1454 e-Letters

  • Content vs Context in scoring systems

    The need to improve outcomes in child health is not disputed, especially in the UK where performance lags behind the rest of Europe [1]. Mechanisms which detect, and respond, to the deteriorating child in an effective manner should be validated and shared so we welcome further research by Chapman et al. [2] which demonstrates the complexity of producing tools which do this. However, we support the concern raised by Cheung and Lachman [3] in ensuring that appropriate conclusions are drawn from this work. As a research group funded to investigate these systems, from both a quantitative and qualitative viewpoint, we would like to highlight some of the dangers in use of terminology in this area. The concept that systems may be a better paradigm than scores (i.e. the amalgamation of observations into binary or composite measures which determine pre-defined actions) is not new [4] and it is already recognised that both afferent and efferent limbs are vital in order to complete what Joffe described as the, “chain of events needed to improve response to inpatient deterioration.” We note Maconochie and Lillitos use the term PES (Paediatric Early Warning System) and differentiate trigger systems from PEWS (Paediatric early warning scores). It is not however clear why trigger systems are treated as separate from PEWS as the literature contains numerous examples of where a trigger type system has been labelled as a PEWS [5]. While we entirely agree there is a challenge in labelling...

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  • Is limiting parental authority the answer?

    The authors conclude here that when withdrawing treatment in PICU is considered parents' refusal
    to consent can cause additional suffering as clinicians tend to extend burdensome treatment beyond
    what they think is reasonable to allow parents time to reconsider. Moreover, both parents and
    clinicians try to avoid approaching the courts for a decision.
    On the basis of these findings the authors suggest that limiting parental authority by using the concept of parental assent instead of consent could lead to an expeditious resolution in cases of disagreement and should be the focus of further research.
    This suggestion is not supported by the parental quotes used in this article. Indeed, one of the parent's objection to a court decision stems from his opinion that the decisions regarding withdrawal of treatment should be the domain of the parents. Limiting parental authority might therefore lead to increased adversarial relationships between the treating team and parents especially when parental views are overruled.
    Some quotes in this article as well as other research show that parents at the end of their child's life need time to
    often extensively research alternative treatments 'because you just need to have looked and
    exhausted every avenue'. Rather than limiting parental authority, it may thus be better to start the
    discussion regarding end of life care, including withholding treatment earlier....

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  • "Human factors matter" - Statistical analysis of performance of trigger systems misses the point

    Chapman et al (1) present a valuable evaluation of the performance characteristics of 18 commonly used paediatric early warning systems. They observed that the performance of the 12 “scoring” systems (where cumulative component values for vital signs are used to identify thresholds for escalation of care) was superior to 6 “trigger” systems (where breaching set thresholds for one or more vital signs lead to escalation without the need for adding numerical scores), based on sensitivity, specificity and area under the operating curve (AUROC). Although they do not specifically claim that this finding should be extrapolated to suggest that all scoring systems outperform trigger systems, this is the implication both in the results and discussion section. Indeed, the associated editorial by Lillitos & Maconochie confirms this implied conclusion, when they state that “In conclusion…overall, PEWS perform better than Trigger systems.” (2)

    We contend that this is an erroneous and misleading conclusion and far outstrips the scope and methodology of the study. Firstly, the findings are related to the performance of 16 specific tools and no comment can be made about whether it is the Trigger or the Score aspects which are responsible for this difference. Using the analogy of a therapeutic trial, there can be no basis to conclude that this is a “class effect” rather than specific to each tool. Secondly, the authors themselves recognise that it is the thresholds for escalation...

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  • Response to: The choking hazard of grapes: a plea for awareness

    I am a paediatric cardiothoracic surgeon who came across the article in a public account of Wechat (a popular Chinese social network app). With great interest, I tried to find and have read the full text of this paper. The reason why I am so interested in this topic is that I myself, as a father of two, experienced the same event happening to the younger sister of my children and so fortunately, I managed to have expelled the whole grape with Heimlich manoeuvre and saved her. It was an evening one year ago when my girl was 6 and a half months old. When I was having a shower in the bathroom at home, my wife suddenly screamed and cried to ask me out immediately. Her voice sounded so urgent that I could hardly have time to put on my underwear to rush out. The baby was then already drowsy, presenting with lip cyanosis and spit bubbles in the mouth. It would seem to be useless if I call medical emergency service. I had no time to think about but tried to perform Heimlich manoeuvre with hands pushing down and cephalad in her stomach, the first sets of pushes didn’t work. I rushed her to living room to check her response and did the second sets. Fortunately, the whole peel-off grape was expelled out of her mouth. Her face started to turn red and she fell asleep. The grape was peeled by my sister-in-law (as a babysitter). She intended to hold it to the baby to suck the juice. Unexpectedly, the grape was suddenly sucked deeply in by my girl! As of now, my girl is very healthy and a...

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  • Night activity Paediatric Consultant Advisory Service (PCAS) for General Practitioners in Oxfordshire: sweet-talk for healthcare & efficiency ?

    Our Paediatric Consultant Advisory Service (PCAS) was set up in 2010 as communication between Oxfordshire General Practitioners and General Paediatricians to provide a cost-saving means of reducing the numbers of outpatient face-to-face attendees. Twelve General Paediatrician Consultants rostered for Resident-oncall night duty (21.00h-09.00h) respond to email queries from Oxfordshire GPs, aiming for a standard response within 24h period. Thirty-six GP surgeries utilised this email service and Resident Paediatric Consultants responded as part of Night activity a mean of 9 emails (median 8, range 3-20) during night hours. This confirmed that between 2011-2013 there was a five fold increase of number of GP advice-seeking emails (Annual Total for [2011-2012] was 156; for [2012-2013] was 780); between 2013-2016 emails have now doubled to 1800 emails per year (5,400 emails); there were only 2 Complaints, 15 Compliments to advisory service; the complexity of questions has emerged from 1-2 line questions in 2010-2011, to paragraphs, now seeking response to a range clinical questions entailing 10-12 lines and attached clinic consultation letters.
    Quality anlaysis of a 3 month period of audit (1st September – 30th November 2013), 122 email questions arrived: of these 81 (66%) were responded to within <24hours (set standard); 15 ( 12.3%) in 24-48h; 26 (21.3%) > 48hours. 6 did not have adequate patient details so did not receive first advice response; )

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  • Medical visits before diagnosis of type 1 diabetes mellitus in Taiwan

    The paper by Yang et al1 provided an interesting epidemiological picture regarding the healthcare use in the year before correct diagnoses are confirmed for childhood cancer, type 1 diabetes mellitus (T1DM) and other immune diseases. Despite the presence of known clinical presentations associated with these diseases, diagnoses are not usually made until after couples of medical visits, except in cases with T1DM. Nearly two thirds of newly diagnosed T1DM patients presented emergent diabetic ketoacidosis. This rate was similar to that reported in a single-center Taiwanese study2 but still much higher than those in the US and Europe.3,4 This finding raised a question whether diabetic ketoacidosis at diagnosis of T1DM was a result of missed recognition for diabetic symptoms. In this regard, I am surprised that common urological symptoms, such as proteinuria and polydipsia2, found in Taiwanese T1DM patients were not included in the ICD-9 codes grouped for the urogenital problems, although the data showed an increase in urogenital problems shortly before the diagnosis of T1DM.1 From a clinical perspective, it is also crucial to know how the access to healthcare before diagnosis differ between those with and without diabetic ketoacidosis.3 If the analysis can be stratified by this factor, we may better evaluate the performance and impact of pre-diagnostic outpatient visits on subsequent healthcare for T1DM. There is always room for improvement in terms of increasing awareness of...

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  • An additional age-appropriate vancomycin formulation for Clostridium Difficile Infection disease in infants and young children.

    To the editor:

    We have read with great interest the investigation by Ivanovska et al in which they compared the antibiotic formulations included on the WHO Essencial Medicines List for Children (EMLc) versus four pertinent International Formularies (-1- ). As a result, they identified nine clinically relevant additional formulations on the comparator lists which were not listed on the WHO EMLc.
    We would like to mention another relevant formulation of great interest, which was not studied by the authors as it was not included on the lists they selected for the comparison study.
    They found only one vancomycin formulation on the WHO EMLc (250mg powder for injection) and two additional formulations on the comparator lists (125mg and 250mg oral capsules). Neither the WHO EMLc nor the comparator lists had any reference about oral liquid formulations of vancomycin; they are commercially available only in a few countries. However, they are necessary to simplify and facilitate the proper oral administration of the drug to infants and young children to treat Clostridium Difficile (CD) Infection (CDI) disease in accordance with therapeutic guidelines.

    CD has become the most common cause of health care-associated infections in US hospitals (-2- ). Since the discovery of CDI there has been an alarming increase in the incidence, severity, recurrence rate of the disease and mortality. The emergence of an epidemic hypervirulent strain of toxin –producing CD in r...

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  • Prevalence and Aetiology of ADHD

    I would like to thank Professor Taylor for his response, and apologise if my second response seems rude. I thought the first one had been overlooked.

    We do indeed agree that there is a large unmet need due to the under-recognition of ADHD and, I would suggest, other developmental disorders with a supposed genetic aetiology which seem to be more common than they were. The question of aetiology is, of course, pertinent to the epidemiology and the service needs assessment. Urgent too, if children's community services are not to be overwhelmed.

  • Dual-strain probiotics reduce NEC, mortality and neonatal bloodstream infections among extremely low birth weight (ELBW) infants

    Berrington and Ward Platt recently summarized current advances in the management of preterm infants born < 1000 g, so called extremely low birth weight (ELBW) infants (1). In this thoroughly done review, the authors highlighted the findings of the 2014 Cochrane review showing probiotics to reduce all-cause mortality and NEC in preterm infants, but not in the subgroup of ELBW infants (2). They hypothesized the lacking protective effect in this extremely vulnerable population to be attributable to their general immaturity, the timing of probiotic exposure or the small sample size of only 575 ELBW infants analyzed. Another recent meta-analysis did not show a significant beneficial effect of probiotics on sepsis in 771 ELBW infants included (3). This demands further studies with adequate power on the use of probiotics in infants born < 1000 g. Almost at the same time, we published a multi-center time series analysis supporting the beneficial effects of dual-strain probiotics on NEC, overall-mortality and nosocomial bloodstream infections (BSI) in preterm infants (4). Beyond that, we performed a subgroup analyses with 4683 ELBW infants. Routine use of dual-strain probiotics significantly reduced the risk of NEC (HR 0.48, 95 % CI 0.36 – 0.64), overall mortality (HR 0.59, 95 % CI 0.41 – 0.84) and nosocomial BSI (HR 0.83, 95 % CI 0.74 – 0.94) in this cohort. Further, probiotics also protected ELBW infants from mortality following NEC (HR 0.40, 95 % CI 0.19 – 0.85). Up to dat...

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  • Pulse oximetry in children under the magnifying glass

    Dear Authors.

    In your paper [1], you did not mention a previous prospective study performed by our group [2], on 148 otherwise healthy children referred to a Sleep Center for suspected OSA. In our study, pulse oximetry metrics were similar on the two consecutive nights. The McGill Oximery Score (MOS) on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive. We highlighted that the findings may not apply to younger infants, to adolescents, or to children with complex comorbidities.

    Our conclusions were different from yours for at least two main reasons.

    Firstly, you accepted oximetry recording lasting ≥ 4 hrs. On our opinion, this cut off is too low and it cannot be sufficiently representative of an overnight study. In our study [2], we accepted recordings lasting ≥ 6 hrs according to the ATS guidelines for sleep study.

    Secondly, you used a Nonin 9600 Pulse Oximeter with Nellcor neonatal-adult SpO2 sensor. In our study [2], we used a motion-resistant Radical 5 Masimo Pulse Oximeter. Previous studies [3,4], demonstrated the superiority of the Radical Masimo technology.

    We believe that your study was performed using suboptimal technology and the criteria for minimum acceptable recording time didn’t respect the ATS guidelines. Therefore, your results should be considered with caution.

    Convincing data already exist on pulse oximetry and the analysis of MOS as a useful tool for...

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