eLetters

132 e-Letters

published between 2014 and 2017

  • 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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  • 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; )
    Prev...

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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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