RCPCH Conference 2019 - answers to your questions at plenaries

At this year's Conference, delegates were invited to submit questions via the 'Sli.do' function on our app. We didn't have time to answer all of these during the presentations, but our speakers have kindly provided these responses below.
Last modified
2 August 2019

Application of community child health survey data for estimating health risks from air pollution and exposure to cigarette smoke during pregnancy

Speaker: Dr Gibby Koshy, Senior National Public Health Specialist Advisor, Public Health England

Are all your associations confounded by poverty?

We did include lower socioeconomic status as one of the confounding factors as part of the logistic regression analysis. Townsend scores were used for socioeconomic categorisation, as this was used in all the previous follow up surveys.

What was the reason to look for a gender effect, and why was increased female births presented as a negative?

We looked at all data available for birth and child health outcomes in relation to maternal smoking during pregnancy and air pollution. Since we had data on male and female births, this was also included as one of the outcomes.

Significant association does not prove causality, This finding has also been reported as an association in many other studies published in peer reviewed journals. This needs to be looked into more detail for any dose response association and also there is need for including more related confounding factors in future studies. So, it is not being presented as negative, and it could be just a possible association.

All data seemed to come from deprived areas already at risk of your proven adverse consequences of smoking and air pollution (obesity).

All available confounding factors including lower socioeconomic status were included in the final logistic regression analysis, and there was a significant association even after adjusting for all the confounding factors. We did have four categories of socioeconomic status including lower and upper socioeconomic status based on Townsend scores.

You get to exhale now? Growing up LGBT+ in Britain today

Speaker: Dr Mike Farquhar, Consultant in Children’s Sleep Medicine, Evelina London Children's Hospital

Discrimination is often driven by representatives from faith groups. How can this be addressed and we as NHS professionals help?

Universal human rights issues are just that – universal, and there shouldn’t be any weight given to people who want to pick and choose only some elements of those to be taught to children. See the RCPCH's statement in this Telegraph article.

Is being a victim of bullying or cyberbullying in secondary school associated with subsequent risk-taking behaviour and delinquency in adolescence?

Speaker: Dr Rakhee Shah, North Middlesex, University Hospital

What are the best resources we can signpost to?

Here is a list of resources that you can signpost victims of bullying/cyberbullying and their parents/carers to;

  1. Childline provides several ways for young people who are victims of bullying to get support including counselling through chatting online, telephone and email. Young people under 19 can confidentially call, email or chat online about any problem big or small. Freephone 24h helpline: 0800 1111
    Young people can sign up for a Childline account on the website to be able to message a counsellor anytime without using your email address or chat 1:1 with an online advisor.
  2. Youngminds provides support for both victims of bullying and their parents/carers. Its crisis messenger provides free 24-hour crisis support across the UK when young people are experiencing a mental health crisis- for urgent help young people can text YM 85258.
    All texts are answered by trained volunteers, with support from experienced clinical supervisors. Texts are free from EE, O2, Vodafone, 3, Virgin Mobile, BT Mobile, GiffGaff, Tesco Mobile and Telecom Plus.
    Youngminds also has a helpline for parents/carers of victims of bullying who need to speak with someone a get advice.
  3. The Mix is an organisation that connect young people to experts and their peers who then provide the support and tools young people need to take on a wide range of  challenges including bullying victimisation. 
    Young people aged under 25 can talk to The Mix for free on the phone, by email or on their webchat. Young people can also use the phone counselling service, or get more information on support services that they might need. 
    Freephone: 0808 808 4994 (13:00-23:00 daily). 
  4. The NSPCC  and the Antibullying Alliance also have very useful resources for both young people who are experiencing bullying victimisation and their parents, teachers and schools. 

Are we still using the word "delinquent"?

The answer to this is both yes and no. The word “delinquency” was used in this study because the scale that was used to measure whether young people had been involved in criminal behaviour is named the ‘Self-reported delinquency scale (SRD)’. ‘Delinquency’ is a dated term, with negative connotations attached to it – some of the alternatives I has previously considered were ‘anti-social behaviour’ or ‘conduct disorder’; however, conduct disorder as an outcome for research purposes requires a formal diagnosis which was not made in this study. 

Any suggestions how to intervene?

Yes, the good news is that there are several things that we can do to intervene either as clinicians or in our advocacy/policy making roles.

  1. As paediatricians that work with young people who engage in risk-taking behaviour or weapon carrying we need to consider and ask specifically about bullying/cyberbullying victimisation when taking a history. Frameworks such as the HEADSSS assessment are very useful.
    Taking a focused internet use history from young people needs to become part of routine practice to pick up cyberbullying victimisation. 
  2. As clinicians in advocacy roles and non-clinicians in health promoting and policy making roles we need to address the more upstream factors that predispose young people to bullying victimisation including poverty, low parental education, overcrowding in schools and childhood emotional problems. 
  3. The evidence points towards using whole school approaches to reduce both bullying perpetration and bullying victimisation in schools. The All Together Programme is a whole school anti-programme bullying programme which is open to new schools.
    School interventions to reduce bullying victimisation are invaluable; however, they cannot completely eradicate bullying victimisation and have not been proven to reduce cyberbullying victimisation. Therefore, to reduce risk-taking and delinquent behaviour associated with bullying victimisation, whole school interventions in school could widen their scope to focus on increasing resilience among young victims of bullying. 
  4. To prevent and reduce cyberbullying as clinicians and policy makers we need to work closely with the large technology giants (social media companies) to ensure that social media platforms safeguard young people, making it difficult for underage use, and use innovation to reduce cyberbullying victimisation and perpetration.

Did you have any additional data on LGBT bullying as Dr Mike Farquhar referred to?

As the baseline group of secondary school students had a mean age of 11.7 years, only a handful of young people identified as LGBT in the self-reported questionnaire and therefore there was unfortunately too little data to consider whether identifying as LGBT was an important confounding factor in the analysis.

Future studies need to consider how young people’s sexuality can be asked about in a sensitive manner to reduce under-reporting. 

Emergency treatment with levetiracetam or phenytoin in status epilepticus in children: a pragmatic, randomised controlled trial (the ‘EcLiPSE Trial)

Speaker: Richard Appleton, Chief Investigator, EcLiPSE, Consultant and Honorary Professor in Paediatric Neurology

How did deferred consent go through the ethics committee?

There was no difficulty in obtaining approval from the National (Central) Ethics Committee. The Committee understood the principle and the importance of undertaking research in paediatric emergency medicine. We also cited a previous study in which I had been a co-designer, co-applicant and author and which had also used deferred consent, or ‘research without prior consent (RWPC)’. As far as we were aware at the time of this earlier study, it was the first to use this approach.

This is the study: McIntyre J, Robertson S, Norris E, Appleton R, Whitehouse W, Phillips B, et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomized controlled trial. Lancet 2005; 366: 205-10.

Why was it designed as a superiority rather than a non-inferiority trial?

A superiority trial was considered more appropriate based on the considerable anecdotal data on levetiracetam which had suggested its efficacy in terminating convulsive status epilepticus ranged from 65% to 90%. Conversely, the very limited data on phenytoin had suggested an effectiveness rate of approximately 60%. We therefore considered a superiority protocol was both appropriate and relevant for what we hoped to demonstrate in the trial.

The results of EcLiPSE clearly emphasise the importance of undertaking robust randomised controlled trials (RCTs).

If parents do not consent to trial but have already been randomised, how do you explain their treatment to them?

This was clearly an important issue identified by both the Trial Management Group and the site investigators. Understandably, many of the sites had never heard of the principle of deferred consent (RWPC) and were somewhat apprehensive. Consequently it was very carefully discussed at each site initiation visit of the 31 participating sites. This included a very clear and informative video of a simulated interview between the parents of a child that had been enrolled, randomised and treated and a member of the research nursing team – as a model of how such a potentially interview should be conducted.

As stated in the presentation, only 19 (6.6%) families declined consent when the process of their child’s enrolment, randomisation and treatment had been explained by an appropriate member of the site’s EcLiPSE research team. This included one family whose child had died for reasons that were definitely unrelated to the trial medications.

None of these 19 families subsequently ‘complained’ about their child being treated without having first obtained consent.

Do we need to change all our operating procedures in ED (Emergency Departments) now?

No, there should be no national, including APLS (Advanced Paediatric Life Support), change for now.

Clearly, some ED clinicians may decide to use levetiracetam first based on the EcLiPSE results, speed of administration and lack of any know serious adverse reactions. This will be a personal decision.

As mentioned in the presentation, a very similar study from New Zealand and Australia was also published in the same issue of the Lancet on 17 April 2019. Their results showed a slight and statistically non-significant trend in favour of phenytoin, in contrast to our study which showed a statistically non-significant trend in favour of levetiracetam. A meta-analysis between the two studies is planned.

In addition, a US study (the ESETT study) will publish its results in 2020. This study has three arms, fosphenytoin (a pro-drug of phenytoin and which is the US’s preferred anticonvulsant), levetiracetam and sodium valproate.

Wisdom would dictate that a multi-specialty group in the UK, comprising of paediatric emergency medicine, general paediatrics, paediatric neurology, paediatric intensive care and paediatric pharmacology, meet to discuss these new data and produce a recommendation. I have asked the Chair of the British Paediatric Epilepsy Group (BPEG, which is the specialist advisory group on epilepsy to the BPNA) to convene this meeting in late 2019 or early 2020. This may be prior to publication of the ESETT study, as these meetings and their outputs take time and I do not think they should necessarily postponed because of ESETT, if the publication of its results is delayed.  

Is there utility is considering the difference between time taken to administer levetiracetam and phenytoin rather than from the end of the infusion?

The EcLiPSE team were surprised by the time taken to prepare and administer both drugs. However, this is artificially long because of the wish not to prolong administration of either levetiracetam or phenytoin because of the process of randomisation which included opening the envelope and proceeding as per its contents. This is why a post hoc sensitivity analysis looked at cessation of the status from the start of the infusion and not only from the time of randomisation.

The sensitivity analysis confirmed the pre-determined outcome in there being no statistically significant difference between the two drugs from the start of their infusion.

There is clearly a practical benefit is using levetiracetam in preference to phenytoin because of its easier preparation and relative rapid administration. These are important factors in ‘real life’ and may help to decide that levetiracetam replaces phenytoin as the preferred first-choice second-line drug in the management  

When are NICE revising guidelines?

They are currently reviewing all aspects of epilepsy, including the management of status epilepticus. It is expected the revised guideline will not be published until mid to late 2020.

Tenfold medication errors in children – Welsh Paediatric Surveillance Unit Study 2017–18

Speaker: Dr David Tuthill, Consultant Paediatrician, Children’s Hospital for Wales

Would we get different problems with electronic prescribing?

Depends on how advanced the system is (all different) – it will result in different problems. Newcastle has just done a big study pre and post change to e-prescribing so should get some results when it gets published later this year.

How do you plan to expediate safe electronic prescribing and will it include community as well as hospital settings?

The nature of the different hospital trusts means all systems will be different. We feel the great work in Wales to standardise prescribing chart will be lost if all systems are different – we need to lobby for the NHS to have single systems that look the same. Junior doctors are the biggest prescribers in hospitals and they move around every six months needing to learn a new system. That is a big risk.

Is there similar data for rest of UK?

There is no population data anywhere in the world. One children’s hospital in Canada published their data. Dr Tse has looked at England and Wales NRLS data but there is no denominator data and it is incomplete due to the massive number of data and inability to search precisely.