Experiences of children with bronchiectasis and their parents in a novel play-based therapeutic exercise programme: a qualitative analysis.

OBJECTIVES: To explore the experiences and perceptions of children with bronchiectasis and their parents regarding an 8-week play-based therapeutic exercise programme. DESIGN: Qualitative study with inductive content analysis. SETTING: Individual semistructured interviews were conducted. Interview recordings were transcribed verbatim, and coding was guided by the content. Content categories were established via consensus moderation. PARTICIPANTS: 10 parents and 10 children with bronchiectasis aged 5-12 years. RESULTS: From the perspective of children, the most important components of the programme were fun with friends and being active at home as a family. Parents valued the community-based sessions, perceived the programme to be engaging and motivating. Parents perceived improvements in their child's endurance, coordination and physical activity level. They described the home programme as fun but noted that finding time was difficult. Both parents and children thought that in-person exercise sessions would be better than exercise sessions delivered online. CONCLUSIONS: Children who participated in the play-based exercise programme, found it fun, motivating and accessible. Parents perceived positive impacts on fitness, coordination and physical activity. TRIAL REGISTRATION NUMBER: The trial was registered with, Australian and New Zealand Clinical Trials Register (ACTRN12619001008112).

Fluid and electrolyte pathophysiology in common febrile illness in children and the implications for clinical management.

Achieving fluid homeostasis and the management of fluid and electrolyte complications are constants in the treatment of seriously ill children worldwide. Consensus on the most appropriate fluid strategy for unwell children has been difficult to achieve and has evolved over the last two decades, most notably in high-income countries where adverse events relating to poor fluid management were identified more readily, and official robust inquiries were possible. However, this has not been the situation in many low-income settings where fluids that are prohibited from use in high-income countries may be all that are available, local guidelines and processes to recognise adverse events are not developed, and there has been limited training on safe fluid management for front-line healthcare workers. This narrative review outlines the fluid and electrolyte pathophysiology of common febrile illnesses in children, describes the evolution of this field and concludes with implications and principles of a fluid management strategy for seriously ill children. This review was prepared as a physiological background paper to support evidence presented to the WHO Guideline Development Group for Fluid Guidelines in Children, Geneva, March 2024.

Effectiveness of a hybrid closed-loop system for children and adolescents with type 1 diabetes during physical exercise: A cross-sectional study in real life.

OBJECTIVE: The aim of the study was to describe how physical exercise affects metabolic control, insulin requirements and carbohydrate intake in children who use hybrid closed-loop systems. METHODS: Cross-sectional study design. The sample included 21 children and adolescents diagnosed with type 1 diabetes. During the study, participants were monitored for a period of 7 days to gather comprehensive data on these factors. RESULTS: Nine participants (42.9%) had switched to exercise mode to raise the target glucose temporarily to 150 mg/dL. The HbA1c values ranged from 5.5% to 7.9% (median, 6.5%; IQR, 0.75). The percentage of time within the target range of 70-180 mg/dL was similar; however, there was an increased duration of hyperglycaemia and more autocorrections on exercise days. The time spent in severe hyperglycaemia (>250 mg/dL) increased by 2.7% in exercise compared to non-exercise days (P = .02). It is worth noting that hypoglycaemic episodes did not increase during the exercise days compared with non-exercise days. CONCLUSION: The hybrid closed-loop system was effective and safe in children and adolescents with type 1 diabetes during the performance of competitive sports in real life.

The spectrum of co-existing disease in children with established kidney failure using registry and linked electronic health record data.

BACKGROUND: Children with established kidney failure may have additional medical conditions influencing kidney care and outcomes. This cross-sectional study aimed to examine the prevalence of co-existing diseases captured in the electronic hospital record compared to UK Renal Registry (UKRR) data and differences in coding. METHODS: The study population comprised children aged < 18 years receiving kidney replacement therapy (KRT) in England and Wales on 31/12/2016. Comorbidity data at KRT start was examined in the hospital record and compared to UKRR data. Agreement was assessed by the kappa statistic. Associations between patient and clinical factors and likelihood of coding were examined using multivariable logistic regression. RESULTS: A total of 869 children (62.5% male) had data linkage for inclusion. UKRR records generally reported a higher prevalence of co-existing disease than electronic health records; congenital, non-kidney disease was most commonly reported across both datasets. The highest sensitivity in the hospital record was seen for congenital heart disease (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.51, 0.78) and malignancy (OR 0.63, 95% CI 0.41, 0.85). At best, moderate agreement (kappa ≥ 0.41) was seen between the datasets. Factors associated with higher odds of coding in hospital records included age, while kidney disease and a higher number of comorbidities were associated with lower odds of coding. CONCLUSIONS: Health records generally under-reported co-existing disease compared to registry data with fair-moderate agreement between datasets. Electronic health records offer a non-selective overview of co-existing disease facilitating audit and research, but registry processes are still required to capture paediatric-specific variables pertinent to kidney disease.

The League: A person-centred approach to the development of social robotics for paediatric anxiety.

BACKGROUND: Social robots are promising tools to improve the quality of life of children and youth living with anxiety and should be developed based on the priorities of end users. However, pathways to include young people in patient-oriented research, particularly in the overlap between technology and mental health, have been historically limited. OBJECTIVE: In this work, we describe engagement with experts with lived experiences of paediatric anxiety in a social robotics research programme. We report the experiences of patient advisors in a co-creation process and identify considerations for other research groups looking to involve end users in technology development in the field of youth mental health. DESIGN: We engaged individuals with a lived experience of paediatric anxiety (current, recent past, or from a parent perspective) using three different models over the course of three years. Two initial patient partners were involved during project development, eight were engaged as part of an advisory panel ('the League') during study development and data analysis and four contributed as ongoing collaborators in an advisory role. League members completed a preparticipation expectation survey and a postparticipation experience survey. FINDINGS: Eight individuals from a range of anxiety-related diagnostic groups participated in the League as patient partners. Members were teenagers (n = 3), young adults aged 22-26 years who had connected with a youth mental health service as children within the past eight years (n = 3) or parents of children presently living with anxiety (n = 2). Preferred methods of communication, expectations and reasons for participating were collected. The League provided specific and actionable feedback on the design of workshops on the topic of social robotics, which was implemented. They reported that their experiences were positive and fairly compensated, but communication and sustained engagement over time were challenges. Issues of ethics and language related to patient-centred brain health technology research are discussed. CONCLUSIONS: There is an ethical imperative to meaningfully incorporate the voices of youth and young adults with psychiatric conditions in the development of devices intended to support their mental health and quality of life. PATIENT OR PUBLIC CONTRIBUTION: Six young people and two parents with lived experiences of paediatric anxiety participated in all stages of developing a research programme on social robotics to support paediatric mental health in a community context. They also provided input during the preparation of this manuscript.

Family-centred care interventions for children with chronic conditions: A scoping review.

INTRODUCTION: Children with chronic conditions have greater health care needs than the general paediatric population but may not receive care that centres their needs and preferences as identified by their families. Clinicians and researchers are interested in developing interventions to improve family-centred care need information about the characteristics of existing interventions, their development and the domains of family-centred care that they address. We conducted a scoping review that aimed to identify and characterize recent family-centred interventions designed to improve experiences with care for children with chronic conditions. METHODS: We searched Medline, Embase, PsycInfo and Cochrane databases, and grey literature sources for relevant articles or documents published between 1 January 2019 and 11 August 2020 (databases) or 7-20 October 2020 (grey literature). Primary studies with ≥10 participants, clinical practice guidelines and theoretical articles describing family-centred interventions that aimed to improve experiences with care for children with chronic conditions were eligible. Following citation and full-text screening by two reviewers working independently, we charted data covering study characteristics and interventions from eligible reports and synthesized interventions by domains of family-centred care. RESULTS: Our search identified 2882 citations, from which 63 articles describing 61 unique interventions met the eligibility criteria and were included in this review. The most common study designs were quasiexperimental studies (n = 18), randomized controlled trials (n = 11) and qualitative and mixed-methods studies (n = 9 each). The most frequently addressed domains of family-centred care were communication and information provision (n = 45), family involvement in care (n = 37) and access to care (n = 30). CONCLUSION: This review, which identified 61 unique interventions aimed at improving family-centred care for children with chronic conditions across a range of settings, is a concrete resource for researchers, health care providers and administrators interested in improving care for this high-needs population. PATIENT OR PUBLIC CONTRIBUTION: This study was co-developed with three patient partner co-investigators, all of whom are individuals with lived experiences of rare chronic diseases as parents and/or patients and have prior experience in patient engagement in research (I. J., N. P., M. S.). These patient partner co-investigators contributed to this study at all stages, from conceptualization to dissemination.

Climate change and children's respiratory health.

Climate change has significant consequences for children's respiratory health. Rising temperatures and extreme weather events increase children's exposure to allergens, mould, and air pollutants. Children are particularly vulnerable to these airborne particles due to their higher ventilation per unit of body weight, more frequent mouth breathing, and outdoor activities. Children with asthma and cystic fibrosis are at particularly high risk, with increased risks of exacerbation, but the effects of climate change could also be observed in the general population, with a risk of impaired lung development and growth. Mitigation measures, including reducing greenhouse gas emissions by healthcare professionals and healthcare systems, and adaptation measures, such as limiting outdoor activities during pollution peaks, are essential to preserve children's respiratory health. The mobilisation of society as a whole, including paediatricians, is crucial to limit the impact of climate change on children's respiratory health.

The effect of virtual reality versus standard-of-care treatment on pain perception during paediatric vaccination: Study protocol for a randomised controlled trial.

AIMS AND OBJECTIVES: To study the effects of virtual reality (VR) on pain perception among a paediatric population while being vaccinated. We will also investigate the effects of VR on the fear experienced by children during the vaccination procedure, as well as parental satisfaction levels. BACKGROUND: Many studies, for example, in the fields of oncology, dermatology or plastic surgery, have described the benefits of using VR to reduce the perception of pain among paediatric populations. These results are encouraging, but their main limitations were the small sample sizes they included or their methodological design. DESIGN: This will be a randomised clinical trial. METHODS: SPIRIT guidelines were followed to report this protocol, and we will use the CONSORT and CONSORT-EHEALTH guidelines to report the randomised clinical trial. The sample will comprise 148 children aged 3-14 years who will come for vaccination at the Tres Forques Health Center. The participants will be randomly allocated into intervention group (VR; n = 74) or (the control group standard-of-care; n = 74) at a 1:1 ratio. The intervention group will view experiences with a VR headset as a distraction measure. The study variables will be the level of pain and fear perceived by the child during vaccination, parental satisfaction with the vaccination procedure, and sociodemographic and vaccination variables. RESULTS: The start of the study is planned for September 2020, and the results will be expected in September 2021. CONCLUSIONS: This study aims to identify what measures reduce pain and fear in children during vaccination, which in turn, can help to improve the degree of parental satisfaction with these procedures. RELEVANCE TO CLINICAL PRACTICE: Vaccination is an independent function of the nursing profession. Identifying which distraction measures reduce the perception of pain and fear in the paediatric population will not only improve children's experiences but will also improve the satisfaction of both parents and children, thus increasing the degree of compliance with the vaccination schedule.

Prospective development and validation of a universal classification for paediatric videolaryngoscopic tracheal intubation: the PeDiAC score.

BACKGROUND: The VIDIAC score, a prospectively developed universal classification for videolaryngoscopy, has shown excellent diagnostic performance in adults. However, there is no reliable classification system for videolaryngoscopic tracheal intubation in children. We aimed to develop and validate a multivariable logistic regression model and easy-to-use score to classify difficult videolaryngoscopic tracheal intubation in children and to compare it with the Cormack and Lehane classification. A secondary aim was to externally validate the VIDIAC score in children. METHODS: We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ videolaryngoscopes in all children undergoing tracheal intubation for elective surgical procedures. We validated the VIDIAC score externally and assessed its performance. We then identified eligible co-variables for inclusion in the PeDiAC score, developed a multivariable logistic regression model and compared its performance against the Cormack and Lehane classification. RESULTS: We studied 809 children undergoing 904 episodes of tracheal intubation. The VIDIAC score outperformed the Cormack and Lehane classification when classifying the difficulty of videolaryngoscopic tracheal intubation, with an area under the receiver operating characteristic curve of 0.80 (95%CI 0.73-0.87) vs. 0.69 (95%CI 0.62-0.76), respectively, p = 0.018. Eight eligible tracheal intubation-related factors, that were selected by 100-times repeated 10-fold cross-validated least absolute shrinkage selector operator regression, were used to develop the PeDiAC model. The PeDiAC model and score showed excellent diagnostic performance and model calibration. The PeDiAC score achieved significantly better diagnostic performance than the Cormack and Lehane classification, with an area under the receiver operating characteristic curve of 0.97 (95%CI 0.96-0.99) vs. 0.69 (95%CI 0.62-0.76), respectively, p < 0.001. CONCLUSION: We developed and validated a specifically tailored classification for paediatric videolaryngoscopic tracheal intubation with excellent diagnostic performance and calibration that outperformed the Cormack and Lehane classification.

Pituitary deficiencies related to optic nerve hypoplasia and visual acuity.

OBJECTIVE: Optic nerve hypoplasia (ONH), the congenital underdevelopment of the optic nerve, is an increasing cause of visual impairment and is associated with pituitary dysfunction. Past studies have focused on the relationship between ONH, pituitary deficiencies, and brain imaging. However, recent studies have demonstrated the true risk for hypopituitarism lies with the presence or absence of ONH, irrespective of midline brain findings. This study reviewed the relationship between the health of the optic nerve (visual acuity) and pituitary gland (number and age of development of pituitary deficiencies) as a way to stratify risk, regardless of imaging findings. DESIGN, PATIENTS AND MEASUREMENTS: Retrospective chart review of 197 patients seen at a single center from 2013 to 2022. Visual assessment was defined by distance acuity, and the presence of nystagmus or afferent pupillary defect. Pituitary deficiencies were diagnosed per Endocrine Society guidelines. RESULTS: In children with bilateral ONH (bONH), profound visual impairment was associated with more pituitary deficiencies between 0 and 15 years of age. The odds of having any pituitary deficiency were 4.9 times higher (95% confidence interval [95% CI]: 2.4-10.1) for patients with bONH versus unilateral ONH (uONH). Central hypothyroidism was the most common first presenting pituitary deficiency followed by growth hormone across all patients. CONCLUSION: This study shows a significant association between severity of visual impairment and increased probability of pituitary deficiencies in children with bONH versus uONH. Children with ONH require urgent endocrine evaluation due to risk of pituitary deficiencies, but risk stratification may also be based on severity of visual impairment.

Factors associated with difficult intravenous access in the paediatric emergency department: A prospective cohort study.

OBJECTIVES: Although it is the most performed invasive procedure, peripheral intravenous catheter (PIVC) insertion in children can be difficult. The primary objective of the study was to identify the factors associated with difficult intravenous access (DIVA) in the paediatric ED, including patient, proceduralist and situational factors. METHODS: This was a single-centre prospective observational cohort study conducted over 28 consecutive days. Research assistants observed PIVC insertion attempts for children under 16 years of age and recorded data for variables relating to the patient, proceduralist and event. Univariate logistic regression modelling was performed to identify factors associated with DIVA, defined as unsuccessful PIVC insertion on the first attempt. RESULTS: A total of 134 participants were recruited; 66 were male (49%) with a median age of 5.7 years. Fifty-two (39%) were classified as having DIVA. There was a total of 207 PIVC insertion attempts with two or more attempts needed for 48 children (36%). Patient factors associated with DIVA included age of 3 years or less and limited vein options. Proceduralist factors included gestalt of 50% or less chance of success, use of a larger gauge (smaller bore) PIVC and less PIVC insertion experience. Situational factors included a combative child, higher pain score and loud ambient noise. CONCLUSIONS: The present study identified multiple patient, proceduralist and situational factors that were associated with DIVA in the paediatric ED. Future studies should explore the development and implementation of a package to address DIVA in children, with the patient-centred goals of reducing pain and improving success.

Direct correlation of MR-DWI and histopathology of Wilms' tumours through a patient-specific 3D-printed cutting guide.

OBJECTIVES: The International Society of Paediatric Oncology-Renal Tumour Study Group (SIOP-RTSG) discourages invasive procedures to determine the histology of paediatric renal neoplasms at diagnosis. Therefore, the histological subtype of Wilms' tumours (WT) is unknown at the start of neoadjuvant chemotherapy. MR-DWI shows potential value as a non-invasive biomarker through apparent diffusion coefficients (ADCs). This study aimed to describe MR characteristics and ADC values of paediatric renal tumours to differentiate subtypes. MATERIALS AND METHODS: Children with a renal tumour undergoing surgery within the SIOP-RTSG 2016-UMBRELLA protocol were prospectively included between May 2021 and 2023. In the case of a total nephrectomy, a patient-specific cutting guide based on the neoadjuvant MR was 3D-printed, allowing a correlation between imaging and histopathology. Whole-tumour volumes and ADC values were statistically compared with the Mann-Whitney U-test. Direct correlation on the microscopic slide level was analysed through mixed model analysis. RESULTS: Fifty-nine lesions of 54 patients (58% male, median age 3.0 years (range 0-17.7 years)) were included. Forty-four lesions involved a WT. Stromal type WT showed the lowest median decrease in volume after neoadjuvant chemotherapy (48.1 cm3, range 561.5-(+)332.7 cm3, p = 0.035). On a microscopic slide level (n = 240 slides) after direct correlation through the cutting guide, stromal areas showed a significantly higher median ADC value compared to epithelial and blastemal foci (p < 0.001). With a cut-off value of 1.195 * 10-3 mm2/s, sensitivity, and specificity were 95.2% (95% confidence interval 87.6-98.4%) and 90.5% (95% confidence interval 68.2-98.3%), respectively. CONCLUSION: Correlation between histopathology and MR-DWI through a patient-specific 3D-printed cutting guide resulted in significant discrimination of stromal type WT from epithelial and blastemal subtypes. CLINICAL RELEVANCE STATEMENT: Stromal Wilms' tumours could be discriminated from epithelial- and blastemal lesions based on high apparent diffusion coefficient values and limited decrease in volume after neoadjuvant chemotherapy. This may aid in future decision-making, especially concerning discrimination between low- and high-risk neoplasms. KEY POINTS: MR-DWI shows potential value as a non-invasive biomarker in paediatric renal tumours. The patient-specific cutting guide leads to a correlation between apparent diffusion coefficient values and Wilms' tumour subtype. Stromal areas could be discriminated from epithelial and blastemal foci in Wilms' tumours based on apparent diffusion coefficient values.

Successful Intraosseous (IO) Adenosine Administration for the Termination of Supraventricular Tachycardia (SVT) in a 3.5-Year-Old Child-Case Report and Literature Review.

Paediatric supraventricular tachycardia (SVT) is a common arrhythmia of great clinical significance. If not treated promptly, it can cause heart failure and cardiogenic shock. Depending on the patient's condition, SVT treatment involves vagal manoeuvres, pharmacological, or direct current cardioversion. The goal of acute SVT management is to immediately convert SVT to a normal sinus rhythm (NSR) and prevent its recurrence. Adenosine is recommended as the first-line treatment for stable SVT by the European Resuscitation Council (ERC) and American Heart Association (AHA) guidelines, when vagal manoeuvres have proven ineffective. The ERC and AHA guidelines recommend the intravenous route of administration. The intraosseous (IO) administration technique is also possible, but still relatively unknown. The aim of this paper is to describe a 3.5-year-old child with SVT that was converted to NSR following IO administration of adenosine. Successful conversion was achieved after the second attempt with the adenosine dose. In the described case, there was no recurrence of SVT.

Lower indoor spatial frequency increases the risk of myopia in children.

BACKGROUND/AIMS: Animal models have shown that the absence of high-frequency visual information can precipitate the onset of myopia, but this relationship remains unclear in humans. This study aims to explore the association between the spatial frequency content of the visual environment and myopia in children. METHODS: Images from the rooms of children and their frequently visited outdoor areas were taken by their parents and collected by the researcher through questionnaires. The spatial frequency was quantified using Matlab. Cycloplegic refraction was used to measure the spherical equivalent (SE), and IOL Master was used to measure axial length (AL) and corneal radius (CR). AL/CR ratio was calculated. RESULTS: The study included 566 children with an average age of (8.04±1.47) years, of which 270 were girls (47.7%), and the average SE was (0.70±1.21) D. Image analysis revealed that indoor spatial frequency slope was lower than that of the outdoor environment (-1.43±0.18 vs -1.11±0.23, p<0.001). There were 79 myopic individuals (14.0%). Images from indoor content of myopic children had a lower spatial frequency slope than non-myopic children (-1.47±0.16 vs 1.43±0.18, p=0.03) while there was no significant difference in outdoor spatial frequency slope. Regression analysis indicated that the indoor spatial frequency slope was positively associated with SE value (ß=0.60, p=0.02) and inversely related to myopia (OR=0.24, p<0.05). CONCLUSION: The spatial frequency of the outdoor environment is significantly higher than that of the indoor environment. Indoor spatial frequency is related to children's refractive status, with lower indoor spatial frequency being associated with a higher degree of myopia.

Centre-based childcare in early childhood and child obesity: systematic review and meta-analysis protocol.

OBJECTIVES: Centre-based childcare has been identified as a promising environment for obesity prevention in early childhood, but the longitudinal relationships between attending centre-based childcare and child obesity are not well understood. The objective of this systematic review is to evaluate the longitudinal associations between centre-based childcare attendance in early childhood and child body mass index compared with other childcare settings or parental care. Subgroup analyses will also be conducted to determine if socioeconomic factors and characteristics of the childcare setting modify the relationships. METHODS: Databases that will be searched include MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database and Web of Science. Longitudinal prospective cohort studies, retrospective cohort studies, case-control studies and intervention trials conducted in middle-income and high-income countries will be included in the search strategy. Sensitivity and subgroup analyses will be conducted to explore factors that may modify the findings. Study selection, data extraction, risk of bias and quality of evidence assessments will be conducted independently and in duplicate by two reviewers. Risk of bias will be assessed using the Risk Of Bias In Non-randomized Studies - of Exposure tool. Meta-analysis will be conducted using random effects models to account for between-study variation. Heterogeneity across included studies will be estimated using the I2 statistic. If meta-analysis is not possible, a narrative summary will be provided. The quality of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. ETHICS AND DISSEMINATION: Ethical approval is not required for this study since no data will be collected. Findings aim to inform interventions and guide efforts in childcare settings to support optimal child growth. Results will be published in a peer-reviewed journal. Results may be of relevance for childcare and public health policy, researchers, parents and healthcare practitioners. PROSPERO REGISTRATION NUMBER: CRD42023436911.

How excellent can centres of excellence be? The impact of prevalence on service quality.

Centres of Excellence (CEs) are thought to provide better quality services for their speciality than Generic Services (GS). However, clinical test theory suggests this may arise from differences in the prevalence of these specialities' conditions in their referral populations, which affects the services' ability to detect diagnoses accurately, even with similar diagnostic sensitivities and specificities. Furthermore, GS' insensitivity to rarer diagnoses is necessary to avoid serious overdiagnosis despite using skills equivalent to CEs. Good GS can perform as well as CEs for disorders of 15% to 20% or greater prevalence in their referral populations, depending on the Minimal Clinically Important Difference (MCID) decided for their diagnoses' positive predictive values or degree of bias. CEs are necessary for rare disorders and have a role in determining MCIDs and the sensitivity and specificity of new measures. Sensitivity, specificity, positive & negative predictive values, and true diagnostic prevalence should be routine outcome measures.

Transition from Paediatric to Adult Diabetes Care in People with Type 1 Diabetes: An Online Survey from France.

INTRODUCTION: The transition from paediatric to adult diabetes care (TPA) of children/adolescents with type 1 diabetes (T1D) represents a unique challenge and remains a critical phase in the T1D care pathway. This study aims to describe and understand the experience of the transition process from a participant's perspective in young adults who are living in France with T1D and to measure their satisfaction. METHODS: An online questionnaire was presented to people with T1D in France on a global online participant community platform. The questionnaire was developed by a scientific committee including paediatric and adult diabetologists and refined by a group of participants. Thematic qualitative analysis was performed on the responses. RESULTS: A total of 104 respondents were included in the survey (mean age 24.4 years [95% CI 23.8-25.0]; 61.5% female). The mean age at the time of transition was 18.4 years (95% CI 17.8-18.9), and 56% of respondents had their first adult diabetology follow-up in the same institution. During TPA, of the 76 participants who experienced personal issues, 74% experienced at least one issue with their diabetes management in the months following the transition. In the following months, 61% experienced new or unexpected problems in monitoring their diabetes after transition and 44% reported unusual glycaemic imbalances, including hypoglycaemia (8%) and hyperglycaemia (9%) requiring hospitalisation. Presence of personal issues during TPA was significantly associated with occurrence of problems with diabetes management or glycaemic imbalance. Three factors identified for a successful transition were (i) early meeting with the 'adult' diabetes care team, (ii) letting the participants choose the right age to leave paediatric clinic and (iii) having good diabetes control at the beginning of the TPA process. CONCLUSION: Most young adults with T1D report experiencing issues around TPA with significant consequences on their disease management. Hence, it is necessary to identify these issues to better support them and improve diabetes management during this phase.

Minimal effects after a massive intravenous terbutaline overdose in a child.

A 22-kg female in early childhood with a history of reactive airway disease presented to a paediatric emergency department with acute shortness of breath, tachypnoea and wheezing. Despite treatment with albuterol and corticosteroids, her bronchospasm persisted, prompting the administration of terbutaline. The patient received 220 mcg (10 mcg/kg) terbutaline intravenously, followed immediately by an inadvertent supratherapeutic intravenous dose of 10 000 mcg (454.5 mcg/kg). The patient's laboratory results obtained minutes after the medication error were notable for: potassium, 3.1 mmol/L, lactate, 2.6 mmol/L and troponin I, 0.30 ng/mL (normal <0.03 ng/mL). Over the next 48 hours, serial serum troponin values decreased. The patient was discharged home approximately 72 hours after the initial presentation and she remained well based on follow-up calls over the next several months. Given the timing and trend of troponin concentrations, we do not believe the terbutaline overdose to be responsible for the myocardial injury.

Dr Catherine Chisholm, 'children's physician': Her work for child welfare and feminist networking in Manchester.

Catherine Chisholm BA MB ChB MD FRCP CBE (1879-1952) is celebrated as the first woman to qualify in medicine from Manchester University in 1904 and is remembered for founding the Manchester Babies Hospital in 1914 (later renamed in 1935 as the Duchess of York Hospital for Babies). She was indefatigable in her pursuit to improve the education and status of women doctors; the first woman member and president of the British Paediatric Society; first woman president of the Manchester Medical Society and was mainly responsible for establishing the Medical Women's Federation in 1917. Her career was a complex mixture of medical and social networks that linked her work as a children's physician to the Manchester Public Health Committee, Liberal politics and feminist groups. These networks played an important role in Dr Chisholm's successful career and are at the centre of this paper.

'We're taught green is good': Perspectives on time in range and time in tight range from youth with type 1 diabetes, and parents of youth with type 1 diabetes.

AIMS: Continuous glucose monitoring (CGM) systems are standard of care for youth with type 1 diabetes with the goal of spending >70% time in range (TIR; 70-180 mg/dL, 3.9-10 mmol/L). We aimed to understand paediatric CGM user experiences with TIR metrics considering recent discussion of shifting to time in tight range (TITR; >50% time between 70 and 140 mg/dL, 3.9 and 7.8 mmol/L). METHODS: Semi-structured interviews and focus groups with adolescents with type 1 diabetes and parents of youth with type 1 diabetes focused on experiences with TIR goals and reactions to TITR. Groups and interviews were audio-recorded, transcribed and analysed using content analysis. RESULTS: Thirty participants (N = 19 parents: age 43.6 ± 5.3 years, 79% female, 47% non-Hispanic White, 20 ± 5 months since child's diagnosis; N = 11 adolescents: age 15.3 ± 2 years, 55% female, 55% non-Hispanic White, 16 ± 3 months since diagnosis) attended. Participants had varying levels of understanding of TIR. Some developed personally preferred glucose ranges. Parents often aimed to surpass 70% TIR. Many described feelings of stress and disappointment when they did not meet a TIR goal. Concerns about TITR included increased stress and burden; risk of hypoglycaemia; and family conflict. Some participants said TITR would not change their daily lives; others said it would improve their diabetes management. Families requested care team support and a clear scientific rationale for TITR. CONCLUSIONS: The wealth of CGM data creates frequent opportunities for assessing diabetes management and carries implications for management burden. Input from people with type 1 diabetes and their families will be critical in considering a shift in glycaemic goals and targets.