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Re: A/H1N1: Effectiveness of prevention in childhood

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Re: Managing frequent medical absences from school.

We were interested to read the paper by Jones at al1 on ‘Frequent medical absences in secondary school students’. They conclude that ‘this study should prompt education departments and their NHS partners to look more critically at the problem … and to establish a system that provides more comprehensive assessment and treatment.’

Within Bolton PCT such a system has been designed in order to identify causes of frequent medical absences from school and to provide interventions aimed at supporting students to achieve an earlier and consistent return to school. Originally in Bolton (from the year 2000) referrals were made by the Education Social Work Department to a Senior Clinical Medical officer to undertake medicals on children with poor school attendance reported as due to ill health. This provided evidence to support an identified medical problem or for the LEA to issue a fixed penalties notice to the parent or carer. Since the issue of school attendance subsequently became a high priority policy concern for both the DfES and the DoH this service was re structured to develop an innovative Advanced Nursing Practitioner (with a school nursing background) led model for the evaluation of health issues for children and young people with poor school attendance. The main focus of the model was to enhance joint working between the advanced practitioner, Education Social Worker, schools and families. Changes have included a standardised threshold for referral (when attendance falls to 80%), agreed minimum information sets on referrals, agreed time frames for assessments and production of correspondence, holistic assessment, onward referrals, investigations and reintegration programmes to aide full return to school.

Over the last academic year 251 new referrals were received form the Education Social Work department (previously 55 a year). There were two peaks of referral (December 51, April 40). There were 120 referrals from primary schools and 131 for secondary schools. Referrals included 122 boys and 129 girls. Referrals to the service from 18 individual education social workers varied from 1 - 41 (median 14). The main causes of school absence were asthma, recurrent URTI, headache, sore throat, menstruation problems, chronic fatigue, skin problems, emotional and behavioural problems and inadequate provision for special needs within school. A variety of onward referrals were made including ENT, community paediatrics, dietetics, Young Carers, social care, occupational care, physiotherapy, CAMHs and two admissions to hospital. Support packages of care have been initiated for some together with supported reintegration plans to enable the young person to return to regular school attendance. Pathways are being devised for young people identified with ‘school phobia’ (jointly with CAMHs) and also a menstruation pathway for girls presenting with complex menstrual history.

In all cases of non attendance it is essential that preventative and early intervention should be seen as the cornerstone of multiagency working in order to ensure pupils right to education and to protect their health and well being. The redesigned service in Bolton has made good progress towards achieving these aims.

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Re: "Siginificant value" of CT scan in diagnosis of Hirschsprung's associated enterocolitis?

In the “Images in Paediatrics” section of ADC, Sept 2009 (1), I read with interest, and some alarm, Sheth et al.’s assertion that CT scan findings were of “significant value” in establishing the diagnosis of Hirschsprung’s associated enterocolitis.

As the authors themselves point out, diagnosis of enterocolitis in a child with a history of endorectal pull-through operation for Hirschsprung’s disease should be made on clinical grounds, with a plain abdominal X-ray being the investigation of choice, if required. Although it appears from the clinical history that the authors give that the CT scan was performed on their patient in order to rule out intussusception - a very reasonable intervention in the circumstances– the conclusion that the authors draw in proclaiming CT scan findings to be of significant value in establishing the diagnosis of enterocolitis surely cannot be justified. In the case they describe, the CT scan was useful in ruling out diagnosis of intussusception, not in confirming the diagnosis of enterocolitis. The message from the article may be misinterpreted by practitioners who are less clinically astute than the authors as a recommendation to use CT scan, with all its inherent risks and side- effects, as a diagnostic tool of “significant value” in children with known Hirschsprung’s disease presenting in this way.

As a general paediatrician coming across such patients in the acute setting in my practice, I would be loathe to subject my patients to the radiation, not to mention the likelihood of sedation or anaesthesia, of a CT scan which does not influence my diagnosis or management. In my non- prefessional capacity, as the parent of a 13-month old infant with Hirschsprung’s disease who has been admitted on several occasions with suspected Hirschsprung’s associated enterocolitis, I would be even more loathe to consent to such an investigation for the indications the authors seem to suggest.

References 1. Sheth et al Images in Paediatrics “CT images of Hirschsprung’s associated enterocolitis: a rare finding. ADC 2009; 94: 816

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Re: Paediatric training for GP's

I read with interest the article ‘making choices: why parents present to the emergency department for non-urgent care’ published in ADC journal in the October 2009 edition. Amongst the reasons mentioned for coming to PED, a total of 26 parents (18%) responded that they were either unhappy or wanted a second opinion for their child’s condition. It is this group of patients who increase the workload of staff and waiting times in A&E. I agree that very child had the right to health, but sometimes the parents’ perspective of ‘childhood illness’ can be quite demanding to deal with. So many of us would have come across parents who wait with their ‘unwell’ kids in A&E for nearly 3 ½ hours and finally decide to leave only when the doctor’s wait is going to take an extra 10-15mins. I empathise with such parents because strong emotions can completely cloud your judgement and make you behave in a totally inappropriate manner.

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Re: Re: Bulging fontanelle in febrile infants: lumbar puncture is mandatory

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Re: Children's growth: measured but rarely plotted

Lek and Hughes(1) recently highlighted concerns that opportunities for growth measurement in children attending hospital are frequently missed. This has important implications for the current UK policy for growth monitoring, which encourages opportunistic measurement. It also has important implications for clinical practice –growth faltering may result from any chronic illness or may be the only marker of abuse or neglect. In this context growth measurement in children attending hospital should not be seen as opportunistic, but as an essential part of good clinical care.

Lek and Hughes examined measurement of growth in a hospital with both paediatric and non-paediatric patients. We aimed to determine the frequency of growth measurement in a dedicated children’s hospital. In addition we examined whether growth was assessed by plotting data on a centile chart.

We undertook a cross-sectional study of all patient episodes (outpatient visits, admissions and inpatients) over a 24 hour period in September 2009 at the Royal Hospital for Sick Children, Glasgow. We excluded children attending specifically for growth problems, and those attending the emergency department, fracture clinic and day care units. We examined case records to determine whether height, weight and head circumference (in children <2 years) had been recorded and plotted on a standardised growth chart. Recent measurements during the current admission were accepted for in-patients.

Comparisons were made between measurements below and above 2 years of age and between in-patient and out-patient settings. Statistically significant differences were identified using Fisher’s exact test.

Data were available for 323 children (140 in-patients, 183 out- patients). Mean age was 6.14(range 0.02-17.79) years. 89 children were under 2 years (53 in-patients, 36 out-patients). Table 1 summarises measurements recorded and plotted, and comparison between groups. Weight was recorded in 234 (72%) cases, of which 59 (25%) were plotted. Weight was significantly more likely to be recorded in in-patients (p=0.02), but less likely to be plotted (p=<0.01). Height was recorded in 152 (47%) cases, of which 49(32%) were plotted. Outpatient heights were more likely to be plotted (p=0.03). Head circumference was recorded in 5 (6%) of the 89 children under 2 years, only 3 were plotted.

In Lek and Hughes study weight and height were recorded in 51.5% and 12.5% of children respectively. Our data suggests that growth measurements are more frequently recorded in this children’s hospital, however opportunities are still missed. Measurement of head circumference was particularly poor. We also found that growth measurements were rarely assessed by plotting on a growth chart. Plotting is a key method of identifying growth trends.

Some specialities used computer calculated standard deviation scores for growth monitoring. This may be useful as a screening tool but only identifies children outwith the normal range and not those with abnormal trends. In-patient height recording is likely to have been improved by local use of the PYMS score(2)for nutritional screening; however this tool is not designed to monitor growth.

We agree with Lek and Hughes that growth measurement in hospital needs to be improved. In busy hospitals measurement and plotting of growth parameters may be time-consuming, but simple changes such as mandatory placement of growth charts in notes, decimal age calculators and staff training could help. Computer software could potentially be used to plot growth parameters, flag up ‘danger’ signs and provide a central database for monitoring. Any such software would need to be easily accessed by all professionals.

Growth measurements need to be made, recorded, assessed and acted upon to form an effective part of good paediatric care.

References

1. Opportunistic growth measurements are not frequently done in hospital. Lek N, Hughes IA. Archives of Disease in Childhood 2009;94:702- 704

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Re: The TSH Threshold in Neonatal Screening for Congenital Hipothyroidism: a Variable Solution

THE TSH THRESHOLD IN NEONATAL SCREENING FOR CONGENITAL HYPOTHYROIDISM: A VARIABLE SOLUTION

Dear Editor:

In their paper on the TSH threshold in neonatal screening for congenital hypothyroidism (CH), Korada et al. (1) conclude that a threshold of 6 mIU/L for DELFIA-measured TSH in samples collected between days 5 and 8 may be preferable to the 10 mIU/L recommended by the UK Newborn Screening Programme Centre. Our laboratory instituted DELFIA measurements of TSH in 5-8—day paper-borne heelprick samples in 1985. Since 1998 we have used an accelerated AutoDELFIA(R); method – fully endorsed by the results of external quality control services (DGKL, NEQAS, AECNE) – that takes about 2 h and thus allows follow-up samples to be called for, if necessary, on the same day as the first sample is analysed. Since 2003, heelprick has been performed on day 3 in response to the desire of paediatric endocrinologists to begin the treatment of CH patients as early as possible, even though the typical physiological TSH peak on day 2 reduces the efficiency of screening thresholds; Table 1 summarizes the distribution of TSH levels in the 102,789 newborns screened during this period.

Having observed significant between-lot variation in TSH assay kits, since November 2004 we recalculate our TSH threshold for every run in the light of two factors: a) the dispersion of the calibration data in the vicinity of 10 mIU/L; and b) measurements of certified control samples with concentrations close to 10 mIU/L that are supplied by Perkin Elmer and, within its Newborn Screening Quality Assurance Program, by the CDC. Defining CV10 as the coefficient of variation of two replicate fluorescence measurements of the calibration standard nearest to 10 mIU/L, expressed as a percentage, factor (a) is assigned the value zero if CV10 < 10, and the value 0.1 x CV10 otherwise. The control samples (C1 and C2, of certified concentrations c1 and c2, respectively) are each measured once; in each case a parameter bi (i = 1,2) is assigned the value zero if the measured value mi is greater than 90% of the certified value, or the value 10 x (ci – mi)/ci otherwise; and the value of factor (b) is defined as the greater of b1 and b2. Finally, the TSH threshold is defined as (10 – j) mIU/L, where j is the larger of factors (a) and (b). This entirely empirical algorithm is displayed in flow-chart form in Fig. 1. In the 1171 runs in which the above procedure has been followed, the threshold so determined was > 9 mIU/L in 54.7%, 8 9 mIU/L in 35.3%, 7-8 mIU/L in 8.5%, and < 7 mIU/L in 1.5%. Of the 62 cases of CH that we have detected in this time, three (all with adequate weight at birth) had first-sample TSH levels lower than 10 mIU/L (see Table 2 for details).

Cristobal Colon and Jose Ramon Alonso-Fernandez. Metabolopathy Laboratory, Departament of Paediatrics, Clinical Hospital and Universiy of Santiago de Compostela (Spain).

References 1) KORADA SM, PEARCE M, PLATT MPW, AVIS E, TURNER S, WASTEL H, CHEETHAM T. Dificulties in selecting an appropriate Neonatal TSH screening threshold. Arch Dis Child (Online First), 12 Aug 2009. 2) ALONSO-FERNANDEZ JR. V Reunion Nacional de la Sociedad Española de Química Clínica. Santiago de Compostela 28 y 29 de abril de 1985. 3) POMBO M, ALONSO-FERNANDEZ JR, BRAVO M, FRAGA JM, PEÑA J. Diagnostico Precoz del Hipotiroidismo Congénito y de la deficiencia de Hormona del Crecimiento. An Esp Ped. 1987;27(sup.28):44-47. 4) COLON C, ALONSO-FERNANDEZ JR. Depistage de L’Hipothiroidie neonatal avec un inmuno-essai marque a l’Europeum. Etude comparative de curbes de calibrage. Proceedings of “Reunion Europeene sur le Depistage Neonatal en 1986. Evian (France). 28-30 de abril de 1986. 5) ALONSO-FERNANDEZ JR, COLON C, FRAGA JM. Neonatal Screening of Hipotiroidism: A comparative study of RIA Technique and the Non Isotopic Inmunoessay DELFIA System. In BL Therrel; Advances in Neonatal Screening pp 163-164 (1987). Excerpta Medica. 6) COLON C, ALONSO-FERNANDEZ JR, CASTIÑEIRAS DE, ROMERO ME, FRAGA JM, PEÑA J. Posible Causes of Bordeline TSH: a Summary of our experrience. In F Delange, DA Ficher, D Glinder; Research in congenital Hypothyroidism, pp 316, 1989. Plenum Press. 7) COLON C.Epidemiological study of thyroid stimulating hormone (TSH) levels in the Galician neonatal population (Estudio epidemiologico de los niveles de hormona estimuladora del tiroides (TSH) en la poblacion neonatal gallega). Microfiche ISBN 13: 978-84-8121-340-9. ISBN 10:84-8121- 340-3. Ed. Universidade de Santiago de Compostela. 1995. 8) ALONSO-FERNANDEZ JR, CASTIÑEIRAS DE, CASTIÑEIRAS C, VILLAR P. Determinacion de TSH Neonatal con el método DELFIA reduciendo a dos horas el periodo de Elucion-Incubacion, concentrando el trazador y el analito. Immunoensayo 97. La Habana (Cuba) 14-18 de septiembre de 1997.

Post date

In 1985 (2, 3) we propound the adaptation of DELFIA test for seric TSH measurement to the newborn screening sample (DBS). Once Perkin-Elmer marketed the neonatal screening TSH test, we suggested a calibrate modification, increasing from 3 to 5 points and using the interpolation with logarithmic spline instead linear regression such as made in the procedure for seric and neonatal screening TSH determination (4). It is compared with the RIA test using until then (5). In 1988 we discussed the causes of borderline results (6), one of the main reasons for recall sample. In the PhD thesis of one of us (C. Colon) in 1995 (7), we could verify that the gestational age, the birth weight, and the age of analysis, influence on the TSH values. Also was found the thyroid function alteration due to antiseptic iodine use (effect Wolff-Chaikoff).

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Re: this article

Dear Editor

Dr Vijay Palanivel has suggested that the first emergency treatment should have been needle aspiration in this situation. I think this is not the right management step and possibly a dangerous one.

If you carefully examine this chest radiogrph, you will realise that the boarder of the radioluscent shadow can be fully traced in all directions. In case of massive pneumothorax onely medial and inferior boarders of the radioluscent shadow will be visible. The lateral boarder will be formed by chest wall. This is the differetiating feature between massive pneumothorax and a cystic lesion in the left hemithorax.

The clinician should be able to make a definitive diagnosis of pneumothorax before embarking on emergency needle aspiration. An urgernt radiology openion would be what is really needed, although it may not be possible out of hours in district general hospitals.