The question asks would a rapid PCR test on blood alter management in
a febrile infant by way of discontinuing antibiotic therapy if found to be
negative.
The multiplex PCR offered would not alter management in a "hot,
grumpy, 2 month old" even if it offered 100% certainty that the infant did
not have bacteraemia. Bacteraemia implies bacterial infection directly in
the blood and is only one of a number of potentia...
The question asks would a rapid PCR test on blood alter management in
a febrile infant by way of discontinuing antibiotic therapy if found to be
negative.
The multiplex PCR offered would not alter management in a "hot,
grumpy, 2 month old" even if it offered 100% certainty that the infant did
not have bacteraemia. Bacteraemia implies bacterial infection directly in
the blood and is only one of a number of potential sources of bacterial
infection in this clinical scenario. Limiting multiplex PCR tests to
blood would not eliminate the need for CSF, urine and chest-xray analysis
in identifying the source of the pyrexia. The question fails to
acknowledge the fact that an infant may have a serious bacterial infection
in the absence of bacteraemia. In fact, traditional methods of bacterial
blood culture are often negative despite positive urine/CSF culture, or
infective changes on a chest xray/ultrasound.
Therefore, in reality, antibiotics would continue irrespective of the
accuracy and "evidence" associated with the multiplex PCR test described
in your article. It would simply be another tool for rapidly assessing a
sick infected infant.
The second paragraph of this brief note is entirely incorrect, as the
trial from Malawi is indeed included in the BMJ meta-analysis. It is
included as reference #34 and mentioned explicitly by name in Tables 1 and
2 and Figures 2 and 3. That trial in fact provided approximately 2/3 of
the participants included in the meta-analysis.
We support Drs. Munro and Flanagan's recommendations to increase
awareness of the need for larger volumes of bloods for culturing in
children,1 and additionally recommend larger volumes of cerebrospinal
fluid during lumbar puncture, given the increasing availability of
molecular diagnostic tests for viruses causing meningitis. However, we
believe that the findings of their recent audit identifying similar blood
volumes...
We support Drs. Munro and Flanagan's recommendations to increase
awareness of the need for larger volumes of bloods for culturing in
children,1 and additionally recommend larger volumes of cerebrospinal
fluid during lumbar puncture, given the increasing availability of
molecular diagnostic tests for viruses causing meningitis. However, we
believe that the findings of their recent audit identifying similar blood
volumes being taken from 14 year-olds as 1 month-olds (mean 1.92ml vs.
1.00ml respectively) most likely reflect standard practice in most
National Health Service hospitals in England, which allows us to compare
our positivity rates with historical studies with more confidence. At the
same time, though whilst it is true that the sensitivity of paediatric
blood cultures remains limited, it has improved substantially with recent
automated microbiological culturing processes, such as those used in the
trusts within our study. Moreover, our low positivity rates are in keeping
with other studies of bacteraemia in industrialised countries with
established national immunisation programmes,2-5 including the UK.6,7 In
particular, we are not aware of any hospitals in England that recommend
the collection of 40-60mL of blood volume in older children; these
recommendations from the IDSA/ASM are based on expert opinion extrapolated
from adult blood volumes rather than actual observations.8 The
recommendations also advocate much lower blood volumes in infants and
toddlers who have the highest burden of infection, in keeping with other
recent studies reporting higher culture positive rates with larger blood
volumes (?0.5 mL for <1 month-olds, ?1.0 mL 1-36 month-olds and ?4.0 mL
for ?36 month-olds).5 Therefore, whilst we need to increase awareness for
reasonable age-appropriate blood and CSF volumes to be taken for culture
and molecular testing in children, the audit by Drs. Munro and Flanagan
does not change our findings of low childhood invasive bacterial infection
rates. We now need to this information to develop and implement strategies
to reduce childhood hospitalization rates and manage low-risk febrile
children at home.
AUTHORS:
Kirsty LeDoare, Adam Irwin, Mike Sharland, Shamez Ladhani
Paediatric Infectious Diseases Research Group, St. George's Hospital NHS
Trust, Blackshaw Road, London SW17 0QT, UK
E-mail: shamez.ladhani@phe.gov.uk
REFERENCES
1. Munro APS, Flanagan P. Cultural awareness; small volumes of blood
for culture cause under-detection of invasive infections. Arch Dis Child
2014 xxx
2. Haddon RA, Barnett PL, Grimwood K, et al. Bacteraemia in febrile
children presenting to a paediatric emergency department. Medical J Aust.
1999 May 17;170(10):475-8.
3. Sard B, Bailey MC, Vinci R. An analysis of pediatric blood cultures in
the postpneumococcal conjugate vaccine era in a community hospital
emergency department. Pediatr Emerg Care. 2006 May;22(5):295-300.
4. Bressan S, Berlese P, Mion T, et al. Bacteremia in feverish children
presenting to the emergency department: a retrospective study and
literature review. Acta Paediatr. 2012 Mar;101(3):271-7.
5. Connell TG, Rele M, Cowley D, Buttery JP, Curtis N. How reliable is a
negative blood culture result? Volume of blood submitted for culture in
routine practice in a children's hospital. Pediatrics. 2007 May;119(5):891
-6.
6. Martin, NG Sadarangani M, Pollard AJ, Goldacre MJ. Hospital admission
rates for meningitis and septicaemia caused by Haemophilus influenzae,
Neisseria meningitidis, and Streptococcus pneumoniae in children in
England over five decades: a population-based observational study. Lancet
Infect Dis. 2014 Mar 13. pii: S1473-3099(14)70027-1.
7. Irwin, A., Community-acquired bacteraemia presenting to the Alder Hey
Children's Hospital Emergency Department, BPAIIG winter meeting oral
presentation, 13/12/2013.
8. Baron E, Miller J, Weinstein M, et al. A guide to utilization of the
microbiology?laboratory for diagnosis of infectious diseases: 2013
recommendations by?the Infectious Diseases Society of America (IDSA) and
the American Society?for Microbiology, Clinical Infectious Diseases, 2013
Aug; 57 (4) : e22-?e121.
We were interested in the paper by Srinivasan and colleagues1 as it
brings into focus the differences in the epidemiology of firearm injuries
in children and young people between the USA and the United Kingdom and
the importance that gun control has had in child and adolescent safety
here. Through the Child Death Review in Wales we have previously reviewed
deaths from firearm injuries in the UK. This followed the death i...
We were interested in the paper by Srinivasan and colleagues1 as it
brings into focus the differences in the epidemiology of firearm injuries
in children and young people between the USA and the United Kingdom and
the importance that gun control has had in child and adolescent safety
here. Through the Child Death Review in Wales we have previously reviewed
deaths from firearm injuries in the UK. This followed the death in Wales
of a young person by his own hand using a shotgun. This prompted us to
examine the problem of firearm deaths to children and young persons in
Great Britain2. We hoped to search for common themes that underpin the
causes of childhood firearm deaths and investigate the scope for
prevention.
In the paper from America1, the incidence of fatal firearm injuries
attending emergency rooms was 0.4/100,000 (CI -02-1.0) with a non-fatal
rate of 23.5 (CI 14.1 to 32.9). The fatal rate quoted is for children
presenting dead or dying to emergency departments and the overall rate of
firearm injuries deaths is much larger 3.2/100,000 children3 in 2010. Of
the injuries in Emergency Room study, 64% were unintentional. Some of
these unintentional shootings may occur when children are unsupervised in
a home, find a loaded gun and accidentally fire it. There are also youth
suicides.
In our study between 2005 and 2010, 41 children were killed by firearms: 1
in Scotland, 4 in Wales and 36 in England. Looking at England and Wales
the incidence in children 0-18 years is 0.057/100,000/ year. The age range
was 18 months to 17 years, with a majority (32) aged 15-17 years. There
were 8 accidental deaths, 6 suicides and 27 murders. 8 deaths involved air
rifles. Notably of the murders, 24 children were of Afro-Caribbean origin
and 4 were female. There was a geographical variation, with 16 murders
occurring in London and 6 in Manchester. 19 cases of murder were linked to
criminal gangs.
The incidence of deaths from firearms based on figures from Children's
Defense Fund (from U.S. Centers for Disease Control and Prevention) is
approximately 56 times more common per 100,000 population in America than
England and Wales. This provides important lessons for the United States
but there are lessons also for us in Britain with reducing of violent
youth crime in big urban centres and reducing the exposure of children to
air rifles and shotguns.
References
1. Srinivasan S, Mannix R, Lee L K Epidemiology of paediatric firearm
injuries in the USA, 2001-2010. 10.1136/archdischild-2013-304642
2. Murch H et al. Review of child deaths from firearms in Great
Britain 2005-2010. Is there scope for prevention? Welsh Paediatric Journal
2012; 37:17-20
3. Protect Children not Guns 2013. Children's Defense Fund. 25 E
Street, N.W., Washington, DC 20001
Mitch Blair's article is an important commentary on the relationship
between academic enquiry and changes which affect child health, and
justifies some amplification. The two examples he relies on are very
different and obscure a third.
The benefit of antenatal steroids in reducing R.D.S. was based on research
but occurred as a result of a steady increase in collaboration of
paediatricians (responsible for treatment of R....
Mitch Blair's article is an important commentary on the relationship
between academic enquiry and changes which affect child health, and
justifies some amplification. The two examples he relies on are very
different and obscure a third.
The benefit of antenatal steroids in reducing R.D.S. was based on research
but occurred as a result of a steady increase in collaboration of
paediatricians (responsible for treatment of R.D.S. ) and obstetricians
(responsible for prescribing steroids). This started in the 1970's and
allowed the agnostics to gradually convert, rather than by a sudden
watershed in 1990.
The cot death story obscures the major alteration in infant care
which aroused little comment in this country ,although it did in the
Netherlands. Clear evidence that preterm infants benefited from lying
prone led to a major change, instigated mainly by midwives who felt that
'normal' babies should not be excluded from the benefits given to those in
'Special Care'. Both midwives and mothers noted that some babies slept
more soundly when prone.
Ruth Gilbert has documented how evidence for the adverse effect of
prone sleeping was accumulating, but the studies were observational , of
small numbers and with confidence limits which nobody judged sufficient to
advise changing the sleeping position of what had become the majority of
infants.
In 1989 F.S.I.D. recognised that the search for medical diagnoses had
only been successful in a few cases, and Risk Related Intervention was not
practical for the whole population. I set up a working group, including
leading professionals , to advise on the most promising measures which
might reduce deaths and could be advised for virtually all
babies.Sufficient evidence from intervention studies was lacking, although
there were documented initiatives advising locally on issues such as
overheating and prone sleeping.
Early in 1991 Ed Mitchell published results of the New Zealand
intervention study which reached a wider community at a meeting in Rouen
that summer. This was judged sufficient for action; a campaign was swiftly
prepared based on the recommendations of the working party and F.S.I.D.
launched the "Reduce the Risk " campaign in October. The delay in acting
on evidence was in months not 20 years. The D.O.H. followed with
television advertisements ,a temporary leaflet('Back to Sleep') and
funding for the C.E.S.D.I. study.
To make significant improvements one needs more than well founded
research; the data and the arguments for change must be easily available
and understandable., and robust enough to prevent calls for more research
before action. The benefits should be major and the risks minimal. The
agents of change , parents, nurses and midwives, and medical staff all
have individual needs in the way information is presented, and while the
state needs to take ultimate responsibility a bureaucratic response could
bring its own disadvantages including a lack of motivation .
Conflict of Interest:
Former Trustee; Foundation for the Study of Infant Death
Dear Sir,
We read with interest the work by Duke et Fuller (1) demonstrating an
increase in the publication of randomized controlled trial (RCT); total:
1553) in 76 low- and middle income countries (LMIC) over a 11-year period.
Of note, studies of nutrition (366 publications, 23.6%) and malaria (336
publications, 21%) predominated. Trials of infectious diseases - most
importantly malaria involved a comprehensive range of...
Dear Sir,
We read with interest the work by Duke et Fuller (1) demonstrating an
increase in the publication of randomized controlled trial (RCT); total:
1553) in 76 low- and middle income countries (LMIC) over a 11-year period.
Of note, studies of nutrition (366 publications, 23.6%) and malaria (336
publications, 21%) predominated. Trials of infectious diseases - most
importantly malaria involved a comprehensive range of both treatment and
preventive strategies with the implementation of new interventions as
routine health strategies, and reductions in malaria. The authors
demonstrated that there have been a relatively small number of trials of
interventions for treatment or prevention of acute respiratory infection
(98 publications, 6.3%), neonatal health (64 publications, 4.1%) and
tuberculosis in children (26 publications, 1.7%). Interestingly, in the
last 5 years there has been increasing focus on non-communicable diseases
such as asthma and allergy, obesity, diabetes and cardiac disease, and
behavioural-developmental disorders while mental health conditions have
received little attention (21 publications, 1.4% of publications) (1).
While Duke et Fuller. (1) are to be congratulated for their
systematic analysis, there is an ongoing lack of up-to-date, systematic
reviews that critically assess the role and potential limitations of
evidence-based medicine (EBM) and systematic Cochrane reviews in
particular originating in LMIC. Undoubtedly, EBM has contributed
substantially to improving the quality of medicine in general, and in
neonatology and pediatrics in particular (2). Cochrane reviews are
systematic reviews/meta-analyses of primary research in the medical and
health policy fields. They are considered the highest standard in EBM.
Thus, the Cochrane database may prove particularly beneficial for LMIC
with limited resources. However, most published clinical research has been
conducted in highly industrialised Western countries, and it remains
unclear how the results gained from these RCTs will translate into changes
in medical care in the developing world. Thus, it is important that LMIC
themselves get involved in research activities based on their specific
medical problems and needs - as demonstrated by Duke et Fuller ?1? - but
also in the process of generating of Cochrane reviews as well.
Hence, we would like to share our data analysis on this topic (3). We
performed a systematic literature review of all Cochrane reviews published
between 1996 and 2010 by the Cochrane Neonatal Review Group (CNRG) and in
the field of neuropediatrics. The main outcome parameter of our review was
the assessment of the percentage of reviews that originated in developing
countries and the number of reviews that provided conclusive/ inconclusive
data.
In total, 262 reviews were performed in the field of neonatology and 112
in the field of neuropediatrics. Only a small fraction (15/262 (5.7%) in
neonatology and 16/112 (14.3%) in neuropediatrics) originated in
developing countries. Only seven of those 15 reviews in the field of
neonatology provided conclusive recommendations (six negative, one
positive) while in neuropediatrics 9 reviews provided conclusive
recommendations (five negative and four positive), while six were
inconclusive. One report provided conditional recommendations.
This is of concern, for worldwide the vast majority of neonates and
children are born and raised in these countries. Moreover, the
recommendations issued in Cochrane reviews performed in highly
industrialised countries are largely applicable to the fields of
neonatology and neuropediatrics as practised in industrialised countries
and will potentially exclude the majority of neonates, infants, and
children being born and cared for in the developing world. However,
recently, efforts (through initiatives such as the Effective Health Care
Alliance and the SEA-orchid consortium) have been undertaken to
disseminate knowledge from the CNRG to low- and middle-income countries to
ensure that care practices are evidence-based and that scarce resources
will be used and allocated appropriately (2, 4). These programs target
generators as well as users and teachers of evidence in order to
ultimately ensure the implementation of effective interventions (2, 4).
Moreover, and of note, our study also demonstrated that a substantial
percentage of systematic Cochrane reviews from developing countries were
inconclusive and failed to provide any recommendation with regard to a
specific intervention.
Based on our findings and the work by Duke et Fuller (1), we conclude
that there is an ongoing need for high-quality research that addresses
specific issues that are most relevant to the medical care of children in
developing countries. Funding and research agencies will play a pivotal
role in selecting the most appropriate research programs for the
developing world. Given the limited financial and human resources that are
available in the medical arena in the developing world, future emphasis
must be on long-term outcomes that are vital to infants and children and
their families, as well as to healthcare workers. Importantly, in the
future the effects of interventions not only on survival, but also on long
-term morbidity, must be considered (5). This change in paradigm is
particularly important in perinatal medicine. In doing so, the realization
and implementation of the Millennium Development Goals as defined in 2000
will become realistic, thus reducing child mortality rates worldwide (6,
7). In the future, it will be important to assess effectiveness of
interventions that will have been put in place following the publication
of high quality RCTs - as shown by Duke et Fuller (1) - and systematic
reviews in LMIC.
References
1. Duke T, Fuller D. Randomised controlled trials in child health in
developing countries: trends and lessons over 11 years. Arch Dis Child.
2014 Mar 10. doi: 10.1136/archdischild-2013-305702. [Epub ahead of print]
2. Davis, P.G. 2006. "Cochrane Reviews in Neonatology: Past, Present and
Future." Seminars in Fetal & Neonatal Medicine 11: 111-16
3. Meyer S, Willhelm C, Girisch W, Gottschling S, Gr?ber S, Gortner L. The
role of developing countries in generating Cochrane meta-analyses in the
field of pediatrics (neonatology and neuropediatrics): a systematic
analysis. World Health Popul. 2013;14(2):24-32
4. Henderson-Smart, D.J., P. Lumbiganon, M.R. Festin, J.J. Ho, H.
Mohammad, S.J. McDonald et al. 2007. "Optimising Reproductive and Child
Health Outcomes by Building Evidence-Based Research and Practice in South
East Asia (SEA-Orchid): Study Protocol." BMC Medical Research Methodology
7: 43;doi: 10.1186/1471- 2288-7-43
5. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national
causes of child mortality: an updated systematic review for 2010 with time
trends since 2000. Lancet 2012;379(June 9):2151-61.
6. UNICEF. Committing to child survival: a promise renewed. New York:
United Nations Children's Fund, 2012. Ref Type: Report
7. Willhelm, C., W. Girisch, L. Gortner and S. Meyer. 2012. "Role of
Cochrane Reviews in Pediatric Neurology." Acta Paediatrica 101(4): 352-3.
d
Humphreys et al. investigated a prospective longitudinal study of
sleep duration in 73 children with autistic spectrum disorder (ASD) by
setting controls (1). Sleep data were collected by questionnaire survey
from parents. Although there was no significant difference in total sleep
duration in infancy, shortening of night sleep duration became predominant
in children with ASD from 30 months of age, which was caused by lat...
Humphreys et al. investigated a prospective longitudinal study of
sleep duration in 73 children with autistic spectrum disorder (ASD) by
setting controls (1). Sleep data were collected by questionnaire survey
from parents. Although there was no significant difference in total sleep
duration in infancy, shortening of night sleep duration became predominant
in children with ASD from 30 months of age, which was caused by later
bedtimes and earlier waking times. I recently reported comments on the
etiology and risk assessment of ASD (2, 3), and I present a concern on
their study.
The authors used sleep duration as a main sleep parameter in day-time
and night-time, respectively. These parameters were calculated from the
time of going to bed in the evening and waking in the morning. Hodge
et?al. reported a cross-sectional study by using 8 sub-scales of sleep
parameters from Children's Sleep Habit Questionnaire (CSHQ), and children
with ASD, aged from 3 to 17 years old, showed several difference in sleep
including loss of sleep duration against children with typical development
(TD) (4). Other significant differences were observed in sleep onset
delay, sleep anxiety, night waking, and sleep disordered breathing.
Although CSHQ is a reliable questionnaire (5), there are difficulties in
receiving information form parents in longitudinal study by questionnaire
survey, and other method such as actigraphy should also be considered.
Sitnick et al. described the limitation of actigraphy for detecting night
waking (6). As there is a difference between brain activity and physical
movement during sleep, especially for insomniacs, the validity of
actigraphy as a tool for detecting poor sleep should be checked by sleep
polysomnography as a gold standard.
Malow et al. reported shortening of sleep latency by actigraphy and
improvement of sleep onset by CSHQ after sleep education with statistical
significance. In contrast, sleep duration and night-time waking were
improved by CSHQ, and sleep efficiency was increased by actigraphy after
sleep education. These data present that there are some discrepancy
between subjective and objective sleep parameters (7). In contrast,
Humphreys et al. quoted one reference that the subjective and objective
measures yielded very similar estimates of the rate of sleep disturbances
between children with ASD and with TD (8). On this point, I support the
opinion that the discrepancy of the results should be verified to know the
effect of sleep education for children with ASD (9).
Anyway, sleep for children with ASD should be verified by further
studies.
REFERENCES
1 Humphreys JS, Gringras P, Blair PS, et al. Sleep patterns in
children with autistic spectrum disorders: a prospective cohort study.
Arch Dis Child 2014;99:114-8.
2 Kawada T. Re: Parental depression, maternal antidepressant use
during pregnancy, and risk of autism spectrum disorders: population based
case-control study. BMJ 14 January 2014. Rapid Response
3 Kawada T. Risk assessment for autism spectrum disorders by
representative database. Paediatr Perinat Epidemiol 2014;28:177.
4 Hodge D, Carollo TM, Lewin M, et al. Sleep patterns in children
with and without autism spectrum disorders: Developmental comparisons. Res
Dev Disabil 2014;35:1631-8.
5 Goodlin-Jones BL, Sitnick SL, Tang K, Liu J, Anders TF. The
Children's Sleep Habits Questionnaire in toddlers and preschool children.
J Dev Behav Pediatr 2008;29:82-8.
6 Sitnick SL, Goodlin-Jones BL, Anders TF. The use of actigraphy to
study sleep disorders in preschoolers: some concerns about detection of
nighttime awakenings. Sleep 2008;31:395-401.
7 Malow BA, Adkins KW, Reynolds A, et al. Parent-based sleep
education for children with autism spectrum disorders. J Autism Dev Disord
2014;44:216-28.
8 Souders MC, Mason TB, Valladares O, et al. Sleep behaviors and
sleep quality in children with autism spectrum disorders. Sleep
2009;32:1566-78.
9 Sadeh A. Evaluating night wakings in sleep-disturbed infants: a
methodological study of parental reports and actigraphy. Sleep 1996;19:757
-62.
We endorse the sentiments expressed by Mecrow and O'Connor, and
acknowledge the concerns they raise. As emphasised in our paper, there is
currently a lack of evidence for the efficacy, efficiency and
effectiveness of the child death review process. However, we would argue
that the value of the CDOP process is not predicated on a demonstrable
reduction in mortality alone.
We endorse the sentiments expressed by Mecrow and O'Connor, and
acknowledge the concerns they raise. As emphasised in our paper, there is
currently a lack of evidence for the efficacy, efficiency and
effectiveness of the child death review process. However, we would argue
that the value of the CDOP process is not predicated on a demonstrable
reduction in mortality alone.
While demonstrating a reduction in mortality secondary to CDOP
interventions may be beyond the scope of any individual panel, it is
possible that the process of child death review delivers a range of other
benefits such as promoting wellbeing and reducing morbidity. This does not
negate the need for a comprehensive evaluation as the essence of the issue
is not whether CDOPs deliver valuable outcomes but whether they deliver
good value for money in an economically constrained service.
The lines of accountability for CDOPs should be reviewed and improved
so that, for example, recommendations for improving perinatal care are not
rooted through a Local Children's Safeguarding Board. We completely agree
that national aggregation and analysis of data is the most obvious vehicle
for starting to deliver a reduction in mortality and its absence compounds
any poor return for resources invested. Nationwide collation should be
combined with the capacity to both review effectiveness evidence for
interventions to tackle contributory factors and make recommendations for
national programmes where appropriate.
Joining with our colleagues we reiterate our call for national
collation and analysis of data to derive maximum benefit from the process,
and for a more rigorous evaluation that recognises broader outcomes than
mortality alone.
Dr Luke Allen (corresponding author)
Dr Simon Lenton
Dr James Fraser
Dr Peter Sidebotham
We read with interest your article demonstrating surprisingly low
levels of culture-confirmed invasive bacterial infections in children.[1]
Whilst we agree better strategies are needed for separating low risk,
febrile children from those with invasive-infections, we believe there is
another significant factor contributing to their apparent low rates.
Large studies demonstrate that blood-culture volumes are frequ...
We read with interest your article demonstrating surprisingly low
levels of culture-confirmed invasive bacterial infections in children.[1]
Whilst we agree better strategies are needed for separating low risk,
febrile children from those with invasive-infections, we believe there is
another significant factor contributing to their apparent low rates.
Large studies demonstrate that blood-culture volumes are frequently
inadequate in children.[2] It is well documented that the most significant
factor in yielding an organism from culture is the volume of blood
sampled.[3, 4] Insufficient volumes lead to large numbers of false-
negatives, and it is estimated that 50% of cultures taken from children
are of inadequate volume.[2]
We audited blood-culture volumes locally, analysing 66 patient
samples (target volumes from previous studies [2]). We documented an
overall compliance of 33%. Significantly this included 0% compliance in
the >10yr age-group (N=11). Similar volumes were taken from 14 year-
olds as 1 month-olds (Mean 1.92ml vs 1.00ml respectively), despite the
>10-fold difference in circulating volume and haemodilutionary effect
on bacterial concentrations. From our intervention we learned this was
largely due to a lack of education of how much blood was necessary from
different sized children. Better education is clearly needed.
Your article mentions standard practice taking "at least 1 - 2ml
blood"[1], however for at least the >6000 tests performed in the 5-15
year-olds, 1-2ml of blood would be insufficient to produce a reliable
result. Recent recommendations even suggest for children >36kg, an
adult regime of cultures should be performed (40-60ml).[5]
Even taking into account "modern technologies [making] blood volumes
less problematic"[1] our audit shows many clinicians remain unaware how
much blood it is necessary to take. Considering that children remain
difficult to venesect due to their small veins and poor compliance, the
positive yield of blood-cultures is certain to underestimate the true
number of invasive-infections in children.
References
1. Le Doare K, Nichols A-L, Payne H, et al. Very low rates of culture
-confirmed invasive bacterial infections in a prospective 3-year
population-based surveillance in Southwest London. Arch Dis Child
Published Online First: February 19th 2014. doi:10.1136/archdischild-2013-
305565
2. Connell TG, Rele M, Cowley D, Buttery JP, Curtis N, How reliable
is a negative blood culture result? Volume of blood submitted for culture
in routine practice in a children's hospital, Pediatrics. 2007;119(5):891.
3. Mermel LA, Maki DG, Detection of bacteremia in adults:
consequences of culturing an inadequate volume of blood, Ann Intern Med.
1993;119(4):270.
4. Ilstrup DM, Washington JA 2nd.The importance of volume of blood
cultured in the detection of bacteremia and fungemia. Diagn Microbiol
Infect Dis. 1983;1(2):107
5. Ellen Jo Baron et al, A guide to utilization of the microbiology
laboratory for diagnosis of infectious diseases: 2013 recommendations by
the Infectious Diseases Society of America (IDSA) and the American Society
for Microbiology, Clinical Infectious Diseases, 2013 Aug; 57 (4) : e22-
e121.
Allen et al (1) are to be congratulated in reporting the first
attempt to quantify the efficacy and impact of Child Death Overview Panels
(CDOP) in the UK. They note that Paediatricians contributing to the
workings of the panel are of the view that the panels function well with
71% of responders agreeing or agreeing strongly that they offer good
value. However, the nature of the study may have involved significant bias
as...
Allen et al (1) are to be congratulated in reporting the first
attempt to quantify the efficacy and impact of Child Death Overview Panels
(CDOP) in the UK. They note that Paediatricians contributing to the
workings of the panel are of the view that the panels function well with
71% of responders agreeing or agreeing strongly that they offer good
value. However, the nature of the study may have involved significant bias
as participating Paediatricians were asked to consider a number of
variables where responses were subjective and, because those involved in
the survey are members of CDOP panels, there may have been an
inappropriately positive view of the impact and importance of the process.
Strikingly, only 27% of respondents in the survey identified the
prevention of future child deaths as the most important function of the
process.
The authors acknowledge that a lack of aggregated National data
compromise efficacy of the panels and cite sources indicating that the
cost of introducing the panels across the UK is of the order of ?53
million. As past (IKM) and current (LOC) members of the CDOP panel we
would agree that any value associated with the process remains unclear.
The lack of objective or measurable outcomes hampers any assessment
and it might be argued that the CDOP process could only be seen to work
and offer value for the considerable investment, if a reduction in
childhood mortality could be demonstrated. Our experience, which dates
from the inception of the CDOP process, is that very many hours are spent
reviewing cases where there are very good medical reasons accounting for
the vast majority of deaths. Few deaths are identified as having been
predominantly due to modifiable factors and a large proportion of the
modifiable factors that are identified are already the subject of major
public health campaigns; for example, co-sleeping and smoking in
pregnancy. Further, we have been concerned that the processes of Coronial
review through Inquest and Serious Case Review overlap very significantly
with the CDOP process - an unnecessary duplication of effort.
We would agree that the lack of aggregated National or Regional data
render any analysis of childhood deaths almost impossible. An individual
CDOP cannot know whether there is an excess mortality due to any
particular cause. This effectively precludes the institution of actions to
remedy service failings at a local level. Attempts to address this are in
progress. For example, in Greater Manchester, the Chairs of a number of
CDOPs have met to explore whether regional aggregation of data might
assist in identifying trends and areas of good or poor service provision.
Because the numbers of childhood deaths by cause are relatively small even
this approach is a poor substitute for National data.
It may be that the paediatricians involved find the experience of
reviewing child deaths rewarding and there will be some learning from
detailed review of cases. However, these benefits fall someway short of
providing justification of the expense of the process. We urgently need
aggregated data to allow comparison of death rates from specific
conditions. Only then will we know whether the primary aim of the process
can be achieved. Until this data is available the value of the CDOP
process cannot be quantified. We live in a time of huge financial
constraint in the NHS; it is our duty to extract the maximum benefit from
every pound spent in the healthcare economy.
Reference
1. Allen L, Lenton S, Fraser J and Sidebotham P. Improving the
practice of child death overview panels: a paediatric perspective. Arch
Dis Child. 2014;99:193-196
The question asks would a rapid PCR test on blood alter management in a febrile infant by way of discontinuing antibiotic therapy if found to be negative.
The multiplex PCR offered would not alter management in a "hot, grumpy, 2 month old" even if it offered 100% certainty that the infant did not have bacteraemia. Bacteraemia implies bacterial infection directly in the blood and is only one of a number of potentia...
The second paragraph of this brief note is entirely incorrect, as the trial from Malawi is indeed included in the BMJ meta-analysis. It is included as reference #34 and mentioned explicitly by name in Tables 1 and 2 and Figures 2 and 3. That trial in fact provided approximately 2/3 of the participants included in the meta-analysis.
Conflict of Interest:
None declared
We support Drs. Munro and Flanagan's recommendations to increase awareness of the need for larger volumes of bloods for culturing in children,1 and additionally recommend larger volumes of cerebrospinal fluid during lumbar puncture, given the increasing availability of molecular diagnostic tests for viruses causing meningitis. However, we believe that the findings of their recent audit identifying similar blood volumes...
We were interested in the paper by Srinivasan and colleagues1 as it brings into focus the differences in the epidemiology of firearm injuries in children and young people between the USA and the United Kingdom and the importance that gun control has had in child and adolescent safety here. Through the Child Death Review in Wales we have previously reviewed deaths from firearm injuries in the UK. This followed the death i...
Mitch Blair's article is an important commentary on the relationship between academic enquiry and changes which affect child health, and justifies some amplification. The two examples he relies on are very different and obscure a third. The benefit of antenatal steroids in reducing R.D.S. was based on research but occurred as a result of a steady increase in collaboration of paediatricians (responsible for treatment of R....
Dear Sir, We read with interest the work by Duke et Fuller (1) demonstrating an increase in the publication of randomized controlled trial (RCT); total: 1553) in 76 low- and middle income countries (LMIC) over a 11-year period. Of note, studies of nutrition (366 publications, 23.6%) and malaria (336 publications, 21%) predominated. Trials of infectious diseases - most importantly malaria involved a comprehensive range of...
Humphreys et al. investigated a prospective longitudinal study of sleep duration in 73 children with autistic spectrum disorder (ASD) by setting controls (1). Sleep data were collected by questionnaire survey from parents. Although there was no significant difference in total sleep duration in infancy, shortening of night sleep duration became predominant in children with ASD from 30 months of age, which was caused by lat...
Value for money
We endorse the sentiments expressed by Mecrow and O'Connor, and acknowledge the concerns they raise. As emphasised in our paper, there is currently a lack of evidence for the efficacy, efficiency and effectiveness of the child death review process. However, we would argue that the value of the CDOP process is not predicated on a demonstrable reduction in mortality alone.
While demons...
We read with interest your article demonstrating surprisingly low levels of culture-confirmed invasive bacterial infections in children.[1] Whilst we agree better strategies are needed for separating low risk, febrile children from those with invasive-infections, we believe there is another significant factor contributing to their apparent low rates.
Large studies demonstrate that blood-culture volumes are frequ...
Allen et al (1) are to be congratulated in reporting the first attempt to quantify the efficacy and impact of Child Death Overview Panels (CDOP) in the UK. They note that Paediatricians contributing to the workings of the panel are of the view that the panels function well with 71% of responders agreeing or agreeing strongly that they offer good value. However, the nature of the study may have involved significant bias as...
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