eLetters

1454 e-Letters

  • Policy reviews 5 years after valuable in holding to account

    Lemer has very usefully carried out a 5 year review of policy implementation. Policy is only as good as the receivers at the other end and these change frequently along with an ever changing political and economic landscape.Thus the exercise is valuable in not only taking stock but also reminding those in power of an independent review process with recommendations which should transcend governments. Sadly , the focus on funding education of the workforce (recommendations 10-12) do not appear to have been a priority and without this foundation, we will not move ahead sufficiently fast with a child and family friendly service. The Children and Young Persons Outcomes Framework is similarly the result of much work in a previous government and must not be allowed to whither on the vine. Perhaps we should regularly remind policy makers in the current administration of the value of persistence with other such initiatives which have a broad professional consensus and can be dusted off and re-badged as necessary to tempt politicians to move the goal posts a little closer to what is required to optimize child health? Lets see how far we have got in another 5 years.

  • Is Bexsero® (MenB vaccine) effective in preventing invasive meningococcal disease? Experience of a tertiary hospital in the UK

    Is Bexsero® (MenB vaccine) effective in preventing invasive meningococcal disease? Experience of a tertiary hospital in the UK. Novel meningococcus serogroup B vaccine (Bexsero®) was introduced in UK national immunisation programme on 1 September 2015. All babies born from July 2015 were offered the vaccine alongside other routine immunisations and all babies born in May 2015 were offered Bexsero® as a one-off catch-up. Bexsero® is estimated to protect against 73–88% of MenB strains causing invasive meningococcal disease (IMD) in England and Wales1,2. Among the diseases preventable by immunisation, IMD remains a high public profile illness deserving the most rigorous consideration because of its rapid and severe onset, high mortality rate and burden of sequelae. Epidemiological data suggest that infants in the first year of life experience the highest risk of infection peaking at around 5 months and declining thereafter. We continue to observe IMD in the first year of life despite the introduction of Bexsero® in our national immunisation programme (Table 1). This retrospective data was obtained as part of service evaluation at Central Manchester University Hospital Foundation Trust from our microbiology department. We are one of the biggest integrated Children's hospitals in the UK providing a wide range of services for the North West region and have over 220,000 patient visits each year. The epidemiological year starts from July to June, rath...

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  • A false equivalency between CFS/ME and CDF

    The title of the paper and the majority of the introduction imply that the study is about adolescents with CFS/ME. However, the final sentence of the introduction undermines that objective: “As children in our study were not examined by a physician, we have used the term ‘chronic disabling fatigue’ (CDF) rather than CFS/ME to indicate chronic fatigue that is disabling.”

    Those children may have had a variety of different diseases that cause prolonged fatigue, yet we are led to believe that a study of their collective conditions can somehow add to the body of literature on a specific disease process. CFS/ME is a highly contentious disease with a great deal of conflicting evidence and hypotheses; answers as to its exact nature and cause are as yet to be determined. By publishing a study of patients who are so poorly defined as to be undefined, Archives of Disease in Childhood has further muddied already murky waters. The addition of this study to the body of literature is not only unhelpful, but is actively detrimental to the pursuit of answers for patients with this highly disabling disease.

    How are ADC or the authors able to justify publishing a study that to all appearances is about CFS/ME, yet fails to properly assess if any of the study participants actually have CFS/ME?

  • Single night oximetry may be inadequate

    We would like to thank the authors of the Pavone paper for their interest in our paper (1,2). We are sorry for not quoting their paper in our study report but do confirm that we were aware of it (2). In our introduction we selected several papers to quote in order to introduce the uncertainty with respect to the need to record 1, 2 or 3 nights of overnight oximetry and the Pavone paper was not one we selected. The Pavone paper claims excellent night to night consistency in oximetry and that only one night of oximetry measurement is necessary while our study did not find this to be the case (2).
    While we agree that the Pavone study used a pulsed oximeter with some superior properties (Radical Masimo) compared to that which we used (Nonin 9600) we do not believe that this is one of the most important reasons why our results differ from the Pavone study.
    We believe the main reasons for differences between the two papers include;
    1] Different primary aims - our study was aimed to determine whether doing 2 or 3 nights oximetry would increase the chances of getting adequate traces to make a report. We therefore included all studies (whether satisfactory or not). In the Pavone study only those with 2 nights each with > 6 hours satisfactory tracing were included and about one third of the children initially identified were therefore excluded. We do not know what then happened to these children – i.e. whether further studies had to be rescheduled. Clearly selec...

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  • Support for Dr. Goldwater's proposal that an acute respiratory infection may be a causative factor in SIDS

    I agree with Dr. Goldwater that an undetected prodromal respiratory infection can suddenly fulminate and cause acute anoxic encephalopathy. In such an instance, there may not be time for visible pulmonary histological pathology to form. Then if a lung culture is not performed or gives sepsis-negative results, the cause may be coded as SIDS rather than an ARI. See Farber S. Fulminating streptococcus infections in infancy as a cause of sudden death. N Engl J Med 211:154-158, 1934 and Mage et al. .Front Neurol. 2016 Aug 23;7:129. doi: 10.3389/fneur.2016.00129. eCollection 2016. PubMed ID 27602017

  • Re: Conclusions not justified by findings

    Dear Editor,

    We thank Professor Wright for her comments, and we welcome the opportunity to provide some clarification and further analysis. 

    We reported Z-scores rather than percentiles, although some comments on approximate percentiles can be made.  Assuming that Z scores of -1.96 and -3 represent approximately the 2.5th and 0.2nd centiles respectively, 36/101 children were below the 2.5th centile, and 17/101 were below the 0.2nd centile for weight.  Additionally, our mixed effects model (accounting for multiple measurements) modelling the group trend over time estimated the mean weight Z score at 11 years to be -1.63 (approximately 5th centile). 

    Despite the overall short stature of the group, 24/101 children had a BMI Z score of less than -1.96.  So, by this approach, their weight was low even after taking into account stature.  We agree that we cannot infer causality from this observational study, but we believe a proportion of the stunted growth is explained by low weight. We are exploring other measures of malnutrition, such as skin-fold thickness. 

    Whilst our patient numbers are small, they do give some weight to the argument that PEG feeding halts the progression of malnutrition.  We investigated the rate of decline of weight after PEG insertion.  In a mixed effects model with a random intercept for individual patients, the rate of wei...

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  • Tackling the childhood obesity crisis

    I wonder if this brief report by Harvey et al. highlights where we are going wrong. Firstly, the lack of response to the QIP may just reflect the fact that we have such limited ability to influence outcomes when it comes to childhood obesity. If you are working in a busy CAU it seems pointless doing things that are not going to produce a positive outcome.
    However my biggest concern is the statement: "How paediatricians act has a large impact on parents: we cannot expect them to prioritise their child’s obesity if we do not do the same." This appears to be the “nanny state” at work. The fact that parents are not recognising their children’s obesity, if this is really the case given the publicity this topic is receiving, is the main problem. This idea that patients are completely dependent on professionals to bring about change influences the outcome for many chronic conditions. Best results are obtained when patients (and carers) are actively involved in the management of the disease and are equipped to influence outcomes. This can only come about through education.
    My personal experience is that I cannot remember ever seeing an overweight child maintain any significant weight loss. The lack of parental recognition of the fact that their child is overweight is a major problem. I am not sure how long the comment "your child is overweight" stays with parents after they leave the clinic. Do parents feel that an overweight child reflects well on...

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  • Response from the authors

    We are pleased to see the interest shown in our article by Drs Cheung and Lachman, but cannot agree with their assertion that our research ‘misses the point’.
    Despite widespread use, there remains limited research on the effectiveness of paediatric early warning systems (PEWS) in detecting deterioration in hospitalised children. Our paper sought to establish if there were statistically significance differences in performance between 18 published systems. Trigger systems were out-performed by scoring-systems in this relevant but narrow assessment. Our conclusion emphasizes that it is unclear what factors account for these differences in performance.
    Dr Cheung and others feel this observation of statistical inferiority of trigger system is not merited and the observed differences may be influenced by the scoring threshold selected. Dr Cheung illustrates this by comparison to the threshold selection of the C-reactive protein test as an indicator of inflammation. We found this to be rather confusing. The outcomes of trigger-based systems are, by their very nature, dichotomous. Whilst there is always a trade-off between sensitivity and specificity for scoring-based systems, the same does not apply to trigger-based systems. The system is either triggered or not. We note that Dr Cheung does not offer data to support his preference for trigger systems.
    We agree that managing deterioration in children is complex. However it is hard to imagine how this would be im...

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  • Question

    Dear Sir

    I'm Dr. Al-anbuqy Khalid working in HUDERF( Association Hospitalière de Bruxelles – Hôpital Universitaire des Enfants Reine Fabiola) with

    professor Henri Steyaert, MD, PhD ( Avenue Jean-Joseph Crocq, 15 1020 Brussels Belgium Phone : +3224773197

    Fax : +32 (0)2 477.34.49 Email : henri.steyaert@huderf.be) .We are making research over intussusception .

    My question is did you used premedication or sedation in your study in all or some patients(percentage if possible), and if yes what is /are the type of premedication or sedation did you used ?

    Best regards

    Al-anbuqy Khalid, researcher doctor

    Association Hospitalière de Bruxelles – Hôpital Universitaire des Enfants Reine Fabiola (HUDERF)
    Department of paediatric Surgery
    Adress :Avenue Jean-Joseph Crocq, 15,1020 Brussels,Belgium
    Email : Khalid.alanbuqy@huderf.be
    Phone: +32465133654

  • Authors Reply

    Thank you for your letter and for sharing your very personal experience.
    We agree with you that by the time the child who is choking is attended to by advanced medical practitioners the situation is often dire and that the best hope of a good outcome rests with prompt and effective attempts to dislodge the offending object.
    However, knowing that partial airway obstruction may quickly become complete airway obstruction, that (as in the cases we describe) First Aid measures may fail, and that even if the obstruction is relieved the consequences may be significant; we would also advocate that emergency services were alerted as early as possible.
    The Advanced Paediatric Life Support (APLS)1 guidance in the UK gives the clear advice with regard to first aid measures to be employed in the choking child.
    • If the foreign body is easily visible then carefully try to remove it.
    • If the child is coughing effectively and is conscious then encourage them to cough and monitor closely.
    • If the child has an ineffective cough but is still conscious then proceed as follows:
    o An infant should be laid horizontally with head down, supported with airway open (on the rescuer’s forearm or lap) and five sharp back blows delivered between the shoulder blades. If this fails then the infant is turned supine, still head down, and five chest thrusts (sharp and slower compressions using the same landmarks as for CPR) commenced.
    The Heimlich m...

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