Dear Editor-in-chief,
in reaction to Charlotte M Wrights editorial "Failure to wean" (2013, 98:
838-840) we would like to add some data on the option of rapid tube
weaning to enhance the discussion between rapid versus slow weaning
programs and to advocate a flexible and individually tailored approach.
As Mrs Wright comments saying that no program suits every child we would
like to stress that especially medically fragil...
Dear Editor-in-chief,
in reaction to Charlotte M Wrights editorial "Failure to wean" (2013, 98:
838-840) we would like to add some data on the option of rapid tube
weaning to enhance the discussion between rapid versus slow weaning
programs and to advocate a flexible and individually tailored approach.
As Mrs Wright comments saying that no program suits every child we would
like to stress that especially medically fragile patients will need an
individually tailored approach. The more rapid the reduction of tube feeds
is performed, it is more likely that hunger occurs, whereas the child
needs to be evaluated closely during this process.
Our data (1) show that 92% of telemedical vs. 82% onsite treated of
344 children could be weaned completely using a rapid approach ("Graz
model of tube weaning") (2,3). Our data support the option of rapid
reduction of caloric intake. Currently, we are evaluating our long-term
data: relapse rate is <1% (children who had to go back to full tube
feeds - TF), <5% partial TF as a result to unforeseeable medical
events.
As we had 36 patients since 2010 living in the UK, this may show that our
online services (www.notube.com) for counselling are seen as helpful. In
various conferences and lectures throughout GB we taught our approach. We
advocate thorough assessment, team counselling, contact with local
centres. Experience and decidedness give hope for parents and children to
be able to learn to eat.
We understand the concerns of doctors Lin and Fu about reverse
causation regarding the protective effect of fish on eczema at one year of
age. We cannot, of course, be sure that reverse causation does not
contribute to our results, but there are reasons that speak in favour of a
real effect.
Firstly, we found no correlation between time of onset of the eczema
and age at introduction of fish....
We understand the concerns of doctors Lin and Fu about reverse
causation regarding the protective effect of fish on eczema at one year of
age. We cannot, of course, be sure that reverse causation does not
contribute to our results, but there are reasons that speak in favour of a
real effect.
Firstly, we found no correlation between time of onset of the eczema
and age at introduction of fish.
Secondly, when excluding infants with food-induced eczema, there was
still a protective effect, as was the case when excluding infants with
food allergy.
Thirdly, when excluding infants with onset of eczema before 4 months
of age, there was still a protective effect in infants with later onset of
eczema. Also, the protective effect was equal between infants with and
without atopic heredity.
Furthermore, we are not the only group that has reported such
effects. In the BAMSE study (1), Kull et al. found that fish consumption
during the first year of life was protective against allergic disease at 4
years. In a Norwegian study (1), Øien et al. found that fish reduced the
risk of having allergic disease at 2 years. Both studies excluded children
with disease before one year of age to avoid reverse causation.
We are at this moment analysing the data from our follow-up when the
children are 4.5 years old, and will hopefully be able to address the
question further.
References:
1. Kull I, Bergström A, Lilja G, Pershagen G, Wickman M. Fish
consumption during the first year of life and development of allergic
diseases during childhood. Allergy. 2006;61:1009-15.
2. Øien T, Storrø O, Johnsen R. Fish and cod liver oil consumption
during pregnancy and the first year of life and allergic diseases at 2
years of age. A prospective birth cohort study. XXVII Congress of the
European Academy of Allergology and Clinical Immunology, Barcelona.
[Abstract]. 2008.
Yours sincerely,
Bernt Alm MD PhD, Nils Åberg MD PhD, Laslo Erdes MD, Per Möllborg MD,
Rolf Pettersson MD, Gunnar Norvenius MD PhD, Emma Goksör MD, and Göran
Wennergren MD PhD.
In the review by O'Grady and Cody (1), the Authors concluded that "in
the pediatric population with subclinical hypothyroidism (SH), the
majority of children with slightly elevated TSH levels are likely to
normalise without treatment or have persistent mild TSH elevation". Our
goal is to reinforce that conclusion on the basis of the results of an our
study aiming to prospectively evaluate for the first time the natural
co...
In the review by O'Grady and Cody (1), the Authors concluded that "in
the pediatric population with subclinical hypothyroidism (SH), the
majority of children with slightly elevated TSH levels are likely to
normalise without treatment or have persistent mild TSH elevation". Our
goal is to reinforce that conclusion on the basis of the results of an our
study aiming to prospectively evaluate for the first time the natural
course of SH in children and adolescents with no underlying diseases and
no risk factors that might interfere with the progression of SH (2).
In our study clinical status, thyroid function and autoimmunity were
prospectively evaluated at entry and after 6, 12 and 24 months in 92 young
patients (mean age 8.1 /-3.0 years) with idiopathic SH. In the study
population all the etiological causes of SH had been preliminary excluded
at the time of admission. During the two-year follow-up period mean TSH
levels showed a trend towards a progressive decrease while FT4 levels
remained unchanged. Overall, 38 patients normalized their TSH (group A):
16 patients between 6 and 12 months, and 22 patients between 12 and 24
months. Among the remaining 54 patients, the majority maintained TSH
within the baseline values (group B), whereas 11 exhibited a further
increase in TSH above 10 uIU/ml (group C). Baseline TSH and FT4 levels
were similar in the patients who normalized TSH, compared with those with
persistent hyperthyrotropinemia. Even in the patients of group C, both TSH
and FT4 at entry were not different with respect to those of group A and
B. No patients showed any symptoms of hypothyroidism during follow-up and
no changes in both height and body mass index were observed throughout the
observation period (2).
We concluded that the natural course of TSH elevations in children and
adolescents with idiopathic SH is characterized by a progressive decrease
over time and that the majority of patients have a normalization of serum
TSH within a 2-year follow-up (2).
Our conclusions are in agreement with the ones by O'Grady and Code (1) and
support them.
References
1. O'Grady MJ, Cody D. Subclinical hypothyroidism in childhood. Arch Dis
Child 2010. Published Online First: 22 April 2010. doi:
10.1136/adc.2009.181800
2. Wasniewska M, Salerno M, Cassio A, Corrias A, Aversa T, Zirilli G,
Capalbo D, Bal M, Mussa A, De Luca F. Prospective evaluation of the
natural course of idiopathic subclinical hypothyroidism in childhood and
adolescence. Eur J Endocrinol. 2009 Mar;160(3):417-21.
Indeed Peanut Oil is not a well known ingredient of Abidec drops, but
on what basis can the authors say this is "clinically vital information"?
Have there been any reports of allergy to Abidec drops?
Abidec drops are regularly given to British babies. The introduction
of a small amount of peanut oil at that age may induce tolerance and
result in LESS allergy.
Indeed Peanut Oil is not a well known ingredient of Abidec drops, but
on what basis can the authors say this is "clinically vital information"?
Have there been any reports of allergy to Abidec drops?
Abidec drops are regularly given to British babies. The introduction
of a small amount of peanut oil at that age may induce tolerance and
result in LESS allergy.
Abidec has other advantages over "nut-free" drops. NHS Healthy Start
vitamin drops contain less Vitamin D (300 units) than Abidec (400 units)
and Dalivit drops have more Vitamin A (5000 units) which can be a problem
if the dose is doubled (as parents often do) compared to Abidec's 1333
units of Vitamin A.
I would be grateful for any documented data on harmful effects of
supplements in infancy. Caution is required before issuing an edict
against this widely used supplement. Paediatricians such as Reginald
Lightwood wrongly suspected Vitamin supplements of causing toxicity
(hypercalcaemia) 60 years ago. As a result, the UK still lags behind most
of the Western world in our Vitamin D supplementation programme.
We are very pleased to see the comment from Dr Burke regarding the
ethical and social considerations of Next Generation Sequencing, in
response to our review.
As we noted in our original article, the field is very complex, with
a major issue being the interpretation of sequencing data, such that
without follow up investigations many variants cannot be confidently
assigned as either beni...
We are very pleased to see the comment from Dr Burke regarding the
ethical and social considerations of Next Generation Sequencing, in
response to our review.
As we noted in our original article, the field is very complex, with
a major issue being the interpretation of sequencing data, such that
without follow up investigations many variants cannot be confidently
assigned as either benign or pathogenic. Given that this is the case,
reporting on such variants is premature.
It is also true that further research is urgently needed to determine
the potential benefits or harm of wide scale sequencing in children.
However, until we have clearer information on what variants can be
considered pathogenic, in addition to clear irrefutable evidence that
genetic testing in children is beneficial and not harmful, we would
continue to recommend that children be entitled to an open future and
allowed to choose testing for themselves at the appropriate age.
Most patients presenting to a paediatric department for acute care
will be weighed as part of the nursing assessment especially because
weights are important for drug and fluid prescriptions.
Junior doctors however generally fail to take the next step in this
opportunistic contact to plot these weights. Unless clinically indicated
e.g. as part of body surface area for drug prescriptions, the height is
often not measured,...
Most patients presenting to a paediatric department for acute care
will be weighed as part of the nursing assessment especially because
weights are important for drug and fluid prescriptions.
Junior doctors however generally fail to take the next step in this
opportunistic contact to plot these weights. Unless clinically indicated
e.g. as part of body surface area for drug prescriptions, the height is
often not measured, nor is head circumference routinely measured.
Indeed, this is a reflection of less than best practice and needs to be
highlighted as part of junior doctor induction.
I read with interest the article published by Archer et al on
Multisource Feedback of paediatric registrars. This article is very
encouraging for trainees like me and also answers doubts about the
validity and reliability of such work place based assessments.
One of the main conclusions of the authors is that self selection of
assessors by trainees should end. But this raises questions about the
validity of an...
I read with interest the article published by Archer et al on
Multisource Feedback of paediatric registrars. This article is very
encouraging for trainees like me and also answers doubts about the
validity and reliability of such work place based assessments.
One of the main conclusions of the authors is that self selection of
assessors by trainees should end. But this raises questions about the
validity of an assessment which as reported by the authors is based on the
length of working relationship, and trainees would be the best judge of
choosing assessors with whom they have had a reasonable length of working
relationship in terms of number of shifts worked. But as the authors
report that unregulated self selection of assessors can lead to selection
bias. A possible solution could be that the trainee provides a list of
assessors and their supervisor then invites certain number of assessors
selected randomly to provide feedback.
Another point to be considered in the same context of length of
working relationship is the timing of the MSF sessions. If trainees are
changing posts every six months which is still possible in the current
training pattern it might be useful to have these sessions towards the
later part of the post rather than in the middle as they currently are
done.
One of the other questions raised by the authors is the seniority of
the assessors which I feel is partly corrected by the current system of
MSF which suggests that trainees should choose a certain number of
consultants including their supervisor and certain number of nursing
colleagues as well.
The interesting and well-conducted study of Potijk et al reminds us
once again (though we probably don't need reminders) of the important
difference between statistically versus clinically significant differences
in research studies. The authors report that moderately preterm-born
children had significantly worse scores on all subscales of the CBCL than
did term born children; inspection of the P values in Table 2 shows t...
The interesting and well-conducted study of Potijk et al reminds us
once again (though we probably don't need reminders) of the important
difference between statistically versus clinically significant differences
in research studies. The authors report that moderately preterm-born
children had significantly worse scores on all subscales of the CBCL than
did term born children; inspection of the P values in Table 2 shows that,
statistically, this is quite correct. What is not discussed in the paper,
however, is the clinical significance of these differences. A commonly
used metric for evaluating the clinical significance of observed
differences is Cohen's effect size coefficient 'd'. This 'd' is the ratio
of the mean difference in scores between two groups to the standard
deviation in scores of the groups. Most of the differences shown in Table
2 have a 'd' value of 0.2 or less, which by convention would be considered
at the lower end of a small effect size. None of this takes away from the
finding that there were differences between the groups, but it is
important for readers (and authors) to consider the clinical significance
of differences. The use of large study samples can make differences that
are small and even trivial clinically, appear quite impressive
statistically.
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
Poor weight gain over the first 6-8 weeks is known to be a risk
factor in its own right for developmental delay, which can be demonstrated
not only at school age but, as shown by McDougall et al as early as 4
months.1
McDougall et al suggest that the Child Health Surveillance check at 6
-8 weeks provides the opportunity to identify infants with early weight
faltering; and that future research could ascertain whet...
Poor weight gain over the first 6-8 weeks is known to be a risk
factor in its own right for developmental delay, which can be demonstrated
not only at school age but, as shown by McDougall et al as early as 4
months.1
McDougall et al suggest that the Child Health Surveillance check at 6
-8 weeks provides the opportunity to identify infants with early weight
faltering; and that future research could ascertain whether intervention,
presumably to increase weight gain, would improve later outcomes for
infants. However the first 6-8 weeks are the vulnerable period,
interventions are needed during and not after the completion of this time.
It has already been shown that interventions can be used to encourage
weight gain in both breast and formula fed infants during this early
“window” of opportunity.2 3
UK Health Visitors (and midwives) carry calibrated electronic
weighing scales and see mothers frequently during this important time. If
infants are weighed weekly, then there is the opportunity to detect and
promptly remedy weight faltering thereby reducing the risk of
developmental delay. Also since the effect on later intellectual
development has been shown to be approximately linear over the whole range
of weight velocities, there is the opportunity to help all babies.4
The proposal to omit the first 2 weeks from the WHO2006 breastfed
weight charts (for UK use),5 thereby also removing birth weight from the
chart so that birth centile cannot be identified, may unfortunately limit
the implementation of a cheap worthwhile public health intervention.
Yours sincerely
Dr C A Walshaw
References
1 McDougall P., Drewett R.F., Hungin P, Wright C.M. The detection of
early weight
faltering at the 6-8 week check and its association with family
factors, feeding and
Dear Editor-in-chief, in reaction to Charlotte M Wrights editorial "Failure to wean" (2013, 98: 838-840) we would like to add some data on the option of rapid tube weaning to enhance the discussion between rapid versus slow weaning programs and to advocate a flexible and individually tailored approach. As Mrs Wright comments saying that no program suits every child we would like to stress that especially medically fragil...
Sir,
We understand the concerns of doctors Lin and Fu about reverse causation regarding the protective effect of fish on eczema at one year of age. We cannot, of course, be sure that reverse causation does not contribute to our results, but there are reasons that speak in favour of a real effect.
Firstly, we found no correlation between time of onset of the eczema and age at introduction of fish....
In the review by O'Grady and Cody (1), the Authors concluded that "in the pediatric population with subclinical hypothyroidism (SH), the majority of children with slightly elevated TSH levels are likely to normalise without treatment or have persistent mild TSH elevation". Our goal is to reinforce that conclusion on the basis of the results of an our study aiming to prospectively evaluate for the first time the natural co...
Indeed Peanut Oil is not a well known ingredient of Abidec drops, but on what basis can the authors say this is "clinically vital information"? Have there been any reports of allergy to Abidec drops?
Abidec drops are regularly given to British babies. The introduction of a small amount of peanut oil at that age may induce tolerance and result in LESS allergy.
Abidec has other advantages over "nut-free"...
To the Editor,
We are very pleased to see the comment from Dr Burke regarding the ethical and social considerations of Next Generation Sequencing, in response to our review.
As we noted in our original article, the field is very complex, with a major issue being the interpretation of sequencing data, such that without follow up investigations many variants cannot be confidently assigned as either beni...
Most patients presenting to a paediatric department for acute care will be weighed as part of the nursing assessment especially because weights are important for drug and fluid prescriptions. Junior doctors however generally fail to take the next step in this opportunistic contact to plot these weights. Unless clinically indicated e.g. as part of body surface area for drug prescriptions, the height is often not measured,...
I read with interest the article published by Archer et al on Multisource Feedback of paediatric registrars. This article is very encouraging for trainees like me and also answers doubts about the validity and reliability of such work place based assessments.
One of the main conclusions of the authors is that self selection of assessors by trainees should end. But this raises questions about the validity of an...
The interesting and well-conducted study of Potijk et al reminds us once again (though we probably don't need reminders) of the important difference between statistically versus clinically significant differences in research studies. The authors report that moderately preterm-born children had significantly worse scores on all subscales of the CBCL than did term born children; inspection of the P values in Table 2 shows t...
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...
Poor weight gain over the first 6-8 weeks is known to be a risk factor in its own right for developmental delay, which can be demonstrated not only at school age but, as shown by McDougall et al as early as 4 months.1
McDougall et al suggest that the Child Health Surveillance check at 6 -8 weeks provides the opportunity to identify infants with early weight faltering; and that future research could ascertain whet...
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