Screening for enteroviral meningitis in infants and children-Is it useful in clinical practice?

Enteroviral meningitis in infants and children commonly leads to hospital admission. Diagnosing viral meningitis can be difficult clinically. We examined the usefulness of enteroviral polymerase chain reaction (PCR) testing using cerebrospinal fluid (CSF) samples on clinical practice by comparing positive enteroviral CSF PCR cases (n = 39/136) to negative controls using both clinical outcomes and laboratory parameters. A positive result correlated with a reduced admission to high dependency unit, reduced the duration of antibiotics and a shorter length of stay (P < .05). Adjusted CSF white cell count > 5/µL correlated with positive PCR (P < .05) but would have missed 32% of cases of enteroviral meningitis. Following these findings, an algorithm for the management of suspected viral meningitis has been introduced.

Limited role of HLA DQ2/8 genotyping in diagnosing coeliac disease.

The European guidelines for diagnosing coeliac disease in children were revised in 2012. These recommend that in symptomatic children, a diagnosis of coeliac disease can be made without small-bowel biopsies provided their anti-tissue transglutaminase (anti-tTG) titre is >10 times of upper-limit-of-normal (>10×ULN) and anti-endomysial antibody is positive. In order to firm up the diagnosis in these children with very high anti-tTG titre, HLA-DQ2/DQ8 should be checked and be positive. Approximately 25-40% of white Caucasian population has HLA-DQ2/DQ8 haplotype. However, only 0.1-1% of the population will develop coeliac disease. Therefore, HLA-DQ2/DQ8 testing must not be done to 'screen' or 'diagnose' children with coeliac disease. Its use by paediatricians should be limited to children with anti-tTG>10×ULN, where the diagnosis of coeliac disease is being made on serology alone. A review of case referrals made to a tertiary paediatric gastroenterology centre in Southwest England demonstrated that HLA-DQ2/DQ8 testing is being requested inappropriately both in primary and secondary care suggesting a poor understanding of its role in diagnosis of coeliac disease. This article aims to clarify the role of HLA-DQ2/DQ8 testing for clinicians working in non-specialist settings.

Severe iron deficiency anaemia as a manifestation of silent coeliac disease: case report and literature review.

Coeliac disease (CD) occurs in individuals sensitive to gluten protein contained in wheat products. It affects at least 1:100 children and may present with extra-intestinal manifestations such as iron deficiency anaemia, short stature and delay in puberty. A case of severe iron deficiency anaemia as a manifestation of CD is described here. There is a need to raise awareness among health professionals about CD and its extra-intestinal presentations. Suspicion of CD should lead to antibody screening tests and positive results should be followed by an intestinal biopsy for a definitive diagnosis. Involvement of a paediatric dietitian is vital in the management of CD and lifelong adherence to a gluten-free diet is necessary. We hope this article leaves the reader with a heightened awareness about CD and will lead to appropriate early referral to the paediatric services.

Feeding growth restricted premature neonates: a challenging perspective.

Nutrition in the postnatal period is essential to achieve optimal growth and maintain biochemical normality. Feeding growth-restricted premature neonates remains a big challenge for pediatricians and neonatologists. The choice of milk is one of the biggest challenges. Breast milk is recommended, although feeding with preterm formulas can ensure a more consistent delivery of optimal levels of nutrients. The timing of introduction of feeds and the rate of advancement of those feeds in preterm infants are both topics of significant controversy. Early feeding is advantageous because it improves the functional adaptation of the gastrointestinal tract and reduces the duration of total parenteral nutrition. A faster rate of advancement will also reduce the duration of need for parenteral nutrition. Despite this, enteral feeding is often delayed and is often slowly increased in high-risk infants because of a possible increased risk of necrotizing enterocolitis (NEC). Growth-restricted neonates are at increased risk of developing NEC due to a combination of antenatal and postnatal disturbances in gut perfusion. If enteral feeding is introduced earlier and advanced more quickly, this may lead to increased risk of NEC, but slower feeds extend the duration of parenteral nutrition and its risks and may have adverse consequences for survival, growth, and development. Premature infants pose a significant nutritional challenge. Overall, we would suggest the preferential use of human breast milk, early minimal enteral feeds, and standardized feeding protocols with cautious advancements of feeds to facilitate gastrointestinal adaptation and reduce the risk of NEC, however further research is needed.

Accidental hanging injuries in children: recognition and management.

Accidental hanging is rare in childhood but is often fatal. Window blind cords pose a particular and unique risk to young children in the UK, accounting for one to two deaths annually. These accidents are frequently associated with non-adherence to the safety instructions provided by the manufacturers. Early discovery of the child and initiation of effective cardiopulmonary resuscitation at the site of the incident are likely to improve the outcome. Prolonged suspension, children who are pulseless at first contact by the emergency paramedic responder, and patients with prolonged periods of remaining in asystole before return of spontaneous circulation after starting cardiopulmonary resuscitation are unlikely to have intact neurological survival. Management in the hospital includes early airway protection by intubation, maintenance of normal oxygen saturation, normothermia, active control of clinical and sub-clinical seizures, and strict electrolyte and glucose regulation. Child safeguarding concerns should be considered when children have asphyxial injuries, and other signs of child physical abuse should be actively looked for. There is a need for stronger legislation in the UK to prevent some of these accidents, especially those relating to window blind cords.

NICE guidelines on bronchiolitis: a robust appraisal of current evidence.

Bronchiolitis is common in infants. Oxygen therapy, fluids and occasionally respiratory support remain the mainstay of treatment. The NICE guidelines are expected to streamline the management of bronchiolitis and minimize potentially harmful interventions. Further research to find other useful therapies is necessary.

Recognition and management of children with protracted bacterial bronchitis.

Chronic moist cough in children can be associated with serious pathologies. Protracted bacterial bronchitis remains a clinical diagnosis causing persistent moist cough, disturbed sleep, exercise intolerance and significant levels of morbidity. Management involves minimal investigations and prolonged courses of antibiotics.

Diagnosing coeliac disease in children.

Small bowel biopsies and histology had been the gold standard for diagnosis of coeliac disease, an immune-mediated systemic disorder. European guidelines recommend that in certain symptomatic patients, coeliac disease can be diagnosed without small bowel biopsies. A gluten-free diet is the only method of managing coeliac disease.