1476 e-Letters

  • Response to comments from Prof. Niels Lynøe et al and Dr. Nicholas R. Binney et al

    We welcome scientific debate around the recognition of abusive head trauma. The SBU report concludes ‘There is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking’ (1). We have provided a methodological critique of the SBU report  (2) which we hope provides points for others to consider when interpreting it.

    We would just like to correct a couple of inaccuracies presented in the letter from Binney et al and reiterate the importance of correct terminology in this field. Binney et al state that we ‘claim the SBU are inconsistent by saying that shaking may cause the triad’ then concluding ‘that there is insufficient evidence that the triad is diagnostic for shaking’. And secondly that we ‘argue that studies the SBU dismiss due to circularity bias would if included, support the “correct” conclusion that the triad is specific for abuse’.  We would like to make it absolutely clear that at no point do we advocate that the ‘ triad is specific for abuse’ or ‘diagnostic of shaking’.  We simply propose that in light of the SBU  statement about the two studies that they included in their systematic review…  ‘Although both studies (moderate quality) have methodological limitations, they support the hypothesis that isolated traumatic shaking can...

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  • Calcineurin inhibitors tacrolimus and Cyclosporine A in the treatment of Henoch- Schönlein Purpura in children

    I read with great interest the article titled “Off-label use of tacrolimus in children with Henoch-Schönlein purpura nephritis: a pilot study” by Zhang et al.(1). To my great astonishment the authors did not discuss any of the studies published on the use of another calcineurin inhibitor Cyclosporine A (CyA)  in the treatment of Henoch Schönlein purpura in children.

    In the first chapter of the discussion section they refer to our report where we compared methylprednisolone pulse treatment (MP) and CyA in a randomized trial (2) stating that “Remission was achieved slowly and only in 53% of patients with methylprednisolone” (1).

    I would like to draw the readers´s attention to the fact that in the same paper we showed that another calcineurin inhibitor i.e. CyA was by no means inferior to MP for the treatment of severe HSN (2). Indeed, CyA was even more efficacious than MP, since remission was achieved within 3 months in all CyA-treated patients (N=11) compared to 54% (7/13) in MP group (p=0.016). All the CyA treated patients responded to the treatment with no need for additional immunosuppressive therapy. In contrast, in MP group 6/13 (46%) needed additional immunosuppressive treatment. The remission rates in the MP treated patients were 85% (11/13) and 77% (10/13) after 1 and 2 years, respectively in contrast to 100 % in CyA-treated patients. The renal survival rate in the CyA group was 100%, as against 85% in the...

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  • Easier to see the speck in your critical peers’ eyes than the log in your own? Response to Debelle et al.

    Corresponding author: Niels Lynøe, Stockholm Centre for Healthcare Ethics, Karolinska Institutet, 171 77 Stockholm, Sweden.
    Göran Elinder, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Boubou Hallberg, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Måns Rosén, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Pia Sundgren, Department of Diagnostic Radiology, Clinical Sciences, Lund University, Lund, Sweden.
    Anders Eriksson, Department of Community Medicine and Rehabilitation , Forensic Medicine, Umeå, Sweden.

    Once again (1) a group of paediatricians has made critical comments about our systematic review of the shaken baby literature (2, 3). Surprisingly, however, this time the criticism includes accusations of circular reasoning! Surprisingly, because the main reason that we assessed the shaken baby studies as biased was that they were based on circular reasoning (2, 3). Even though it may be easier to observe ”the speck in your friend’s eye than the log in your own”, it is remarkable that Debelle et al avoid criticizing circular reasoning within their own research area. On the contrary, the authors maintain that the clinical investigations of suspected cases of SBS/AHT are based on “rigorous assessment”, “comprehensive clinical investiga...

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  • Don’t Blame the Messenger: A Response to Debelle et al. and the RCPCH

    Instead of acknowledging the clear lessons of the SBU’s review, Debelle et al.(1) choose to attack the messenger for delivering news about the impoverished state of the medical literature on shaken baby syndrome/abusive head trauma.
    They criticise the SBU’s literature search, but fail to put forward the body of unbiased literature that the SBU has supposedly overlooked, which suggests that the SBU have been thorough.
    They claim the SBU are inconsistent by saying that shaking may cause the triad and that there is insufficient evidence that the triad is diagnostic for shaking. However, this is no more inconsistent than saying that influenza can cause headache but headache is not diagnostic of influenza.
    They claim that the SBU’s research question, the specificity of the triad as an indication of shaking, is clinically irrelevant. Yet elsewhere they acknowledge the significance of isolated shaking and the perceived diagnostic value of the triad, by saying that “it is now agreed that shaking alone can produce severe head injury in infants” (2), and that “There has also been an increasing emphasis on going beyond the simple triad of injuries that is often cited when arriving at a diagnosis of AHT” (3).
    They argue that studies the SBU dismiss due to circularity bias would, if included, support the “correct” conclusion that the triad is specific for abuse. This indicates that Debelle et al. are willing to overlook the problems of bias. Unlike other biases,...

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  • The use of nasal mask continuous positive airway pressure in preterm infants.

    The evidence that nasal mask continuous positive airway pressure (CPAP) is better than bilateral, short nasal prong CPAP is convincing.1 However the evidence of benefit is only for short-term outcomes. I have significant concerns about using nasal mask CPAP continuously over many days in extremely preterm or extremely low birth weight infants. These babies have soft malleable skulls. We saw that this was a problem decades ago when small babies were primarily nursed with their head on the side; and subsequent dolichocephaly was very common as a result.2 The hat and straps needed to keep a mask in place put pressure on a baby's soft, malleable skull in a different way to the hat used during nasal prong CPAP. The long term effects of this pressure on boney development, particularly of the midface, are unknown, but they could be considerable. Because of these concerns I do not use nasal mask CPAP continuously. I alternate the use of masks with nasal prongs.

    1. Kieran EA, Twomey AR, Molloy EJ, et al. Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics 2012;130:e1170–6.doi:10.1542/peds.2011-3548.

    2. Ifflaender S, Rüdiger M, Konstantelos D, Wahls K, Burkhardt W. Prevalence of head deformities in preterm infants at term equivalent age. Early Human Development 2013;89(12):1041-1047.

  • Authors' reply:

    I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.

    Previous research:
    CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
    However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]


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  • CRP first? : Less is better for education

    With great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
    The algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
    As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show traine...

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  • Population-based study of cognitive outcomes in congenital heart defects: Novel Information about a not so uncommon entity

    I read the article with interest and wish to congratulate the authors for their genuine work on a little known subject.
    However there are certain points which require elaboration:
    (a) It is likely that there are independent genetic factors that are responsible for a baby being born SGA and the same factors may be playing a role in affecting cognitive outcomes.These factors have not been addressed in the study.
    (b) Cognitive outcome of a child is the result of certain internal and certain extraneous factors (eg environmental stimulation).The extraneous factors may confound the results of the above study.
    (c) Open heart surgery per se may be detrimental to the cognitive development of a child .But there are certain factors such as Bypass time,duration of mechanical ventilation,exposure to hypotensive milieu,etc that need to be explored in order to get an indepth insight into the subject.
    To summarize, the article is a praiseworthy effort into a novel field which opens up potentials of further avenues of research.

  • Response to Seizures, safety and submersion: sense and sensibility

    I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders...

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  • Testing in relation to timing of illness needs to be considered

    The authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.

    1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
    S. Rainbow, R. Wall and M. Blair
    Is procalcitonin a discriminant marker of early
    invasive bacterial infection in children?
    Current Paediatrics (2003) 13, 399

    2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&amp;E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from:...

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