DFTB17 – Defence Against The Dark Arts

In just two weeks time we are going to be running our very first conference. We have been very lucky to draw on the expertise of some amazing speakers from around the world of paediatrics. Tim Horeczko is hosting an exciting evidence-based medicine panel discussion and wants you to join in.

 

It is my job to arm you against the foulest creatures known to wizardkind. You may find yourself facing your worst fears in this room. Know only that no harm will befall you whilst I am here. I must ask you not to scream. It might provoke them!

Gilderoy Lockhart

What is evidence based medicine?

I think this quote from one of the fathers of evidence-based medicine states it best

“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. … [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research”

David Sackett

The panel are going to explore four papers, picking them apart in an easy to understand way. This isn’t about fancy statistical tests but how to take the evidence we are presented with and translate it into real life.

So if you want to join in this endeavour then take a peek at the papers we are going to discuss. If you can’t make it then don’t worry, Aidan Baron will be our fearless Twitter moderator and can field your questions from afar.

Who is on the panel?

This years panel consists of:-

And so to the papers…

We’ll provide you with a (bubble) wrap up after the conference.

At a glance…ondansetron and cardiac arrhythmias

Ondansetron used to be the preserve of the Oncologists for children struggling with chemotherapy-induced nausea. Recently, however, its use for the symptomatic relief of nausea and vomiting in the Emergency Department has significantly increased.

Less vomiting = less chance of dehydration and need for admission for fluids. All good? Well, not quite.

In 2011 in the USA the Food and Drug Administration (FDA) issued a warning that Ondansetron administration was associated with fatal arrhythmias. So, should we stop using ondansetron? What’s the actual risk of arrhythmia?

Freedman et al looked at this dilemma in this paper form the Annals of Emergency Medicine which can be found here.

And I have summarised in the infographic below:

Fetal alcohol spectrum disorder

Callum is a 6 year old boy who has been referred to paediatrics by his GP due to school concerns regarding his poor attention span and difficulty with learning and remembering new information. Whilst his peers in year 1 are working on their sight words, Callum is unable to recognize any sight words. He is described as a very social and talkative child although he doesn’t appear to always understand tasks despite being able to repeat the instructions. His parents are concerned as Callum’s older sibling also has learning difficulties. On your thorough history, you note that Mum consumed alcohol during pregnancy and you wonder whether this child could have FASD… 

Why is diagnosis important?

  • Allows focused interventions that better benefit the child
    • Early diagnosis enables early intervention6
    • Is a recognised diagnosis with NDIS!1 (permanent impairment – no further assessment required)
    • May be eligible for a Centrelink carers allowance2
  • Comfort” may be found in a “label” by the family (regardless of the perceived guilt that you may assume would occur)
  • Help to develop appropriate expectations for the young person and their family3
  • Can allow medical practitioner to better “screen” for associations (physical and behavioural/cognitive)
  • Allows identification of women at risk of harm from alcohol and allow referral and treatment which may in turn prevent the birth of a subsequent affected child6

 

What is it?

Fetal alcohol spectrum disorder (FASD) is a non-diagnostic umbrella term used to describe the permanent, severe neurodevelopmental impairments that may occur as a result of maternal alcohol consumption during pregnancy.4 A history of alcohol consumption during pregnancy alone is not sufficient for diagnosis however; further assessment and clinical examination is required before assigning this significant label (with significance applicable not only for the child but also the family).

FASD is an umbrella term that includes a range of disorders3 including:

  • Fetal alcohol syndrome (FAS) – the most common clinically recognisable manifestation of FASD
  • Partial fetal alcohol syndrome
  • Alcohol related neurodevelopmental disorder (ARND)
  • Neurobehavioural disorder associated with prenatal alcohol exposure
  • Alcohol related birth defects (ARBD)

 

Diagnostic criteria for foetal alcohol spectrum disorders3

 FASD Diagnostic criteria
 Fetal alcohol syndrome

At least two characteristic facial features

Growth retardation

Clear evidence of brain involvement

Neurobehavioral impairment

With or without documented prenatal alcohol exposure

Partial fetal alcohol syndrome

With documented prenatal alcohol exposure:

§  At least two characteristic facial features

§  Neurobehavioral impairment

Without documented prenatal alcohol exposure:

§  At least two characteristic facial features

§  Growth retardation OR clear evidence of brain involvement

§  Neurobehavioral impairment

Alcohol-related neurodevelopmental disorder

Documented prenatal alcohol exposure

Neurobehavioral impairment

(This diagnosis cannot be definitively diagnosed in children <3 years of age)

Alcohol-related birth defects

Documented prenatal alcohol exposure

At least one specific major malformation associated with prenatal alcohol exposure

Neurobehavioral disorder associated with prenatal alcohol exposure

Documented prenatal alcohol exposure

Neurobehavioral impairment and onset in childhood

Facial features, growth retardation, and clear evidence of brain involvement not necessary (but may be present)

Not better explained by other teratogens; genetic or medical conditions; or environmental neglect

 

Is it actually still “a thing” anymore considering all the media around women not drinking during pregnancy?

Fetal alcohol spectrum disorder is the leading cause of preventable non-genetic intellectual disability in Australia.4,5

Up to 50% of Australian women report drinking during pregnancy. Binge-drinking occurs in 4 – 20% of pregnancies, with a peak in Indigenous Australians with approximately 22% of Aboriginal women stating that they binge drink during pregnancy.5

 

But how much is too much?

Alcohol is a teratogen with irreversible central nervous system effects.3 The teratogenic effects vary depending on:

  • Quantity of alcohol
  • Pattern  of alcohol consumption
  • Maternal and foetal genetics
  • Maternal age
  • Maternal nutrition
  • Smoking

Australian and international guidelines advise that there is no safe level of alcohol consumption during pregnancy, with alcohol avoidance being the goal.7 As such, the level of danger has not been determined. Some suggestions have been that the foetus is more at risk where:

  1. >6 drinks per week for >2 weeks
  2. >3 drinks per occasion on >2 weeks
  3. Documentation of alcohol related social or legal problems
  4. Documentation of intoxication by blood, breath or urine alcohol testing

 

What are the consequences of alcohol during pregnancy?

It has the potential to cause harm at all stages of gestation.

  • First trimester à facial anomalies and major structural anomalies including brain anomalies
  • Second trimester à increased risk of spontaneous abortion
  • Third trimester à weight, length and brain growth

Neurobehavioural/neurodevelopmental effects may occur throughout gestation/pregnancy, even in the absence of facial or structural brain anomalies.3

 

Alcohol in pregnancy

https://www.cdc.gov/dotw/fasd/index.html

1 https://www.ndis.gov.au/people-with-disability/access-requirements/completing-your-access-request-form/evidence-disability

2 https://www.humanservices.gov.au/customer/forms/sa426

3 Fetal alcohol spectrum disorder: Management and prognosis

4 https://ama.com.au/position-statement/fetal-alcohol-spectrum-disorder-fasd-2016

5 http://www.parliament.wa.gov.au/Parliament/commit.nsf/%28Report+Lookup+by+Com+ID%29/1740F63B37A1314A48257A7F000766DD/$file/Final+FASD+Report+with+signature.pdf

6 http://bestpractice.bmj.com/best-practice/monograph/1141/diagnosis/step-by-step.html

7 National Health and Medical Research Council. (2009). Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Available at: https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf

8 https://pubs.niaaa.nih.gov/publications/fasdfactsheet/fasd.pdf