The impact of dental caries and its treatment under general anaesthetic on children and their families.

OBJECTIVE: To assess the impact of dental caries and treatment under general anaesthetic (GA) on the everyday lives of children and their families, using child-reported measures of quality of life (QoL) and oral health-related quality of life (OHRQoL). METHOD: Participants, aged 5-16 years old having treatment for dental caries under GA, were recruited from new patient clinics at Charles Clifford Dental Hospital, Sheffield. OHRQoL was measured before and 3-months after treatment using the Caries Impacts and Experiences Questionnaire for Children (CARIES-QC). Overall QoL was measured using the Child Health Utility 9D (CHU9D). Parents/caregivers completed the Family Impact Scale (FIS). RESULTS: Eighty five parent-child dyads completed the study. There was statistically significant improvement in OHRQoL (mean interval score difference in CARIES-QC = 4.43, p < 0.001) and QoL (mean score difference in CHU9D = 2.48, p < 0.001) following treatment, with moderate to large effect sizes. There was statistically significant improvement in FIS scores (mean score difference = 5.48, p = 0.03). CONCLUSIONS: Treatment under GA was associated with improvement in QoL and OHRQoL as reported by children, and reduced impacts on the family. This work highlights the importance of GA services in reducing the caries-related impacts experienced by children. Further work is needed investigate the impact of clinical, environmental and individual factors.

Factors affecting the growth of infants diagnosed with cystic fibrosis by newborn screening.

BACKGROUND: Newborn screening (NBS) for cystic fibrosis (CF) improves nutritional outcomes. Despite early dietetic intervention some children fail to grow optimally. We report growth from birth to 2 years in a cohort of children diagnosed with CF by NBS and identify the variables that influence future growth. METHODS: One hundred forty-four children were diagnosed with CF by the West Midlands Regional NBS laboratory between November 2007 and October 2014. All anthropometric measurements and microbiology results from the first 2 years were collated as was demographic and CF screening data. Classification modelling was used to identify the key variables in determining future growth. RESULTS: Complete data were available on 129 children. 113 (88%) were pancreatic insufficient (PI) and 16 (12%) pancreatic sufficient (PS). Mean birth weight (z score) was 3.17 kg (- 0.32). There was no significant difference in birth weight (z score) between PI and PS babies: 3.15 kg (- 0.36) vs 3.28 kg (- 0.05); p = 0.33. By the first clinic visit the difference was significant: 3.42 kg (- 1.39) vs 4.60 kg (- 0.48); p < 0.0001. Weight and height remained lower in PI infants in the first year of life. In the first 2 years of life, 18 (14%) infants failed to regain their birth weight z score. The median time to achieve a weight z score of - 2, - 1 and 0 was 18, 33 and 65 weeks respectively. The median times to reach the same z scores for height were 30, 51 and 90 weeks. Birth weight z score, change in weight z score from birth to first clinic, faecal elastase, isolation of Pseudomonas aeruginosa, isolation of Staphylococcus aureus and sweat chloride were the variables identified by the classification models to predict weight and height in the first and second year of life. CONCLUSIONS: Babies with CF have a lower birth weight than the healthy population. For those diagnosed with CF by NBS, the weight difference between PI and PS babies was not significantly different at birth but became so by the first clinic visit. The presence of certain factors, most already identifiable at the first clinic visit can be used to identify infant at increased risk of poor growth.

An approach to the child with a wet cough.

When children have a wet cough, it suggests the presence of secretions in their airways. This often has an infectious aetiology which is usually a self-limiting viral infection requiring no investigation or treatment. In those with acute wet cough it is, however, important to identify features suggestive of community acquired pneumonia or an inhaled foreign body as these causes require specific management. When there is chronic wet cough, the most common diagnoses are protracted bacterial bronchitis (PBB) and bronchiectasis. The relationship between these two conditions is complex as the development of bronchiectasis manifests as a clinical continuum in which the early features of which are indistinguishable from PBB. It is therefore important to identify PBB and chronic cough endotypes which are associated with an increased risk of bronchiectasis. This article offers a pragmatic approach to the investigation and treatment of children with wet cough. It is hoped this will limit unnecessary investigations whist aiding the prompt diagnosis of conditions needing treatment to reduce symptom burden and prevent further lung damage.

Is hypnotherapy an acceptable treatment option for children with habit cough?

Habit cough is a chronic, persistent dry cough which occurs in children only when awake. It is considered functional (non-organic) and can have a significant impact on the quality of life of the child and their family. One possible treatment option for habit cough is hypnotherapy. At our centre we offered hypnotherapy sessions to patients diagnosed with habit cough, and conducted telephone interviews with patients' parents to determine the acceptability of this therapy. Nine patients' parents were interviewed, and despite being unsure of what to expect with hypnotherapy, all nine found it an acceptable treatment option. Parents reported that hypnotherapy appeared to result in cough reduction or cessation in 6 out of 9 cases.

A systematic review of early life factors which adversely affect subsequent lung function.

It has been known for many years that multiple early life factors can adversely affect lung function and future respiratory health. This is the first systematic review to attempt to analyse all these factors simultaneously. We adhered to strict a priori criteria for inclusion and exclusion of studies. The initial search yielded 29,351 citations of which 208 articles were reviewed in full and 25 were included in the review. This included 6 birth cohorts and 19 longitudinal population studies. The 25 studies reported the effect of 74 childhood factors (on their own or in combinations with other factors) on subsequent lung function reported as percent predicted forced expiration in one second (FEV1). The childhood factors that were associated with a significant reduction in future FEV1 could be grouped as: early infection, bronchial hyper-reactivity (BHR) / airway lability, a diagnosis of asthma, wheeze, family history of atopy or asthma, respiratory symptoms and prematurity / low birth weight. A complete mathematical model will only be possible if the raw data from all previous studies is made available. This highlights the need for increased cooperation between researchers and the need for international consensus about the outcome measures for future longitudinal studies.

Two case reports of the successful eradication of new isolates of Burkholderia cepacia complex in children with cystic fibrosis.

BACKGROUND: Chronic infection with Burkholderia cepacia complex (BCC) has a detrimental effect on morbidity and mortality for patients with cystic fibrosis (CF). It is therefore logical to attempt to eradicate new isolates however there is a paucity of information to guide treatment. We report the successful eradication of new isolates of BCC in two children with CF. CASE PRESENTATION: Burkholderia cepacia was successfully eradicated in a 14 year old boy with CF and Burkholderia gladioli was successfully eradicated in a six year old girl with CF. In both children two weeks of intravenous (IV) tobramycin, ceftazidime and temocillin were used followed by three months of inhaled tobramycin. Bronchoalveolar lavage samples taken during flexible bronchoscopy were used prior to treatment to exclude spontaneous clearance as well as after treatment to confirm eradication. CONCLUSIONS: New isolates of BCC can be successfully eradicated in children with CF. More research is urgently required in this area to identify the best treatment regimen for BCC eradication.

A multicentre, multicycle audit of the prescribing practices of three paediatric dental departments in the North of England.

BACKGROUND: Odontogenic infections are frequently treated with antimicrobials. The inappropriate use of these medications has led to bacterial resistance and the development of species which are resistant to the antimicrobials currently available. This has serious implications for global public health. AIM: A multicycle clinical audit was carried out to compare the prescribing practices of three paediatric dental departments in the North of England. RESULTS: Results revealed deficiencies in prescribing practices in all three centres. Following education and the provision of an aide-memoire in subsequent cycles, improvements were seen in appropriateness of prescribing, increasing from 28% in the first cycle, to 71% in the third cycle.

'I felt weird and wobbly.' Child-reported impacts associated with a dental general anaesthetic.

AIM: This qualitative study sought to obtain children's accounts of having dental extractions under general anaesthesia (GA). The aim was to gain greater understanding of the physical and psychological impacts from a child's perspective. METHOD: Ten children, aged 6-11 years, maintained a video diary to document their feelings and experiences before, and following their hospital admission. Two semi-structured home interviews supplemented the video diary data and analysis was guided by narrative approaches. RESULTS: This research revealed new insights into children's experiences of having teeth removed under GA. Several of the post-operative impacts correlated with those previously reported by parents/carers. These were notably nausea, bleeding and tiredness, although children used different terminology. However, additional physical and psychological outcomes, both positive and negative, emerged from the children's narratives. Negative aspects included hunger, disturbed eating, being scared/worried and experiencing discomfort from the IV cannula. Interestingly, pain was not a strong theme. Positive outcomes were also reported, such as satisfaction with the resolution of their dental problem and receipt of rewards and attention from family members. CONCLUSION: These accounts have implications for improving patient experiences and outcomes throughout the dental GA care pathway. A review of pre-operative fasting protocols should be a priority.

Undergraduates' self-reported clinical experience, confidence and perspectives of hospital and outreach paediatric dentistry: a three-year multi-centre evaluation.

A variety of educational approaches exist within U.K. dental schools, and institutions are constantly striving to improve the quality of their graduates. This study aimed to evaluate the self-reported confidence in, and clinical exposure to, paediatric dentistry at three U.K. dental schools (Liverpool, Manchester and Sheffield) over a three year period. Seventy-five percent of final year BDS undergraduates at the three dental schools completed an anonymous questionnaire capturing student self-reported clinical experience in seven core paediatric dentistry treatment skills, both in hospital and outreach settings. Visual analogue scales were used to record self-assessed confidence levels in aspects of paediatric dentistry and students were also asked to provide a written reflection of both their hospital and outreach placements. The results revealed that despite the variety of educational approaches taken, undergraduates reported very similar levels of clinical experience and confidence. Significant interschool differences in student experience were found with respect to the management of carious primary molars, believed to be a result of individual schools favouring different treatment regimes. Although outreach placements were seen as essential for gaining adequate student experience, the need to improve the consistency of teaching between hospital and outreach centres was highlighted. The study also emphasises the need to take care when using clinical targets in undergraduate teaching and identifies the potential benefits of undergraduate training in inhalation sedation. Finally, despite changes to the paediatric programmes with respect to dental trauma management, students remained lacking in confidence suggesting the need for further development.

Video diaries to capture children's participation in the dental GA pathway.

AIM: To explore children's experiences of having teeth extracted under general anaesthetic, with a focus on opportunities to participate in their care pathway. STUDY DESIGN: Qualitative study where analysis was informed by a narrative approach. METHODS: Ten fit and healthy children, aged 6-11 years, who required multiple dental extractions under general anaesthesia at a UK Children's Hospital, participated in the study. Participants were invited to keep a video diary of their thoughts and experiences leading up to, and following, their hospital admission. Data collection was supported by two semi-structured home interviews. RESULTS: Three themes emerged relating to participation: (i) children's prior knowledge and expectations of the dental general anaesthetic (DGA); (ii) their role in decision-making about the DGA and (iii) opportunities identified by children to actively participate in their care pathway. Children's feedback suggested that they did not feel fully informed or involved in decisions about the procedure and were upset about not being able to keep their extracted teeth. CONCLUSIONS: Child-centred resources and decision-aids may be helpful in providing greater opportunities for children to participate in their DGA pathway. However, considerable challenges lie in engaging children without increasing pre-DGA anxiety or conflicting with parents' views about what is best for their child.

Impact of the Hall technique for preformed metal crown placement on undergraduate paediatric dentistry experience.

The Hall technique, a novel method of placing preformed metal crowns (PMCs) without local anaesthesia or tooth preparation, was introduced to our undergraduate dental curriculum in 2009. This study aimed to describe student experience of, and attitudes towards, PMCs before and after exposure to this new technique. Clinical data were extracted from student logbooks to determine the number of PMCs placed for cohorts graduating in 2005 (n = 55), 2009 (n = 61) and 2010 (n = 75). Five focus groups were also conducted with 29 final-year dental students. Students graduating in 2005, 2009 and 2010 had placed a mean (range) of 0.03 (0-1), 0.63 (0-5) and 1.15 (0-9) PMCs, respectively. The proportion of students who had placed a PMC increased significantly from only 1.9% in 2005 to 75% in 2010 (P < 0.05, ANOVA). Students reported some positive experiences of the Hall technique. However, concern over perceived lack of future clinical support, an anticipated increase in time and financial pressures, and the ease of use of glass-ionomer cement as an alternative were described as potential barriers to PMC use. Findings suggest that the introduction of the Hall technique has had a marked impact on the use of PMCs as a treatment modality for carious primary teeth.