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The role of the clinician can be defined in a number of ways, but one of them must be sifting through signs and symptoms, and trying to work out whether they are meaningful or not. At first, I wrote ‘meaningful or just noise’, but then reflected that this implied a value judgement; of course, in paediatrics we're exquisitely aware that meaning is a consequence of your perspective. For us, a trivial symptom or sign may be the cause of profound concern to a parent—resulting in a serious shift in family dynamics, sleepless nights or unnecessary restrictions to family life. Two excellent papers in this edition give us some more to think about on this theme.
Khan, Hussain and Whitehouse give us a highly practical approach to the evaluation of staring episodes in children (see page 202). If your practice is anything like mine then you'll have found that staring episodes are a growth area for referral, especially influenced by diligent and concerned teachers keen to ensure the best for their pupils. Put in the context of appropriate advice, and a carefully designed pathway, the key flow chart—figure 1, page 205—could be used to prevent some unnecessary referrals from primary care, or even from education.
In a much more generic context, Roland examines paediatric early warning scores (see page 208). Without wishing to give too much away—although most readers will know this already—the clue is in the extended title ‘Holy Grail and Achilles’ Heel’. Roland's review of the area is very thorough, but for me the most important part is tucked away in table 8, which are the things that you ought to think about before introducing an early warning system. The six questions in that one table, ranging from determining which outcome you're trying to alter, via engagement of stakeholders, through to monitoring the effect, do, in fact, give you all of the reasons you need to read this paper.
One of the fun things about being involved with E&P is that the boundaries of my knowledge are always being stretched, and so until I read the article from Bashford and Acerini on ketone metres (see page 217), I'd not realised that these were entering mainstream practice. One of the strengths of the Interpretations series is where our authors provide us with a series of clinical scenarios and examine the usefulness of the test in those scenarios, and it is these scenarios I usually turn to first when I'm reading one of these pieces. Here the authors assemble the evidence and make a good case for this to be a standard part of sick-day care for people with diabetes.
Elsewhere in this issue we have a helpful paper from Andrew, Parr and Sullivan on an approach to managing feeding difficulties in children with cerebral palsy (see page 222), who include a useful multidisciplinary approach to the problems, which might double as a troubleshooting list for ensuring you've covered all the relevant options. On a similar theme we also have a detailed summary of the drugs used in dystonia and spasticity, from Tickner, Apps, Keady and Sutcliffe (see page 230). They present a helpful overview of the options, and although I would not be personally delivering care up at the most complex end of the spectrum, they do describe an escalating regime which I will reach for the next time I'm trying to reduce the distress of such a child on a service weekend.
So, sifting signs and symptoms, trying to figure out what is wheat and what is chaff. Not a bad metaphor for one of the important functions of medicine. You don't have to do it with this month's E&P though; really, I'd say that it's all fun, all good to read.
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