methods:   A prospective cross-sectional study of children with nocturnal enuresis at presentation to a continence service. Data relating to the child's bowel habits, pattern of enuresis and other history items were obtained from parental questionnaires and paediatrician assessments. Presence and severity of constipation was assessed independently by parents and clinicians. Kappa was used to compare agreement between parental reporting and clinician assessment of constipation.
Results:   Of the 277 participants aged 4.8–17.5 years (median 8.6 years), 36.1% ( n  = 95) were identified as constipated by the clinician-based scoring method ('Constipation Score') compared with 14.1% from parental reporting (Kappa = 0.155, P  = 0.003). Despite the poor overall recognition of constipation by parents, parental and clinician assessment of frequency of bowel motions (Kappa = 0.804) and soiling (Kappa = 0.384) were similar. Major factors influencing parental reporting of constipation were frequency of bowel motions and soiling with less emphasis on straining and stool consistency.
Conclusions:   Prevalence of constipation was high among children with nocturnal enuresis as assessed by clinicians despite poor identification by parents. This may limit optimal diagnosis and management.     

Intravenous maintenance fluid therapy in children

Intravenous fluids are frequently used in paediatrics but have been associated with significant adverse outcomes. Understanding the composition of fluid prescribed and administering an appropriate rate is essential for safe fluid administration, along with regular monitoring. Recent evidence has shown that using an isotonic fluid with a sodium concentration similar to plasma can decrease the risk of hyponatraemia without an increase in adverse effects. This should lead to a change in guidelines: isotonic fluid should now be used as the primary maintenance intravenous fluid given to the majority of children.     

Comparison of the play of children with attention deficit hyperactivity disorder by subtypes

Background: Studies have found differences in the nature and severity of social problems experienced by children with different subtypes of attention deficit hyperactivity disorder (ADHD). Given that play is often the context for acquiring social skills, there is surprisingly limited research examining whether these differences distinguish the play of children within the groups. Methods: Using the Test of Playfulness (ToP), we examined the similarities and differences in play between children (aged 5–11 years) diagnosed with the three DSM‐IV ADHD subtypes: inattentive (I‐subtype;n = 46), hyperactive‐impulsive (HI‐subtype;n = 28) and combined subtypes (C‐subtype;n = 31). Results and conclusions: Bias interaction, an item‐by‐item analysis, revealed that the hierarchy of ToP items was similar for children with the HI‐ and C‐subtypes, but differed for children with the I‐subtype. Specifically, children with the I‐subtype found it more difficult to become intensely engaged in play and to take on playful mischief and clowning; however, they found social play items to be easier. Conversely, whereas mischief and clowning were relatively easier for children with the HI‐ and C‐subtypes, many items reflecting social interaction were more difficult. These findings suggest that interventions can be tailored to these differing presentations. However, further research is needed to confirm the findings.     

Paediatric pandemic planning: children’s perspectives and recommendations

Children, as major stakeholders in paediatric hospitals, have remained absent from discussions on important healthcare issues. One critical area where children’s voices have been minimised is in the planning for future pandemics. This paper presents a subset of data from a programme of research which examined various stakeholder experiences of the severe acute respiratory syndrome (SARS) outbreaks of 2003. These data also generated recommendations for future pandemic planning. Specifically, this paper will examine the perspectives and recommendations of children hospitalised during SARS in a large paediatric hospital in Canada. Twenty‐one (n = 21) child and adolescent participants were interviewed from a variety of medical areas including cardiac (n = 2), critical care (n = 2), organ transplant (n = 4), respiratory medicine (n = 8) and infectious diseases (patients diagnosed with suspected or probable SARS; n = 5). Data analyses exposed a range of children’s experiences associated with the outbreaks as well as recommendations for future pandemic planning. Key recommendations included specific policies and guidelines concerning psychosocial care, infection control, communication strategies and the management of various resources. This paper is guided by a conceptual framework comprised of theories from child development and literature on children’s rights. The authors call for greater youth participation in healthcare decision‐making and pandemic planning.     

REVIEW ARTICLE: Paediatric nasopharyngeal rhabdomyosarcoma: A case series and literature review

Rhabdomyosarcoma (RMS) is the most common soft tissue tumour in children, with the head and neck region accounting for 35–40% of cases. Nasopharyngeal RMSs tend to grow rapidly and invade adjacent structures. Both the Intergroup Rhabdomyosarcoma Studies and the European Studies have established that the ideal management of this disease is multimodal, using a combination of surgery, chemotherapy and radiotherapy. This case series examines the role of radiotherapy in the management of paediatric nasopharyngeal RMSs, with particular reference to long-term morbidity and disease-free survival. The cases of five children with nasopharyngeal RMS were reviewed and a systematic review of the literature contained in the PubMed databases was conducted to establish 24 individually detailed cases. Management in all patients was multimodal, using a combination of chemotherapy, radiotherapy as well as surgery. External beam radiotherapy is an integral component of treatment for nasopharyngeal RMSs. With more patients surviving for longer periods, more long-term sequelae of radiotherapy have been reported. Complications include sensorineural deafness, endocrine manifestations following radiation of the pituitary gland, cranial nerve palsies, second malignancies within the radiation field, cataract formation, retinopathy and growth disturbance. Morbidity from radiotherapy may be considerable and depends on the field and dose of radiation. Current advances in radiotherapy are aimed at improving the rate of tumour control and reducing such complications. Recent improvements in imaging and conformal techniques have the potential to reduce the morbidity associated with radiotherapy in this cohort.     

How can your microbiologist help you manage paediatric infection?

The presentation of a child to hospital with an acute illness is distressing for the child and his/her parents or carers. The clinical aim of the admitting paediatric team is to identify the cause of the illness, to treat it effectively and to discharge the child home quickly and safely. Multi-disciplinary care between the paediatric and the clinical microbiology team, who oversee and support the laboratory work of skilled scientists, is essential to manage paediatric infection. In this review, we will focus on current diagnostic methods for common paediatric microbiology consultations, with a focus on newer molecular technology to reduce laboratory turnaround time, and discuss the emergence of multi-drug resistant organisms that are impacting on antimicrobial prescribing practices. We will also highlight useful infection prevention and control advice that will be beneficial to the on-call paediatrician.