Fifteen-minute consultation: Assessment of pain in a non-verbal child.

In both inpatient and outpatient settings, clinicians will encounter patients with pain. This consultation is further complicated if the child is non-verbal. This article aims to equip the clinician with tools to assess these patients comprehensively and develop an appropriate management plan. It will take the clinician through the important aspects of a comprehensive history from the caregiver, thorough examination, importance of understanding how the child communicates and pain assessment tools to consider.

Fifteen-minute consultation: A practical approach to remote consultations for paediatric patients during the COVID-19 pandemic.

OBJECTIVE: This practical approach to the use of telehealth aims to offer clinicians a framework for video and telephone interactions with children and families accessing healthcare. DESIGN: Using a standardised case to illustrate how video and telephone consultations can be used during the COVID-19 pandemic. SETTING: The emergence of 2019 novel coronavirus (COVID-19) is having a massive impact on society. Routine face-to-face consultations were reduced to reduce potential spread of the virus. Clinicians still need to provide ongoing safe care, particularly for more complex patients. Telehealth is the delivery of healthcare services across geographical barriers using information and communication technologies to improve health outcomes. INTERVENTION: In this article, we describe a 'How to' approach to using virtual consultations based on our experience and a review of expert guidelines. CONCLUSION: Virtual consultations can be more convenient and have the potential to improve access for patients. Many have embraced these technologies for the first time during this pandemic.

Pharmacological management of abnormal tone and movement in cerebral palsy.

BACKGROUND: The evidence base to guide the pharmacological management of tone and abnormal movements in cerebral palsy (CP) is limited, as is an understanding of routine clinical practice in the UK. We aimed to establish details of motor phenotype and current pharmacological management of a representative cohort across a network of UK tertiary centres. METHODS: Prospective multicentre review of specialist motor disorder clinics at nine UK centres, collecting data on clinical features and pharmacological management of children and young people (CYP) with CP over a single calendar month. RESULTS: Data were collected from 275 CYP with CP reviewed over the calendar month of October 2017. Isolated dystonia or spasticity was infrequently seen, with a mixed picture of dystonia and spasticity ± choreoathetosis identified in 194/275 (70.5%) of CYP. A comorbid diagnosis of epilepsy was present in 103/275 (37.4%). The most commonly used medications for abnormal tone/movement were baclofen, trihexyphenidyl, gabapentin, diazepam and clonidine. Medication use appeared to be influenced separately by the presence of dystonia or spasticity. Botulinum toxin use was common (62.2%). A smaller proportion of children (12.4%) had undergone a previous neurosurgical procedure for tone/movement management. CONCLUSIONS: CYP with CP frequently present with a complex movement phenotype and comorbid epilepsy. They have multiple therapy, medical and surgical management regimens. Future trials of therapeutic, pharmacological or surgical interventions in this population must adequately encompass this complexity in order to be translatable to clinical practice.

Preoperative botulinum neurotoxin A for children with bilateral cerebral palsy undergoing major hip surgery: a randomized double-blind placebo-controlled trial.

AIM: To assess whether preoperative botulinum neurotoxin A (BoNT-A) affects pain after major hip surgery for children with bilateral cerebral palsy (CP). METHOD: This was a randomized, parallel arms, placebo-contolled trial. Children with hypertonic CP aged 2 to 15 years awaiting bony hip surgery at a tertiary hospital were randomized to receive either BoNT-A or placebo injections into the muscles of the hip on a single occasion immediately before surgery. The primary outcome was the paediatric pain profile (PPP), which was assessed at baseline and weekly for 6 weeks. Treatment allocation was by minimization. Participants, clinicians, and outcome assessors were masked to group assignment. RESULTS: Twenty-seven participants (17 males, 10 females; mean 8y 8mo [SD 3y 9mo], range 3y 4mo-15y 10mo) were allocated to BoNT-A and 27 participants (14 males, 13 females; mean 8y 11mo [SD 3y 5mo], range 4y 1mo-15y 2mo) to placebo. Mean (SD) PPP at 6 weeks for the BoNT-A group (n=24 followed up) was 10.96 (7.22) and for the placebo group (n=26) was 10.04 (8.54) (p=0.69; 95% confidence interval [CI] -4.82, 3.18). There were 16 serious adverse events in total during 6 months of follow-up (n=6 in BoNT-A group). INTERPRETATION: Use of BoNT-A immediately before bony hip surgery for reducing postoperative pain for children with CP was not supported. WHAT THIS PAPER ADDS: Botulinum neurotoxin A (BoNT-A) does not reduce postoperative pain following bony hip surgery. BoNT-A also does not affect postoperative quality of life.

NEUROTÓXINA A BOTULÍNICA PREOPERATORIA PARA NIÑOS CON PARÁLISIS CEREBRAL BILATERAL QUE VAN A SER SOMETIDOS A UNA CIRUGÍA MAYOR DE CADERA: UN ENSAYO ALEATORIO, DOBLE CIEGO, CONTROLADO CON PLACEBO: OBJETIVE: Evaluar si la neurotóxina A botulínica preoperatoria (BoNT-A) afecta el dolor después de una cirugía mayor de cadera en niños con parálisis cerebral bilateral (PC). MÉTODO: Este fue un ensayo aleatorio, con brazos paralelos, controlado con placebo. Los niños con PC hipertónica de 2 a 15 años de edad que esperaban una cirugía de cadera en un hospital terciario se escogieron al azar para recibir inyecciones de BoNT-A o de placebo en los músculos de la cadera una sola administración previa a la cirugía. El resultado primario fue el perfil de dolor pediátrico (PPP, siglas en ingles), que se evaluó al inicio del estudio y semanalmente durante 6 semanas. La asignación del tratamiento fue por minimización. Tanto los participantes, como los clínicos y evaluadores de resultados, eran desconocidos para la asignación de grupo. RESULTADOS: Veintisiete participantes (17 varones y 10 mujeres; medios 8 años 8 meses) [Desviación Estandar SD 3 años 9 meses], rango 3 años 4 meses-15 años 10 meses) se les administro BoNT-A y 27 participantes (14 varones y 13 mujeres; media 8 años 11 meses [SD 3 años 5 meses], rango 4 años 1 mes - 15 años 2 meses) a placebo. La PPP media (SD) a las 6 semanas para el grupo de BoNT-A (n = 24 seguidas) fue de 10,96 (7,22) y para el grupo de placebo (n = 26) fue de 10,04 (8,54) (p = 0,69; intervalo de confianza del 95% [CI, siglas en ingles] -4,82, 3,18). Hubo 16 eventos adversos graves en total durante 6 meses de seguimiento (n = 6 en el grupo BoNT-A). INTERPRETACIÓN: El uso de BoNT-A inmediatamente antes de la cirugía de cadera con el fin de reducir el dolor postoperatorio en niños con PC no fue consistente.

NEUROTOXINA BOTULÍNICA A PRÉ-OPERATÓRIA PARA CRIANÇAS COM PARALISIA CEREBRAL BILATERAL SUBMETIDAS A GRANDE CIRURGIA DE QUADRIL: UM ESTUDO RANDOMIZADO, DUPLO-CEGO, CONTROLADO POR PLACEBO: OBJETIVO: Avaliar se a neurotoxina botulínica tipo A (BTA) pré-operatória A afeta a dor após grande cirurgia de quadril em crianças com paralisia cerebral bilateral (PC). MÉTODO: Este foi um estudo randomizado, com braços paralelos e controlado por placebo. Crianças com PC espástica com idade entre 2 a 15 anos aguardando cirurgia óssea de quadril em um hospital terciário foram randomizadas para receber ou BTA ou injeções de placebo nos músculos do quadril em uma única ocasião imediatamente antes da cirurgia. O desfecho primário foi o perfil de dor pediátrica (PDP), que foi avaliado na linha de base e semanalmente por 6 semanas. A alocação de tratamento foi por minimização. Os participantes, clínicos e avaliadores de resultados foram cegados quanto a atribuição de grupo. RESULTADOS: Vinte e sete participantes (17 homens, 10 mulheres; média de 8 anos e 8 meses [DP 3 anos e 9 meses], com idade entre 3 anos e 4 meses à 15 anos e 10 meses) foram alocados para o grupo BTA e 27 participantes (14 homens, 13 mulheres; média de 8 anos e 11 meses [DP 3 anos e 5 meses], com idade entre 4anos e 1mês à 15anos e 2 meses) foram alocados no grupo placebo. A média (DP) do PDP às 6 semanas para o grupo BTA (n = 24) foi de 10,96 (7,22) e para o grupo placebo (n = 26) foi de 10,04 (8,54) (p = 0,69; intervalo de confiança de 95% [IC] -4,82, 3,18). Houve 16 eventos adversos sérios no total durante 6 meses de acompanhamento (n = 6 no grupo BTA). INTERPRETAÇÃO: O uso da BTA imediatamente antes da cirurgia óssea do quadril para reduzir a dor pós-operatória em crianças com PC não foi apoiado.

Helping doctors in training to STEP-UP: A leadership and quality improvement programme in the Belfast Health and Social Care Trust.

INTRODUCTION: Medical engagement in healthcare organisations can improve service development and patient experience. Doctors in training have limited opportunities to engage in service improvement work and develop leadership skills. METHOD: We describe the Specialist Trainees Engaged in Leadership Programme (STEP), a programme developed to introduce concepts of medical leadership and quality improvement skills in the Belfast Trust. STEP started in 2013 and over 140 trainees have now participated in the programme. RESULTS: Over 42 quality improvement projects have been completed with the support of the programme. Evaluation of STEP has demonstrated an improvement across all domains explored throughout the duration of the programme, with benefits for the individual trainee and the wider organisation. DISCUSSION: We describe the programme in detail. The STEP curriculum can easily be adapted to meet the needs of NHS trainees, allowing them to understand the objectives and strategy of their employers and improve their ability to plan and deliver safe, effective, patient-centred care.

Pain report and musculoskeletal impairment in young people with severe forms of cerebral palsy: A population-based series.

BACKGROUND: While pain is reportedly more prevalent in more functionally impaired children with cerebral palsy, information is scant in those with poor communication skills. METHODS: Young people (4-27 years) with severe forms of cerebral palsy were recruited from a population-based register. The Child Health Questionnaire (CHQ) provided information on general health and bodily pain; the Paediatric Pain Profile (PPP) was used for participants with limited communication; and the Spinal Alignment and Range of Motion Measure (SAROMM) described musculoskeletal impairment. RESULTS: 123 young people (GMFCS IV=55 and V=68) and their families/carers participated. Fourteen percent of CHQ responses (n=123) reported severe/very severe pain in recent weeks, whilst 7% reported pain every/almost every day. CHQ pain report was significantly higher for young people in GMFCS level V and correlated significantly with both global health and musculoskeletal impairment. High levels of pain were recorded on the PPP for non-communicating children but only a weak correlation between PPP and CHQ scores was detected. CONCLUSION: Managing pain in young people with severe musculoskeletal and cognitive impairment presents a huge challenge to carers and professionals. The PPP may represent a useful adjunct in those young people with severe communication difficulties.

Multidisciplinary assessment of vision in children with neurological disability.

INTRODUCTION: There is no consensus as to the best method of assessing vision in children with neurological disability. There are a variety of tests and approaches that can be used. It is important to look at models of assessment that identify the visual diagnosis and provide appropriate feedback and explanation to parents, carers and educational professionals. METHODS: This study reports on the results of comprehensive visual assessments of fifty children with neurological disability over a three year period. It focuses on the feedback from families and professionals after the assessment report was disseminated. RESULTS: The majority of families and professionals strongly agreed that a specialist assessment was needed in this population. Parents and professionals particularly valued the written report which provided guidance on appropriate visual material including advice relevant to education. CONCLUSION: This study highlights the importance of specialist teams engaging with local child development services and indicates how partnership working can potentially be emotionally supportive as well as developmentally beneficial.

Adenylosuccinate lyase deficiency in the United Kingdom pediatric population: first three cases.

Adenylosuccinate lyase deficiency is an autosomal recessive disorder of purine metabolism resulting from mutations in the ADSL gene on chromosome subband 22q13.1 and associated with a wide range of clinical manifestations. Although there is currently no effective treatment of ADSL deficiency, recognition of the condition is important, because prenatal genetic diagnosis can be offered to affected families. Reported here are the cases of the only three children diagnosed to date in the United Kingdom with adenylosuccinate lyase deficiency, to further delineate the clinical phenotype and to raise awareness of this disorder.

Outcome and cost of childhood brain injury following assault by young people.

INTRODUCTION: Media interest in inter-juvenile violence in the UK has emphasised to clinicians the lack of data on medical outcomes following injury. A study was undertaken to examine the incidence of childhood head injury in a large trauma centre serving an inner city multiethnic community. The aim was to establish the physical and financial cost of survival with a head injury following inter-juvenile assault. METHODS: All children aged 8-16 years attending King's College Hospital, London (KCH) because of a head injury were identified restrospectively. The case notes of those admitted to the neurosurgical and neurorehabilitation service with a head injury between 1 August 2006 and 30 September 2008 were reviewed. RESULTS: A total of 1126 children attended KCH with a head injury. Eight boys required admission for treatment of a head injury following alleged inter-juvenile assault. The mechanisms of brain injury included a penetrating knife wound, assault with a bottle and physical assault. One child died following admission as a result of his brain injury. Complete neurological outcome data were available on six cases. Three had a hemiplegia, four had speech and language difficulties, two had visual impairment, five had behavioural changes and five had cognitive difficulties. CONCLUSIONS: This study demonstrates the serious consequences of inter-juvenile assault. Survival can be associated with neurological and psychological deficits. The cost to the health service is substantial. Further work is required to establish the long-term needs of these children.

Botulinum toxin type A injections can be an effective treatment for pain in children with hip spasms and cerebral palsy.

AIM: Botulinum toxin type A (BoNT-A) injections were used in the treatment of lower-limb spasticity in children with cerebral palsy (CP). Anecdotal evidence suggests a reduction in pain after this treatment in children who had pain localized to a displaced hip joint. We report on our current clinical practice. METHOD: Twenty-six children with non-ambulant quadriplegic CP (Gross Motor Function Classification System level V) were assessed as having significant spasticity and pain at the hip level. Twelve were males and 14 females, with an age range of 2 to 19 years (mean age 11y 6mo, SD 4y 9mo). Ten had functional difficulties secondary to predominant spasticity and 16 had a mix of a high-background peripheral tone with superimposed dystonia. Of the 26 children assessed, 10 had at least one hip which was dislocated and three had at least one hip which was subluxed. As part of their spasticity management programme they received targeted BoNT-A injections to the adductor magnus, medial hamstrings and iliopsoas muscle groups. The Paediatric Pain Profile was used as the primary outcome measure. RESULTS: All had highly significant improvement in their recorded pain profile scores measured at 3 months after treatment (p<0.001). There was equal efficacy in response to treatment in the children with subluxed or dislocated hips. In addition, families commented on improved quality of life for the children across several areas, including sleep, postural management, and activities of daily living. INTERPRETATION: This report demonstrates that targeted BoNT-A injections reduced pain in children with significant spasticity and pain at the hip level. They may also improve quality of life of non-ambulant children with CP and a hip problem.