Recent Submissions

  • Proceedings of 20th ISPAD science school for physicians 2021.

    Zuijdwijk, Caroline; Vukovic, Rade; Marks, Brynn E; Mandilou, Steve Vassili Missambou; Ng, Sze May; Wright, Neil; Krogvold, Lars; Barrett, Timothy; Agwu, Juliana Chizo; Agwu, Juliana Chizo; et al. (Wiley, 2021-07-08)
    Proceedings of 20th ISPAD science school for physicians 2021
  • Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline.

    Agwu, Juliana Chizo; Ng, Sze M; Agwu, Juliana Chizo; Paediatrics; Medical and Dental; University of Birmingham; Southport and Ormskirk NHS Trust; University of Liverpool; Sandwell and West Birmingham NHS Trust (Wiley, 2021-05-17)
    Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.
  • Fifteen-minute consultation: Practical use of continuous glucose monitoring.

    Soni, Astha; Wright, Neil; Agwu, Juliana Chizo; Drew, Josephine; Kershaw, Melanie; Moudiotis, Christopher; Regan, Fiona; Williams, Eleri; Timmis, Alison; Ng, Sze May; et al. (BMJ Publishing Group, 2021-05-07)
    Type 1 diabetes is a self-managed condition. Regular monitoring of blood glucose (BG) levels has been the cornerstone of diabetes management. Finger prick BG testing traditionally has been the standard method employed. More recently, rapid advancements in the development of continuous glucose monitoring devices have led to increased use of technology to help children and young people with diabetes manage their condition. These devices have the potential to improve diabetes control and reduce hypoglycaemia especially if used in conjunction with a pump to automate insulin delivery. This paper aims to provide an update on main CGM devices available and practical considerations for doctors if they come across a child with diabetes who is using one of these devices.
  • Effecting a national implementation project through distributed leadership in the West Midlands: rising to the spread challenge.

    Gillies, James; Morton, Victoria A Hodgetts; Jasim, Simone; Fox, Caroline; Broggio, Penny; Pillay, Thillagavathie; Broggio, Penny; Paediatrics; Medical and Dental; NHS England; Birmingham Women's and Children's NHS Foundation Trust; University of Wolverhampton; Sandwell and West Birmingham NHS Trust (BMJ Publishing Group, 2021-05)
    We describe the utility and impact of a distributed leadership model to implement a National Health Service (NHS) England Academic Health Sciences national quality improvement programme, in the West Midlands. This model was adopted to address the inherent difficulties of implementing change in practice in a large geographical region with a diverse population of health service personnel. We report on the inclusion of a senior trainee as part of the implementation team, supported by a multidisciplinary clinical consultant team, with equal agency in decision making, acting as mentors and activators in the background.
  • Development of central precocious puberty following cannabinoid use for paediatric epilepsy: causal or coincidence?

    Krishnan, Aditya; Agwu, Juliana Chizo; Kallappa, Chetana; Pandey, Rajesh; Agwu, Juliana Chizo; Kallappa, Chetana; Pandey, Rajesh; Paediatrics; Medical and Dental; University Hospitals Birmingham NHS Foundation Trust; Sandwell and West Birmingham NHS Trust (BMJ Publishing Group, 2021-04-15)
    Research suggests a role for cannabidiol oil in managing certain forms of paediatric onset epilepsy. However, studies on the impact of cannabis on the hypothalamo-pituitary-gonadal (HPG) axis have conflicting results. Delta-9-tetrahydrocannabinol (Δ9-THC) acutely inhibits gonadotropin-releasing hormone in the hypothalamus, reducing testosterone levels by 65% in rhesus monkeys. Additionally, there have been reports of pubertal arrest and delayed puberty in male cannabis users. In contrast, other studies have reported higher testosterone levels following long-term cannabis use.A 2-year-old boy presented with testicular enlargement, increased penile length and growth of coarse pubic hair developing over 6 months. His mother procured cannabidiol oil online, which he started taking 7 months earlier for severe epilepsy refractory to medical management. Subsequent investigations confirmed central precocious puberty. While it is unclear whether the precocious puberty is a direct consequence of HPG axis activation by Δ9-THC, this case demonstrates a temporal association between cannabis use and development of precocious puberty.
  • Coexistence of medium chain acyl-CoA dehydrogenase deficiency (MCADD) and type 1 diabetes (T1D): a management challenge.

    Afreh-Mensah, Donald; Agwu, Juliana Chizo; Afreh-Mensah, Donald; Agwu, Juliana Chizo; Paediatrics; Medical and Dental; Sandwell and West Birmingham NHS Trust (BMJ Publishing Group, 2021-03-24)
    Medium chain acyl-CoA dehydrogenase deficiency (MCADD) is an autosomal recessive fatty acid β-oxidation defect. The enzyme, medium chain acyl-CoA dehydrogenase is important in the breakdown of medium chain fats into acetyl-CoA to produce ketones. Ketones are used as an alternative energy source when glucose or hepatic glycogen stores become depleted during prolonged fasting. In MCADD during periods of fasting or acute illness, there are insufficient ketones to compensate for the glucose energy deficit, resulting in an hypoketotic hypoglycaemia alongside a build-up of fatty acids. This build-up of fatty acids can be neurotoxic and lead to altered brain function and even unexpected death. Management includes avoiding prolonged periods of starvation, consuming high carbohydrate drinks during periods of illness and in symptomatic patients, reversal of catabolism and sustained anabolism by provision of simple carbohydrates by mouth or intravenously. Coexistence of MCADD and type 1 diabetes (T1D) is rare, there is no causal association though there are some documented cases. A key goal of management in T1D is achievement of good glycaemic control to reduce risk of long-term complications. This can in some cases increase the risk of hypoglycaemia which can be catastrophic in the presence of MCAD.
  • BSACI Nut allergy guideline audit by national survey : a summary of findings

    Norris, Felicity; Dhesi, Amrit; Shaikh, Shifa; Clark, Andrew T; Stiefel, Gary; Dhesi, Amrit; Paediatrics; Medical and Dental; University Hospitals of Leicester NHS Trust; Sandwell and West Birmingham NHS Trust; British Society of Allergy and Clinical Immunology; Cambridge University Hospitals (Wiley, 2024-08-06)
    No abstract available.
  • Clinical characteristics and treatment requirements of children with autosomal recessive pseudohypoaldosteronism.

    Bandhakavi, Meena; Wanaguru, Amy; Ayuk, Loveline; Kirk, Jeremy M; Barrett, Timothy G; Kershaw, Melanie; Högler, Wolfgang; Shaw, Nicholas J; Bandhakavi, Meena; Paediatrics; et al. (Oxford University Press, 2021-05)
    Introduction: Autosomal recessive forms of pseudohypoaldosteronism are caused by genetic defects in the epithelial sodium channel. Little is known about the long-term outcome and medication needs during childhood and adolescence. Objective: This study reports a single-centre experience of children affected with this ultra-rare condition over a 37-year period. Methods: We report the clinical presentation, growth, neuro-development, associated conditions, mortality and medication dosing and administration for 12 affected children from eight families. Results: All children were presented within the first 2 weeks of life with life-threatening, severe hyperkalaemia and hyponatraemia. All parents were consanguineous and of South Asian, Middle Eastern or African ethnic origin. Eight children had homozygous mutations in the SCNN1A and SCNN1G genes, encoding the epithelial sodium channel subunits alpha and gamma, respectively, including one novel mutation. Three children died (25%) and two (16%) had severe neurological impairment post-cardiac arrest secondary to hyperkalaemia. One affected female had a successful pregnancy at the age of 28 years. Conclusion: Despite high mortality and morbidity in this condition, survival with normal physical and neurological outcome is possible, justifying intensive management to prevent electrolyte imbalance.
  • Barriers to paediatric penicillin allergy de-labelling in UK secondary care : a regional survey

    Maduemem, Kene; Clark, Hannah; Sohal, Iseult; Dawson, Tom; Makwana, Niten; Makwana, Niten; Paediatrics; Medical and Dental; Birmingham Women's and Children's NHS Foundation Trust; Worcestershire Acute Hospitals NHS Trust; University Hospitals of North Midlands NHS Trust; Sandwell and West Birmingham NHS Trust (BMJ Publishing Group, 2022-12-19)
    Background: Incorrect penicillin allergy labels result in the use of inappropriately broad-spectrum antibiotics. De-labelling inaccurate penicillin allergy promotes antimicrobial stewardship and optimises prescribing practices. The objectives were to evaluate paediatric clinicians' knowledge and understanding of penicillin allergy and to identify barriers in tackling incorrect penicillin allergy labels. Methods: Paediatric clinicians from across the West Midlands of the UK were surveyed using an online, anonymised questionnaire between 1 August and 30 September 2021. Domains explored were (1) approach to penicillin allergy clinical vignettes, (2) knowledge of the impact of penicillin allergy labels, (3) frequency of allergy-focused history questions and (4) barriers in tackling incorrect penicillin allergy. Results: Responses were received from 307 paediatric clinicians across 12 hospitals. Sixty-one per cent would not prescribe a penicillin-based antibiotic if a family history of penicillin allergy was reported. There was an overall deficit in taking an allergy-focused history with only 36.5% inquiring about diagnostic confirmation. Absence, or lack of awareness of a referral pathway for antibiotic allergy evaluation (58.6%) and unfamiliarity of the indications for oral provocation testing (55%) were the most common reported barriers to penicillin allergy de-labelling. Fifty-one per cent would rather 'play it safe' than explore penicillin allergy confirmation as it is felt that alternative treatments were readily available. Conclusions: The deficiency in antibiotic allergy-focused history among paediatric clinicians highlights the need for better allergy education across all clinical grades. Pragmatic algorithms and clear referral pathways could address barriers faced by non-allergists in de-labelling incorrect penicillin allergy.
  • Type 2 diabetes: summary of updated NICE guidance.

    Moran, Gregory M; Bakhai, Chirag; Song, Soon H; Agwu, Juliana Chizo; Agwu, Juliana Chizo; Sandwell and West Birmingham NHS Trust; Medical and Dental; National Institute for Health and Care Excellence; Luton and Milton Keynes Clinical Commissioning Group; Sheffield Teaching Hospitals NHS Foundation Trust; Sandwell and West Birmingham NHS Trust (BMJ Publishing Group, 2022-05-18)
    No abstract available
  • Do you know when the inhaler is empty?

    Fullwood, I; Evans, T; Davies, Benjamin; Ninan, T; Onyon, C; Clarke, J; Srikanthiah, Rajesh; Frost, Susan; Iqbal, N; Atkinson, M; et al. (BMJ Publishing Group, 2022-05-12)
    Background: Medication review is recommended at asthma appointments. The presence of propellant in the metered dose inhalers (MDIs) makes it challenging to identify when the inhaler is empty. The COVID-19 pandemic has resulted in move towards more virtual monitoring of care. We aimed to evaluate if patients identify when the inhaler is empty and the method of inhaler disposal. Methods: Prospective, multicentre quality improvement project. Data collected from children with asthma and other respiratory conditions. Outcome measures: Children/carers attending hospital were asked how they identify an empty salbutamol inhaler; dose counters in the preventer inhalers and disposal practices were reviewed. Results: 157 patients recruited. 125 (73.5%) patients deemed an empty inhaler as either full/partially full. 12 of 66 (18.2%) preventer inhalers with a dose counter were empty. 83% disposed their inhalers in a dustbin. Conclusions: Patients cannot reliably identify when their MDI is empty. There is an urgent need for improving inhaler technology and providing appropriate guidance on how to identify when an MDI is empty.
  • National Survey of United Kingdom Paediatric Allergy Services.

    Wells, Rosy; McKay, Cathy; Makwana, Nick; Vyas, Deepan; Vaughan, Sophie; Christopher, Anne; Thomas, Lucy; Primett, Misbah; Diwakar, Lavanya; Alvis, Shamir; et al. (Wiley, 2022-08-03)
    Background: Comprehensive national assessments of paediatric allergy services are rarely undertaken, and have never been undertaken in the United Kingdom. A 2006 survey estimated national capacity at 30,000 adult or paediatric new allergy appointments per year and identified 58 hospital clinics offering a paediatric allergy service. Objective: The UK Paediatric Allergy Services Survey was the first comprehensive assessment of UK paediatric allergy service provision. Methods: All 450 UK hospitals responded to a survey. Paediatric allergy services are provided in 154 lead hospitals with 75 further linked hospitals. All 154 lead paediatric allergy services completed a detailed questionnaire between February 2019 and May 2020. Results: The 154 paediatric allergy services self-define as secondary (126/154, 82%) or tertiary (28/154, 18%) level services. The annual capacity is 85,600 new and 111,400 follow-up appointments. Fifty-eight percent (85/146) of services offer ≤10 new appointments per week (no data provided from 8 services-2 no response, 6 unknown) and 50% (70/139) of the services undertaking challenges undertake ≤2 food or drug challenges per week (no data from 3 challenge services). Intramuscular adrenaline is rarely used during challenges-median annual frequency 0 in secondary services and 2 in tertiary services. Allergen-specific immunotherapy is offered in 39% (60/154) of services, with 71% (41/58) of these centres treating ≤10 patients per annum (no data from 2 immunotherapy services). The 12 largest services see 31% of all new paediatric allergy appointments, undertake 51% of new immunotherapy patient provision and 33% of food or drug challenges. Seventy percent (97/126) of secondary and all tertiary services are part of a regional paediatric allergy network. Only nine services offer immunotherapy for any food (3 for peanut), 10 drug desensitization and 18 insect venom immunotherapy. Conclusions: There has been a fourfold increase in paediatric allergy clinics and an approximately sevenfold increase in new patient appointment numbers in the United Kingdom over the past 15 years. Most services are small, with significant regional variation in availability of specific services such as allergen immunotherapy. Our findings emphasize the need for national standards, local networks and simulation training to ensure consistent and safe service provision.
  • A practical approach to continuous glucose monitoring (rtCGM) and FreeStyle Libre systems (isCGM) in children and young people with Type 1 diabetes.

    Soni, A; Wright, N; Agwu, Juliana Chizo; Timmis, A; Drew, J; Kershaw, M; Moudiotis, C; Regan, F; Williams, E C; Wan, Jessica; et al. (Elsevier, 2022-01-13)
    Real-time continuous glucose monitoring (rtCGM) and FreeStyle Libre glucose monitoring systems (isCGM) are new evolving technologies used in the management of Type 1 diabetes. They offer potential to improve diabetes control and reduce hypoglycaemia. rtCGM can be linked to insulin pump providing hybrid closed loop therapy. Families of children and young people are keen to have the benefit from these technologies. These are relatively expensive so it is important that health care professionals, families of children and young people (CYP) with diabetes are adequately trained in the use of these devices. Health care professionals need to be able to make patient selection based on individual needs and preferences to achieve maximum benefit. Association of Children's Diabetes Clinicians (ACDC) developed a comprehensive guideline in 2017 to help identify which patients may be most likely to benefit and how these technologies may be practically implemented. Since then new technologies have been introduced and the use of GCM has expanded in routine clinical practice. This article, aims to provide a practical approach and help identify which patients may be most likely to benefit and how the technology may be implemented in order to maximise the clinical benefits.