Contents Preface s3 - - Executive summary s4 - - Introduction s6 - - Background considerations s6 Definitions s6 The extent of withholding and withdrawal of LST in paediatric practice s6 The legal ...framework s7 Statutes s7 The child and young adult s8 Parental Responsibility s8 The role of the courts in end-of-life decision making s9 Best interests s9 Quality of life and legal decisions s9 Withdrawing treatment s9 The ethical framework s10 Fundamental considerations s10 The interests of the child s10 Parental discretion responsibilities, rights, duties and power s10 Parental interests, wishes and professional duties s11 Involving children s11 Children with disabilities s11 Transition to adult services s12 Axioms on which to base best practice s12 - - The process of decision making s13 Practical considerations; substantial issues in decision making s13 To withhold, to withdraw or to limit? s13 Dealing with uncertainty s13 Situations in which it is appropriate to limit treatment s13 Spectrum of decisions and parental discretion s14 - - Practical aspects of end-of-life care: responsibilities, treatments that may be limited, appropriate or permissible actions s15 Clinical responsibilities of the healthcare team s15 The range of treatments that may be withdrawn s15 Cardiopulmonary resuscitation s15 Clinically assisted nutrition and hydration s16 Muscle relaxants and end-of-life care s16 Palliative care s16 Organ donation s17 - - Practical aspects of decision making s17 The basis of decision making by teams s17 Obtaining second opinions s17 Resource considerations s18 Communication as part of decision making s18 Resolution of different opinions s19 Medical input s19 - - Bereavement s20 Families s20 The healthcare team s20 Key goals in the provision of bereavement support s20 - - Future practicalities s21 Training s21 Resources s21 Research/audit s21 Clinical ethics services s21 - - References s21 - - Appendix 1: Suggested bereavement resources s23 Preface The first edition of the Royal College of Paediatrics and Child Health (RCPCH) document 'Withholding or Withdrawing Life Saving Treatment in Children: A Framework for Practice' was published in 1997 and was one of the first documents produced by the newly-formed College.
Background and Aims Oxidative stress contributes to tissue damage after perinatal asphyxia. The thiol-containing free radical scavenger N-acetylcysteine amide (NACA) is a promising new anti-oxidant ...with good penetration into the mitochondria. The objective was to investigate the protective effect of NACA in a piglet model of birth asphyxia. Methods Anesthetized newborn piglets (n=51) were subjected to global hypoxemia and block-randomized to either intravenous administration of NACA 300 mg/kg and resuscitated with 21% oxygen for 30 min, saline and 21% oxygen, NACA and 100% oxygen or saline and 100% oxygen. After resuscitation, the piglets were followed for 9 hours and samples for several markers of injury and oxidative stress were collected. Reported here are clinical parameters and measurements of reduced to oxidized gluthatione (GSH/GSSG). Results Thirty minutes after end-resuscitation metabolic acidosis was less pronounced in the 100%-NACA group compared to 100%-oxygen-alone (lactate 8.1±2.6 vs 10.9±3.4, p<0.05). This difference was not shown for the 21%-oxygen groups. Mean arterial blood pressure and hemoglobin levels remained similar between the groups. The GSSG values were generally low. At end-resuscitation GSH was lower in 100%-NACA compared to 100%-oxygen-alone group (164±111 vs 255±113 µmol, p<0.05) and delta-GSH during resuscitation greater (143±49 vs 32±66 µmol p<0.001). Conclusions The data indicate that NACA may enhance immediate recovery, improve mithochondrial glutatione metabolism and restore the cell to a normal metabolism following asphyxia and rescucitation. Upcoming analyses of histopathology and injury markers will further elucidate neuroprotective effect of NACA treatment following birth asphyxia.
This study aimed to describe the impact of the first COVID-19 lockdown in France on the activity of a Child Advocacy Center.
This cross-sectional, observational study included all children involved ...in the activity of the CAC during the first lockdown, from March 16 to May 10, 2020 and the next 3 months and the corresponding periods in 2018 and 2019. Cases were considered severe when a hospitalization, social alert and/or judicial report to the prosecutor was decided.
Data for 1583 children were analyzed. During the lockdown, the global center activity decreased with 26.4 consultations per 100.000 children in 2018, 46 in 2019 and 20.7 in 2020 (p < 0.001). Judicial activity decreased (forensic examinations and child forensic interview recordings), whereas assessment consultations increased. Cases were more severe during the lockdown than in 2019 and 2018 (12.3, 9.4 and 6.04/100.000 children, respectively, p < 0.0001). The global activity of the center increased in the 3 months after the lockdown as compared with during the lockdown (38.2/100.000 versus 20.7/100.000, respectively, p < 0.001) but did not differ from activity in 2018 and 2019. Severe cases were more frequent in the 3 months after the lockdown than the previous years (13.7/100.000 in 2020, 9.62 in 2019 and 8.17 in 2018, p = 0.0002).
The CAC activity decreased during the lockdown in France but the increase in incidence of severe abuse cases during the lockdown and the next 3 months confirm the need for optimal screening, care and support of child abuse and neglect victims even in the context of health crisis.
•The first lockdown was associated with a decrease in activity of the child advocacy center.•The decrease in activity was due to a decrease in forensic examinations and child forensic interview recordings.•Children were more severely abused compared with the 2 previous years.•These results highlight the consequences of the lockdown on need of care and its availability for children.•These results call for increased vigilance of the risk of child abuse during periods of crisis.
By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical ...activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.
Prosecution of child sexual abuse cases is an important aspect of a community's response for holding perpetrators accountable and protecting children. Differences in charging rates across ...jurisdictions may reflect considerations made in prosecutors' decision–making process. This mixed–methods, multiphase study used data from a Children's Advocacy Center in a suburban county in the Southern United States to explore the factors associated with child sexual abuse cases that are accepted for prosecution and the process followed by prosecutors. Data were sequentially linked in three phases (qualitative-quantitative-qualitative), incorporating 1) prosecutor perceptions about what case characteristics affect charging potential, 2) 100 case records and forensic interviews, and 3) in–depth reviews of cases prosecuted. Content analysis was used to identify influential case elements, logistic regression modeling was used to determine factors associated with a decision to prosecute, and framework analysis was used to further confirm and expand upon case factors. Overall, findings indicate that prosecution is most strongly predicted by caregiver support and the availability of other evidence. The decision to prosecute was found to include a process of ongoing evaluation of the evidence and determination of a balanced approach to justice. The decision to prosecute a case can be influenced by strong and supportive investigative practices. An important implication is that interaction among multidisciplinary professionals promotes communication and efforts, further enhancing discretion about potential legal actions.
In contrast to other respiratory viruses, children have less severe symptoms when infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this review, we discuss ...proposed hypotheses for the age-related difference in severity of coronavirus disease 2019 (COVID-19).Factors proposed to explain the difference in severity of COVID-19 in children and adults include those that put adults at higher risk and those that protect children. The former include: (1) age-related increase in endothelial damage and changes in clotting function; (2) higher density, increased affinity and different distribution of angiotensin converting enzyme 2 receptors and transmembrane serine protease 2; (3) pre-existing coronavirus antibodies (including antibody-dependent enhancement) and T cells; (4) immunosenescence and inflammaging, including the effects of chronic cytomegalovirus infection; (5) a higher prevalence of comorbidities associated with severe COVID-19 and (6) lower levels of vitamin D. Factors that might protect children include: (1) differences in innate and adaptive immunity; (2) more frequent recurrent and concurrent infections; (3) pre-existing immunity to coronaviruses; (4) differences in microbiota; (5) higher levels of melatonin; (6) protective off-target effects of live vaccines and (7) lower intensity of exposure to SARS-CoV-2.
Background: Some suspected child victims of physical or sexual abuse undergo dental forensic examinations at child advocacy centers (CACs) in Norway. Their oral health history has not previously been ...studied. Objective: This study aimed to compare oral health history of CAC children to matched children. Additionally, the oral health history of children exposed to sexual abuse was compared to children exposed to physical abuse. Participants and setting: The CAC cohort included 100 children, 3–16 years. The matched cohort, with no known history of abuse, included 63 children. Methods: The retrospective study analyzed registered data in the children's dental records. Results: CAC children were more likely than matched children to have caries experience in both primary and permanent teeth, with incidence rate ratio (IRR) 1.50 (95 % CI 1.01–2.25) and 1.92 (1.11–3.30). "Was Not Brought" to dental appointments was more than twice as likely, IRR 2.25 (1.31–3.86), in the CAC cohort. There were no significant differences in reports to the Child Protection Services or dental traumas. Suspected victims of sexual abuse had more caries, IRR 4.28 (2.36–7.77), and fillings, IRR 4.83 (2.55–9.16), in permanent teeth compared to suspected victims of physical abuse. Conclusions: CAC children were more likely to have caries experience and not show up for dental appointments than the matched children. Sexual abuse suspected had four times more caries experience than physical abuse suspected. This study supports the need for addressing oral health in risk evaluations concerning child abuse, and provides valuable information to dental professionals and prosecuting authorities.
Objective: This study sought to revise the scale "that assessed pediatric nurses' ability to achieve practice that advocated for children's rights." Methods: We recruited 1,000 nurses with more than ...three years of experience in childcare at pediatric, university, and general hospitals with pediatric wards, and clinics. We surveyed 818 nurses using an anonymous self-administered questionnaire and obtained 337 (41%) responses; 294 valid responses (36%) were included in the analysis. Results: Item and factor analyses revealed 24 items from the following four factors: "support for the family," "support for the children," "explanation to children and confirmation of their intentions," and "coordination with medical staff." The cumulative contribution was 59.36%. Criterion-related validity was correlated with Oide's existing scale and the four factors, and content validity was demonstrated. In addition, confirmatory factor analysis confirmed that the developed scale had a high degree of fit. Conclusions: We were able to create a practical scale and ensure its validity and reliability.
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