Paediatric opioid poisoning in the UK: a retrospective analysis of clinical enquiries to the National Poisons Information Service.

OBJECTIVE: To evaluate a decade of reported paediatric opioid poisoning cases in the UK. METHODS: The National Poisons Information Service (NPIS) telephone enquiries database (UK Poisons Information Database) was searched for calls regarding opioid poisoning in children under 18 years from 2012 to 2021. The NPIS online clinical guidance database TOXBASE was searched for accesses relating to opioids for both adults and children. The Office of National Statistics provided paediatric data for hospital admissions and deaths in those aged under 20 years old due to opioids. RESULTS: The NPIS received 426 774 telephone enquiries from 2012 to 2021 from across the UK, 3600 in relation to opioid exposures regarding children under 18 years. Annual telephone enquiries regarding paediatric opiate poisoning reduced year on year, from around 450 to 300 calls/year. A rise in all age TOXBASE annual accesses relating to opioids from 71 642 in 2012 to 87 498 in 2021 was noted, a total of 838 455 during the study period. Hospital admissions from opioid poisoning remained consistent, with around 1500 admissions/year. Deaths were uncommon, but averaged 18 deaths annually. Co-codamol was the most reported substance to NPIS, with 1193 calls (36.5%), followed by codeine with 935 (26.1%). CONCLUSIONS: Opioid poisoning in children is not uncommon. There is a general downward trend in telephone enquiries to NPIS, but many childhood exposures may have been dealt with through consultations via TOXBASE, where accesses relating to opioids have increased. Unfortunately, children still die from opioid exposure each year in the UK and this figure has changed little during 2012-2021.

Medication errors involving intravenous paracetamol in children: experience from enquiries to the National Poisons Information Service.

INTRODUCTION: Children are at higher risk of medication errors due to the complexity of drug prescribing and administration in this patient group. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. We provide the first national UK data focusing on paediatric IV paracetamol poisoning. METHODS: All telephone enquiries to the National Poisons Information Service between 2008 and 2021 regarding children less than 18 years old in the UK concerning IV paracetamol overdose were extracted from the UK Poisons Information Database (UKPID). Data were analysed using descriptive statistics. RESULTS: Enquiries were made concerning 266 children, mostly involving children under the age of 1 year (n=145; 54.5%). Acute and staggered overdoses were the most frequent types of exposure. Common error themes included 10-fold overdose in 45 cases (16.9%) and inadvertent concomitant oral and IV dosing in 64 cases (24.1%). A high proportion of cases were asymptomatic (87.1%), with many calls regarding overdoses below the treatable dose of 60 mg/kg (41.4%). Treatment with the antidote acetylcysteine was advised in 113 cases (42.5%). CONCLUSIONS: Inadvertent IV paracetamol overdose appears to occur more frequently in young children. A significant proportion were calculation errors which were often 10-fold errors. While these errors have the potential for causing serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.

When does childhood dental caries become neglect or abuse: do parents think what we think?

Introduction Poor oral health in children may be a marker for wider neglect and abuse, but there is no universally recognised threshold for social services intervention.Aim To compare families' thresholds for referral for social services intervention with those of healthcare workers.Intervention Five standardised vignettes, used previously to investigate the views of healthcare workers on the need for social services intervention, were used to determine the threshold of 250 families for intervention.Results For an unkempt four-year-old girl with extensive dental caries frequently not brought to appointments, 63.6% families suggested a child in need (CIN) referral, against 9% (3/32) dental professionals (p <0.001) and 38% (38/100) paediatric healthcare professionals (PHCPs) (p <0.001). For a bullied, obese 14-year-old boy with extensive dental caries, similar proportions of families (37%; 93/250) and PHCPs (40%; 40/100) advised a CIN referral (p = ns); significantly fewer dental workers did (15.6%; 5/32; p = 0.017). Concerning a four-year-old boy with a bruised ear, over 64% of families and 68% of PHCPs correctly felt engagement with social services was necessary (p = ns) compared to just 12.5% (4/32) of dental practitioners (p <0.001).Conclusion Many parents felt social services involvement would be helpful in these hypothetical cases, often more frequently than healthcare workers.

Can parents believe websites' information about methylphenidate's side effects?

BACKGROUND: Attention deficit and hyperactivity disorder (ADHD) is one of the most common behavioural disorders, affecting around 5% of the global population. Methylphenidate is recommended as the first-line drug treatment for ADHD for children over the age of 5 in the UK. It can have many side effects and it is important that families are well informed. Other than their healthcare professionals and friends, the major information source for families is the internet. AIMS: To evaluate the validity of online information regarding the adverse effects of methylphenidate. METHODS: Side-effects of methylphenidate hydrochloride listed in the British National Formulary for Children (BNFC) were taken as the 'gold standard' and compared with online websites for accuracy. The first 10 websites found on each of nine different search engines were used as comparators. RESULTS: From the 90 hits, 10 top hits found in each of 9 search engines, 25 unique websites were identified. A quarter (six sites; 24%) documented only side-effects that all appeared in the BNFC. Three quarters (19 websites; 76%) had at least one side-effect that did not appear in the BNFC; with six websites documenting more than five side-effects not found in the BNFC. CONCLUSIONS: Methylphenidate's frequent use makes it important that the general public are provided with accurate, reliable and easily accessible information. Most websites have dependable quality information on side effects, but several seem to list excessive side-effects.

Lazarus Syndrome - Challenges Created by Pediatric Autoresuscitation.

ABSTRACT: Pediatric autoresuscitation is extremely rare, with only 4 documented cases in the literature. The longest recorded time between stopping cardio pulmonary resuscitation (CPR) and return of spontaneous circulation is 2 minutes. We report a previously well 18-month-old who attended the emergency department after an unexplained cardiac arrest. After 10 cycles of CPR, resuscitation was stopped; 6 minutes later, the patient had a return of spontaneous circulation and was transferred to the pediatric intensive care unit. The patient remains alive but with significant neurological impairment. There are a variety of theories regarding the pathology of pediatric autoresuscitation. The most commonly accepted model is that there is a degree of autopositive end-expiratory pressure impending venous return as a consequence of vigorous ventilation during CPR. This case challenges clinicians to reassess our current definition of death and reaffirms the need for clearer guidelines surrounding the certification of death.

Incidence of paediatric 10-fold medication errors in Wales.

OBJECTIVES: To estimate the incidence, characteristics and outcomes of 10-fold or greater or a tenth or less medication errors in children aged <16 years in Wales. DESIGN: Population-based surveillance study July 2017 to June 2019. Cases were identified by paediatricians and hospital pharmacists using monthly electronic Welsh Paediatric Surveillance Unit (WPSU) reporting system. PATIENTS: 'Definite' incident occurred when children received all or any of the incorrect dose of medication. 'Near miss' was where the prescribed, prepared or dispensed medication was not administered to the child. MAIN OUTCOME MEASURES: Incidence, patient characteristics, setting, drug characteristics, outcome, harm and enabling or preventive factors. RESULTS: In total, 50 10-fold errors were reported; 20 definite and 30 near miss cases. This yields a minimum annual incidence of 1 per 3797 admissions, or 4.6/100 000 children. Of these, 43 were overdoses and 7 underdoses. 33 incidents occurred in children <5 years of age. Overall, 37 different medications were involved with the majority, 31 cases, being administered enterally. Of these 31 enteral medication errors, all definite cases (10) had received liquid preparations. Temporary harm occurred in 5/20 (25%) definite cases with one requiring intensive care; all fully recovered. CONCLUSIONS: In this first ever population surveillance study in a high-resource healthcare system, 10-fold errors in children were rare, sometimes prevented and uncommonly caused harm. We recommend country-wide improvements be made to reduce iatrogenic harm. Understanding the enabling and preventive factors may help national improvement strategies to reduce these errors.

Service evaluation of laceration risk using trainer adrenaline auto-injectors.

OBJECTIVE: Anaphylaxis is a severe, potentially fatal allergic reaction best treated with intramuscular epinephrine via epinephrine auto-injectors (AAIs). Our published concerns over laceration injuries to young children associated with AAIs led to this service evaluation of the two administration methods: swing and jab (S&J) and place and press (P&P), to determine potential laceration risk. DESIGN: A trainer EpiPen was used with facepaint placed in the needle indentation which would record the length of movement of the AAI. The two different methods 'administered' were alternated. Children were asked to move their leg to simulate a withdrawal reaction. Age, whether they moved, and length of paint mark were recorded. SETTING: Outpatients waiting area in Noah's Ark Children's Hospital, Cardiff. PARTICIPANTS: Children aged 5-11 with no prior knowledge of AAI use. INTERVENTION: No intervention was implemented. RESULTS: 135 children (mean age 8 years; range 5-11 years) were asked to participate; measurements were taken from 100 children. 50 children moved for one or both methods. For those that moved, S&J mean paint length=8.3 mm (SD 17.4, 95% CI 3.4 to 13.3), P&P mean=3.5 mm (SD 11.0, 95% CI 0.4 to 6.6). Mean difference between methods was 4.8 mm (SD 10.1, 95% CI 1.9 to 7.7). Slightly more children moved for S&J (44) compared with 38 for P&P. CONCLUSIONS: S&J produces more movement and longer paint marks than P&P. The risk of laceration when administering an EpiPen to young children may be lower by using the more controlled P&P. We feel it is advisable to teach P&P instead in children below 11 years of age.

PN FOR CHILDREN - INFORMATION LEAFLET.

AIM: To produce a leaflet for parents and carers of children receiving parenteral nutrition (PN) explaining:▸ What PN is▸ Why it is given▸ How it will be given▸ Risks & Complications▸ Other useful information▸ Nutrition team contact informationCurrent practice is for the nutrition team pharmacist to give a verbal account of the above information to parents/carers. It was felt that providing this information in a written format would introduce consisitency and allow parents/carers more time to take information on board. METHOD: An internet search and discussions with other organisations with paediatric gastroenterology specialists was conduted to see if something similar was in existence. A similar information leaflet to what we hoped to produce was not found. Members of the paediatric nutrition team, which included consultants, nurse specialists, pharmacist and dietician, provided input to the type of information that should be included in the information leaflet. A first draft of the leaflet was produced and shown to the parents of current paediatric PN inpatients. Feedback was received and the leaflet updated following consultation with the nutrition team. CONCLUSION: Production of a very useful information leaflet for parents/carers, containing all the relevant information and detail. The leaflet uses colour and pictures to aid the transfer of information and makes it more attractive to read. The pharmacist is the main point of contact for the paediatric nutrition team and will be the individual responsible for distributing them.

A randomized maternal evaluation of epinephrine autoinjection devices.

BACKGROUND: Intramuscular epinephrine (adrenaline) is the first-line therapy for anaphylaxis and prompt administration improves outcome. In 2011, two epinephrine autoinjectors existed in the United Kingdom, differing in their users' administration method: EpiPen(®) and Anapen(®) . We routinely train all families who receive these devices. AIM: To evaluate: Maternal competence in using epinephrine autoinjectors following our standard anaphylaxis training package. Which device mothers found easier to use. METHODS: Mothers with no previous epinephrine autoinjector experience were approached to participate. One clinician provided a standardized demonstration on using a randomly assigned autoinjector device. She immediately evaluated the mothers' performance using ten predetermined criteria. Four criteria were device specific and six were common criteria to both devices. RESULTS: One hundred mothers participated: 50 EpiPen(®) and 50 Anapen(®) . A substantial proportion of mothers (15% overall) were not able to successfully 'fire' these training devices: Anapen(®) 4% and EpiPen(®) 26% (OR 8.43, p = 0.005). Only 22% of mothers overall were able to perform all ten procedures completely successfully: Anapen(®) 32% and EpiPen(®) 12%. Chi-squared analysis showed a significantly higher proportion of mothers correctly performing all Anapen(®) specific procedures than EpiPen(®) (OR 14.24, p < 0.0001). CONCLUSION: It is concerning that 15% of mothers overall could not 'fire' these devices correctly despite a one-to-one demonstration, identifying a need for more user friendly devices and training. Mothers found the Anapen(®) device significantly easier to use, which may have implications for future prescribing. Evaluation of the next generation of autoinjectors and their training packages needs to be performed as important practical differences may be found.

The RCPCH care pathway for children with drug allergies: an evidence and consensus based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) was commissioned by the Department of Health to develop a drug allergy pathway. It focuses on defining the competences to improve the equity of care received by children. METHOD: The drug pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The team decided to focus on IgE-mediated reactions as these have the greatest potential to be life-threatening. RESULTS: The results are presented in four parts: evidence review, pathway mapping, external review and core knowledge documents. The evidence review found a high percentage of putative penicillin allergy is not confirmed by objective testing and that resensitisation to ß-lactam drugs was infrequent. It also highlighted the importance of a detailed history and accurate diagnosis along with clear communication of test results to both family and primary care. CONCLUSIONS: This pathway demonstrates the spectrum of drug allergy is varied and may differ for young children compared with older children and adults. The authors highlight the paucity of evidence to support allergy testing for most drugs, in children, other than supervised incremental provocation tests (when indicated). Acute presentations require emergency health professionals to address underlying allergic issues, including recognition and avoidance of potential drug allergy triggers. Non-acute presentations may include multi-system symptoms which may have a broad differential diagnosis; this document signposts to the relevant partners in the RCPCH care pathway portfolio. Management combines a care package including a definitive diagnosis, initiating treatments and ongoing education.

The RCPCH care pathway for food allergy in children: an evidence and consensus based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; food allergy is the second pathway. The pathways focus on defining the competences required to improve the equity of care received by children with allergic conditions. METHOD: The food allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of the evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. The National Institute of Health and Clinical Excellence simultaneously established a short guideline review of community practice for children with food allergy; close communication was established between the two groups. RESULTS: The results are presented in two sections: a pathway algorithm and the competences. The entry points are defined and the ideal pathway of care is described from initial recognition and confirmed diagnosis through to follow-up. CONCLUSIONS: The range of manifestations of food allergy/intolerance is much more diverse than hitherto recognised and diagnosis can be problematic as many patients do not have classical IgE mediated disease. The pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patient's home as possible. The authors recommend that this pathway is implemented locally by a multidisciplinary team with a focus on creating networks.

The RCPCH care pathway for children with latex allergies: an evidence- and consensus-based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; the latex allergy pathway is the seventh pathway. The pathways focus on defining the competences to improve the equity of care received by children with allergic conditions. METHOD: The RCPCH latex allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. RESULTS: The results are presented in four parts, the evidence review, pathway mapping, external review and core knowledge documents. The evidence review highlighted the paucity of recent evidence for latex allergy in childhood. The review found that the diagnostic sensitivity of different latex extracts for skin-prick testing may differ. It also noted that health professionals should be aware of latex allergy, and care should be taken to avoid contact with latex in young infants, especially when there is a family history for latex allergy. The pathway entry points are defined by the severity at presentation. CONCLUSIONS: The latex allergy pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patients home as possible. The authors recommend that this pathway is implemented locally by a multidisciplinary team with a focus on creating networks between primary, secondary and tertiary care to improve services for children with allergic conditions.

The RCPCH care pathway for children with venom allergies: an evidence and consensus based national approach.

AIMS: The Royal College of Paediatrics and Child Health (RCPCH) Science & Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies; the venom allergy pathway is the seventh pathway. The pathways focus on defining the competences to improve the equity of care received by children with allergic conditions. METHOD: The RCPCH venom allergy pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. RESULTS: The pathway results are presented in four parts: evidence review, mapping, external review and core knowledge documents. The entry points are defined and the ideal pathway of care is described from self-care through to follow-up. The evidence highlighted that venom immunotherapy is safe and effective for bee and wasp allergy and that there are real quality of life benefits for patients. The review also highlighted the value of measuring serum tryptase after reactions. CONCLUSIONS: The venom allergy pathway provides a guide for training and development of services to facilitate improvements in delivery as close to the patient's home as possible. The authors recommend that this pathway should be implemented locally by a multidisciplinary team with a focus on creating networks between primary, secondary and tertiary care to improve services for children with allergic conditions.