I applaud the decision of ADC Online to allow free internet access to
readers of the journal in the developing world. You have clearly thought
about the problems regarding access in these places. However, I would
like to draw to your attention another problem; that of advertising.
I strongly feel that you should vet very carefully the advertisements
that you carry in the context of the...
I applaud the decision of ADC Online to allow free internet access to
readers of the journal in the developing world. You have clearly thought
about the problems regarding access in these places. However, I would
like to draw to your attention another problem; that of advertising.
I strongly feel that you should vet very carefully the advertisements
that you carry in the context of the electronic journal if you are going
to allow unlimited access in the developing world. In particular, for
example, if you were to note an increase in the amount of powdered milk
advertising, I would be worried that free ADC Online access might add to the very
great harm that these companies have already done in developing countries.
I believe that free access is the only way ahead - indeed the only
way of survival - for medical journals in both the developed and
developing world. However, this must be combined with a strict ethical
approach to advertising which should be a central feature of editorial
policy.
The two publications on fertility preservation for children [1,2]
raise important issues but several issues need to be clarified.
Specifically, ICSI is not a method to reverse male infertility in
whatever circumstance. ICSI provides an effective solution to severe male
infertility problem but, offspring and partner issues need to be
considered carefully [3-6]. The suitability of pre-pu...
The two publications on fertility preservation for children [1,2]
raise important issues but several issues need to be clarified.
Specifically, ICSI is not a method to reverse male infertility in
whatever circumstance. ICSI provides an effective solution to severe male
infertility problem but, offspring and partner issues need to be
considered carefully [3-6]. The suitability of pre-pubertal testicular
tissue is questioned since technology surrounding cryopreservation and in-
vitro manipulation of prepubertal testicular tissue is stated as being
'entirely experimental'. This is also true of adult testicular tissue
which may similarly have immature germ cells.
The question of peripubertal boys and the use of rectal
electrostimulation raises seriously important issues about the pain and
psychological effect this procedure as a `first sexual experience' could
have on the patients future sexual development and outlook [7,8]. The
procedure needs to be performed under anaesthesia. Any suggestion that
this approach could be tried on peri-pubertal patients would be ill
advised since aiming to obtain an ejaculate necessarily signifies post
pubertal status and one has to be certain this level of maturity has been
attained. This technique could be open to abuse since in strict cultures
where masturbation is forbidden a parent could ask and consent to this
procedure in post pubertal boys leading to a conflict in the requirement
of an 'autonomous consent'. Sperm storage under forced conditions will
most likely be illegal, with possibilities of assault charges to the
person taking the sperm sample. There remains also the probability of
having mature sperm even if the patient has not yet reached the HFEA
stated Tanner stage II maturity level. Such a situation would present a
legally awkward sperm storage scenario with apparently no regulatory
guidance [9].
With respect to the statement that 'fertility preservation procedures
for children are experimental', it is worth stating that the whole field
of human assisted reproductive technology (ART) , ranging from
cryopreservation of sperm, oocyte, embryo, blastocysts, to the use of
IVF, ICSI and PGD has never undergone classical clinical trial evaluation.
In this respect ART continues to be experimental which is partly why the
field is uniquely regulated by statute under the HFEA. There are
advantages in bringing children's gonadal tissue under regulation since
in the eventual use for procreation the HFEA's permission will be needed.
The second paper deals with the complex issue relating to the ethics
of consent for gamete storage and experimentation. The title is broadly
incorrect since children's gonadal tissue do not contain `gametes'. Where
gametes are contained we have adopted the term adolescents [10] to help
achieve consistency with reproductive biology, development and regulatory
framework which strictly requires consent under the HFEAct 1990 [9,11].
The appeal for 'intervention to preserve fertility to have sound basis for
evidence and moral provenance' is reasonably well understood by all
practitioners but in the report [2] seems to signal 'why things should not
be done'. It should be remembered that the whole field of ART continues
to be practised on its experimental origins world-wide reasonably sensibly
and sensitively. Most of the consent models referred to in the text are
the US style 'assent type consent' which deserve acknowledgement [12,13].
The statement that 'the HFEA recommendations were understandably not
designed with children or cancer patients in mind' is not entirely correct
in relation to cancer patients where the HFEA displayed enormous
sensitivity and fairness. Following our representation on behalf of
cancer patients in the year the HFEAct came into force, the HFEA responded
by issuing a special direction to allow extension beyond the restrictive
10 year storage time for sperm, after considering the implication
especially for adolescent cancer patients.
In the long term efforts should be made to find ways of bringing
childrens gonadal tissue under statutory HFEA regulation [14,15]. This
can be done by persuading Parliament through professional or patient
representation to enlarge the regulatory remit of the HFEA, to help
enhance patients interest, and in achieving consistent policies.
Furthermore, it should be borne in mind that the UK legal landscape has
changed significantly with the Human Rights Act 1998 [16], favouring
patients determination and sensibly engaging this Act may become a useful
option .
References
(1) Grundy R, Gosden RG, Hewitt M, Larcher V, Leiper A, Spoudeas, HA,
Walker D, Wallace WHB, 2001. Fertility preservation for children cancer
treated for (1): scientific advances and research dilemmas. Arch Dis
Child, 84, 355-359.
(2) Grundy R, Larcher V, Gosden RG, Hewitt M, Leiper A, Spoudeas HA,
Walker D, Wallace WHB. 2001. Fertility preservation for children cancer
treated for (2): ethics of consent for gamete storage and experimentation.
Arch Dis Child., 84, 360-362.
(3) Bonduelle M, Camus M, Devos, A et al., 1999, Seven years of
intracytoplasmic sperm injection and follow up of 1987 subsequent
children. Hum Reprod., 14 (Suppl.1), 243-264.
(4) Ericson A and Kallen B, 2001. Congenital malformations in infants
born after IVF: a population based study. Hum Reprod., 16, 3, 504-509.
(5) Wennerholm UB, Bergh C, Hamberger L., et al., 2000, Incidence of
congenital malformations in children born after ICSI. Hum Reprod., 15, 944
-948.
(6) Ahuja KK, Simons EG. Cancer of the colon in an egg donor: policy
repercussions for donor recruitment. Hum Reprod 1998; 12: 2230-2234.
(7) Hogav Y, Dan-Goor M, Yaffe H, Almagor M, 2001. Electroejaculation
before chemotherapy in adolescents and young men with cancer. Fertil
Steril., 75, 4, 811-813.
(8) Schmiegelow ML, Sommer P, Carlsen E, Sonksen JOR, Schmiegelow K,
Muller JR, 1998, Penile vibratory stimulation and electroejaculation
before anticancer therapy in two pubertal boys. J Pediatr Hematol Oncol,
20, 426-8.
(9) Bahadur, G., Whelan, J., Ralph, D., and Hindmarsh, P., 2001,
Gaining consent to freeze spermatozoa from adolescents with cancer: legal,
ethical and practical aspects. Hum. Reprod., 16, 1, 188-193.
(10) Bahadur, G., and Hindmarsh, P., 2000, Age definitions, childhood
and adolescent cancers in relation to reproductive issues, Hum. Reprod.,
15, 1, 227.
(11) Bahadur G, Whelan J, Davies MC, Ralph, D., 2001. Cancer patients,
gametes, gonadal tissue, and the UK legal status, Reproductive BioMedicine
Online. 2, 1, 8-10.
(12) Broome., ME ; 1999; Consent (assent) for research with pediatric
patients. Semin Oncol. Nurs., 15, 2, 96-103.
(13) Broome ME and Stieglitz KA; 1992, The consent process and
children. Res. Nurs Health. 15, 2, 147-52.
(14) Bahadur G and Ralph D, 1999, Gonadal tissue cryopreservation in
boys with paediatric cancers. Hum Reprod., 14, 1, 11-17.
(15) Bahadur G, Chatterjee R, Ralph D. 2000, Case report: Testicular
tissue cryopreservation in boys. Ethical and legal issues. Hum Reprod.,
15, 6, 1416-1420.
(16) Bahadur G, 2001. The Human Rights Act (1998) and its impact on
reproductive issues. Hum Reprod., 16, 4, 785-789.
I was very disappointed to see that the first
contribution to the series 'Controversy' was not
written by a paediatrician. There are plenty of
controversial topics in paediatrics, including the one
cited. There are also plenty of paediatricians
perfectly qualified to take part in informed debate
about them, again including the topic cited. The
absence of a contrasting viewpoint in the same issue
suggested to me...
I was very disappointed to see that the first
contribution to the series 'Controversy' was not
written by a paediatrician. There are plenty of
controversial topics in paediatrics, including the one
cited. There are also plenty of paediatricians
perfectly qualified to take part in informed debate
about them, again including the topic cited. The
absence of a contrasting viewpoint in the same issue
suggested to me the feature should be called 'Opinion'
rather than 'Controversy' because the article is not a
balanced review of the current state of allergy
practice.
The BPA and latterly RCPCH have championed for decades
the holistic approach to the care of children.
Paediatricians are best placed to assess the
integrated needs of a child with medical problems.
This principle is very relevant to developing areas of
specialisation in which there is an under supply of
expert advice, such as in allergy. Paediatric
allergists assess the impact of the diagnosis on many
non-medical facets of a child's life, including family
lifestyle, integration into schools and peer groups
and the facilitation of appropriate independence from
parental supervision.
It is tiring to have to rehearse the arguments for the
adequate protection of subjects at risk of
anaphylaxis. Epinephrine (as all doctors should now be
calling adrenaline) is not the only help given in
clinic to families with an allergic child. It is part
of the integrated management plan, which appears to be
effective [1] though difficult to measure [2].
It is very hard to prove that epinephrine saves lives
and I agree that the notional 'number needed to treat' with epinephrine to prevent a death from anaphylaxis is very high. Unsworth's title suggests that this 'very high number' (my phrase) is too high. How has he measured that? What is
too many? He quotes a prevalence of about 1% of
Americans having peanut allergy. That is approximately
3 million subjects. We do not restrict insulin
syringes to just a few insulin dependent diabetics
because diabetes is so common that we cannot
adequately care for all of them. Every allergic child
has the right to best available care, which is not
restricted to the first 100 through the clinic door
(if they can find an allergy clinic).
Laparotomy will not save every patient with a leaking
aortic aneurysm and epinephrine will not save every
person who has anaphylaxis. Anaphylaxis is a critical
situation in which prompt administration of
epinephrine may (but occasionally may not) save a
life. I think it unarguable that it is better to self-
treat and probably survive than not self-treat and
possibly die. Unsworth quotes one early paper about
anaphylaxis from the US [3] and more recent British
data [4,5]. These papers all say to me more that
epinephrine is underused due to unavailability or
inappropriate training and patient confusion than that
epinephrine is useless or dangerous. Most subjects did
not have epinephrine available. Several of the deaths
reported by Pumphrey [5] were due to incorrect use of
available epinephrine. In addition epinephrine appears
to be more dangerous in the hands of doctors who give
it IV than in the hands of allergic subjects who self-
treat IM. I recommend your readers look at the report
on the latest series of food related deaths [6].
In the absence of any perfect predictive test
allergists are confined to basing risk of future
severe reactions on just a few variables. The first
is a history of previous severe reactions [3]. The
majority of peanut allergics have had a severe
reaction in the past [7,8] and more than 60% have
asthma, the second known association with severe
reactions [3,7]. According to current opinion, then,
even after just one reaction to peanut most subjects
are considered at risk of severe future reactions.
Many minor reactors to peanut progress to more severe
reactions [7] and new data confirm this convincingly [9]. I do not think there are adequate data to change
my practice from needing a very good reason not to
prescribe epinephrine to most (but not all) subjects
who have reacted to peanut, a food known to be
associated with a risk of a severe allergic reaction.
Doctors must remember epinephrine is prescribed to be
available for response to infrequent exposure at an
uncertain future date, not to be taken four times a
day. I have referred to this in the past [10] as
analogous to wearing a seatbelt on every car trip,
every day, even though a serious car accident is
unlikely on any individual day.
Unsworth is not up to date in his comments about the
diagnosis of IgE mediated allergy. There are strong
data from huge series of challenges, about the
positive and negative predictive values of the tests
used in allergy clinics [11,12,13]. Unsworth does not
even mention formal challenges, the cornerstone of
modern food allergy practice. No allergist would
prescribe an epinephrine kit on the basis of a
positive SPT in the absence of a significant history
or formal challenge [14].
Children and adults at risk of food-related
anaphylaxis have enough of life's pleasures denied to
them. The provision of epinephrine kits allows normal
life to go on, involving school, overnight stays at
friends, camping and other normal activities of
childhood. Anecdotally, parents seem to me less
stressed when they leave clinic with information
(however awful the scenarios described) and response
strategies than when they arrive. I have never met a
parent who reported being more scared of the
epinephrine kits than of the prospect of allergen
exposure (with or without epinephrine available).
Families must be taught when to use epinephrine and
how to use autoinjectors. Until doctors can tell
families that anaphylaxis will never happen we should
continue to empower families, ensuring they are ready
to respond as best they can to the disaster that
allergen exposure represents. When anyone develops a
real treatment for food-related anaphylaxis I can stop
prescribing epinephrine kits to people who currently
need them.
References
(1) Ewan, P. W. and Clark, A. T. Long term
prospective observational study of patients with
peanut and nut allergy after participation in a
management plan. Lancet 357, 111-115. 2001.
(2) Hill, D. J., Heine, R. G., and Hosking, C. S.
Management of peanut and tree nut allergies. Lancet
357, 87-88. 2001.
(3) Sampson HA, Mendelson L, Rosen JP. Fatal and
near-fatal anaphylactic reactions to food in children
and adolescents . N.Engl.J.Med. 1992;327:380-4.
(4) Pumphrey RS,.Stanworth SJ. The clinical
spectrum of anaphylaxis in north-west England.
Clin.Exp.Allergy 1996;26:1364-70.
(5) Pumphrey RS. Lessons for management of
anaphylaxis from a study of fatal reactions.
Clin.Exp.Allergy 2000;30:1144-50.
(6) Bock, S. A., Muqoz-Furlong, A., and Sampson, H.
A. Fatalities due to anaphylactic reactions to foods.
J.Allergy Clin.Immunol. 107, 191-193. 2001.
(7) Hourihane JO, Kilburn SA, Dean P, Warner JO.
Clinical characteristics of peanut allergy.
Clin.Exp.Allergy 1997;27:634-9.
(8) Sicherer SH, Burks AW, Sampson HA. Clinical
features of acute allergic reactions to peanut and
tree nuts in children. Pediatrics 1998;102:e6.
(9) Vander Leek, T. K., Liu, A. H., Stefanski, K.,
Blacker, B, and Bock, S. A. The natural history
of peanut allergy in young children and its
association with serum peanut-specific IgE. J.Pediatr
2000;137:749-755.
(11) Sampson HA,.Ho DG. Relationship between food-
specific IgE concentrations and the risk of positive
food challenges in children and adolescents. J.Allergy
Clin.Immunol. 1997;100:444-51.
(12) Eigenmann PA,.Sampson HA. Interpreting skin
prick tests in the evaluation of food allergy in
children. Pediatr Allergy Immunol. 1998;9:186-91.
(13) Sporik R., Hill, D. J., and Hosking, C. S.
Specificity of allergen skin testing in predicting
positive open food challenges to milk, egg and peanut
in children. Clin.Exp.Allergy 30 (11), 1495-1498.
2000.
(14) Sicherer SH. Food allergy: when and how to
perform oral food challenges. Pediatr Allergy Immunol.
1999;10:226-34.
We read with interest the paper by Wake, et al [1] which
highlights the relation between child's height and grade progression in
primary school. The authors reported that the group of boys who had
repeated a grade, who were relatively short for their age, appeared to be
responsible for this relation. Children with short stature may experience
academic difficulties, psychological impairment, and emoti...
We read with interest the paper by Wake, et al [1] which
highlights the relation between child's height and grade progression in
primary school. The authors reported that the group of boys who had
repeated a grade, who were relatively short for their age, appeared to be
responsible for this relation. Children with short stature may experience
academic difficulties, psychological impairment, and emotional stress
related to an underlying medical condition or social stigmatization.[2,3]
However, there are some limitations of the study. One of the limitations
is that all short children were included despite heterogeneous nature of
short stature. We didn't see any exclusion criteria such as children with
growth hormone deficiency, Turner's syndrome or chronic disease (ie,
diabetes mellitus, chronic renal failure) or dysmorphic syndrome resulting
short stature. All these conditions have an additional deleterious effect
on psychosocial function and academic achievement of children.[2] Besides
birth weight, sociodemographic influences and ethnic background included
in the study, a lot of other factors (ie environmental, poverty,
nutrition, anemia, lead intoxication, presence of vision and hearing
problems, chronic disease, usage of any medication) can affect academic
achievement. Thus, in order to make a decision about children with school
failure, the conditions affecting academic achievement should be excluded
or examined by multi-factorial analysis. Additionally, the authors
failed to explain why short stature only affected the boys in the
fifth grade. We think that some children in the fifth grade may have already had a growth spurt which would affect the self-esteem and emotional
status of short children. If the authors could explain these limitations, the
article would have a greater value. Further studies in short adolescents
which have already had growth spurts could make clear gender differences in school
achievement and could test the hypothesis of this study that short boys
are disadvantaged.
The article shows that growth monitoring is an important part of school
health supervision. The major role of growth monitoring is to focus the
attention of health workers on the promotion of adequate growth. A growth
chart, which can be easily followed in school, is of the greatest value in
terms of preventive action as it shows any growth problem.[4] The diagnosis of
children with growth retardation must be done at an early school age.
Educational and psychosocial problems associated with short stature can be
alleviated with appropriate case management. Paediatricians, family
physicians, teachers, and parents should be aware of the potential academic,
psychological, and social problems related to short stature. In this way,
short children can be supported and optimum growth can be achieved.
Therefore, a multidisciplinary management approach for short
children in school could allow diagnosis and the appropriate treatment of
conditions resulting in growth retardation, the early detection of problems in
academic achievement and psychosocial development in cases of short
stature. The appropriate educational and
counselling interventions could then be provided.
S Songül Yalçin
References
(1) Wake M, Coghlan D, Hesketh K Does Height influence progression through
primary school grades? Arch Dis Child 2000;82:297-301.
(2) Law CM The disability of short stature. Arch Dis Child 1987;62:855-859.
(3) Reisse PA. Educational, psychologic and social aspects of short
stature. J Pediatr Health Care 1992;6:325-332.
(4) Hall DMB Growth monitoring Arch Dis Child 200;82:10-15.
I read the recent report of an audit of DMSA scans after UTI [1] with
interest, having recently completed an audit of rates of investigation
locally. However the title was a little misleading, it might more
accurately have been called an audit of DMSA scanning after a positive
urine culture.
The definition of UTI used for this audit was a culture of >105
organisms per ml of urine collected by...
I read the recent report of an audit of DMSA scans after UTI [1] with
interest, having recently completed an audit of rates of investigation
locally. However the title was a little misleading, it might more
accurately have been called an audit of DMSA scanning after a positive
urine culture.
The definition of UTI used for this audit was a culture of >105
organisms per ml of urine collected by bag, clean catch or MSU. In the
discussion it is acknowledged that "there may have been some false
positive diagnoses of UTI". Since the false positive rate of urine culture
collected by bag is 50% and for clean catch is up to 30% it is possible
there was a large false positive rate. Since organisms continue to
multiply in urine unless it is chilled specimens from GPs which may take a
number of hours to get to a laboratory are highly likely to give a
significantly higher positive urine culture rate.
The original report from the Royal College of Physicians recommends
that positive bag specimens be confirmed, that specimens be chilled to 40C
and that the time of collection be recorded to establish if it has taken
more than 2 hours to get to the lab. While it was not put in those terms
it would seem reasonable to regard positive urine specimens not fulfilling
these criteria to be just that - positive urine specimens and not urinary
tract infections.
The alternative interpretation of the data in this study could start
from the assumption that the rate of abnormalities may be just the same in
out-patients and in-patients. Since the frequency of abnormalities was 10
times greater in in-patients it is possible that positive urine cultures
from GPs are 10 times more likely to be contaminants or overgrowth during
transit. I don't think this is an unlikely possibility bearing in mind the
multiplicity of difficulties facing GPs in collecting and transporting
urine specimens.
It might have been better to conclude that routine use of DMSA scans
in children over 1 year with a single positive urine culture is unhelpful
and unnecessary. It would be interesting to know what the result of DMSA
scanning was in those children who had a positive repeat urine culture
before treatment. Since those with a single positive urine culture are a
mixture of those in whom it would have been repeatedly positive and those
who would subsequently have had a negative culture, it seems likely there
would be a difference. If this was so it would have an important message
for both hospital and community practice as far as collecting urine
specimens is concerned.
Statistically with a 50% false positive rate on bag specimens one
would expect a 25% false positive rate if two specimens are positive and
12.5% false positive rate if three are positive. It may be that a bag
specimen of urine should be looked on as 1/3 of an investigation.
References
(1) Deshpande PV, Verrier Jones K. An audit of RCP guidelines on DMSA
scanning after urinary tract infection. Arch Dis Child 2001;84:324-327
Dr J M O'Donohoe
Erne Hospital
Enniskillen
Northern Ireland
This short report by Cunningham et al [1], describes changes in FEV1
following nebulised Colistin in cystic fibrosis (C.F.). The authors
report that out of 58 children studied, 34 showed a greater than 10%
reduction in FEV1 and conclude that this is of some significance. The
study in its conclusions can be criticised on a number of grounds.
The choice of cut-off value at 10% change from baseline F...
This short report by Cunningham et al [1], describes changes in FEV1
following nebulised Colistin in cystic fibrosis (C.F.). The authors
report that out of 58 children studied, 34 showed a greater than 10%
reduction in FEV1 and conclude that this is of some significance. The
study in its conclusions can be criticised on a number of grounds.
The choice of cut-off value at 10% change from baseline FEV1 is
arbitrary and probably derived from normal subjects, whereas it is known
that the short term variability of spirometry values in children and
adults with cystic fibrosis is much greater than in normal subjects.
Nickerson et al [2] investigating within-subject variability and percent
change for significance of spirometry found that FEV1 percent change
greater than 23% was required for significance in C.F. Thus all but four
of the results described by Cunningham et al (Figure 1) can be accounted for by
the natural within subject variability of FEV1 in C.F. The study design
could also have been improved by comparing serial spirometry measurements
on a separate occasion, without nebulised Colistin, to determine whether
Colistin imposed any additional variability. Finally, the reported
finding that chest discomfort (9 children) was independent of change in
FEV1, argues against this as being due to broncho-constriction.
Nebulised Colistin is an important therapy in the pseudomonas
colonised/infected C.F. patient. We caution against concluding that
changes in FEV1 after nebulised Colistin which fall within the natural
within-subject variability of the measurement are due to harmful broncho-
constriction.
(1) Cunningham S, Prasad A, Collyer L, Balfour-Lynn I, Wallis C.
Bronchoconstriction following nebulised Colistin in cystic fibrosis.
Arch.Dis.Child 2001; 84: 432-433.
(2) Nickerson BG, Lemen RJ, Gerdes CB, Wegmann MJ and Robertson G. Within-
Subject variability and percent change for significance of spirometry in
normal subjects and in patients with cystic fibrosis. Am Rev Respir Dis
1980; 122: 859-866.
We read with interest the paper by Unsworth [1] regarding the
over prescribing of adrenaline syringes. We are sure we are not the only
community paediatric team who have similar concerns, although perhaps from
a different perspective. Dr Unsworth writes of the safety issues. We have
more experience of the practical problems.
Thanks to the availability of prompt training for school staff by
comm...
We read with interest the paper by Unsworth [1] regarding the
over prescribing of adrenaline syringes. We are sure we are not the only
community paediatric team who have similar concerns, although perhaps from
a different perspective. Dr Unsworth writes of the safety issues. We have
more experience of the practical problems.
Thanks to the availability of prompt training for school staff by
community personnel, it is now rare for a child actually to be excluded
from school because they have an adrenaline injection device, however,
they may very well be excluded from other activities such as guide camp or
trips abroad.
There is also the increasing problem of young people with adrenaline
injection devices moving on to college or work places. Who should train
staff there?
Other problems with adrenaline injection devices in our local
community include two being lost on the bus, and one being accidentally
fired into the interphalangeal joint of a child’s thumb with the needle
becoming bent like a fish hook.
There is also the issue of keeping them in date. Parents often forget
to renew them, particularly those kept in school. Whilst it does not need
to be kept in a refrigerator, adrenaline does deteriorate in warm
conditions, and injection devices should be checked to make sure the
adrenaline inside remains clear and colourless.
Often an adrenaline injection device has been prescribed with no
demonstration to the child or family on how to give it, nor when to give
it. Surely antihistamine should also be prescribed in every case? In most
children, it is the only medication, which is going to be needed. Families
also need clear instructions on when to call an ambulance. They could
easily make the mistake of trying to take a deteriorating child to
hospital in their own car, instead of calling a paramedic ambulance, or
even assume that they do not need to go to hospital at all if they have
given adrenaline. As Dr Unsworth points out the adrenaline injection
does not always save the child's life.
We would suggest that when an adrenaline injection device is
prescribed it must be demonstrated to the parent and child, if old enough.
A dummy pen is helpful for this. Demonstration should be repeated with
each repeat prescription of the device. The child and family should always
have a written management protocol, including instructions on expected
symptoms, when to give antihistamine, when to call an ambulance and when
to give adrenaline. Such a protocol can then be passed rapidly to the
community paediatric team to support the prompt training of school staff.
It is worth remembering that clinical responsibility for the safe
administration of a drug rests with the prescriber.
Dr Toni Wolff
Consultant Community Paediatrician
Mrs Chris Rumney
School Health Liaison Nurse
Birmingham Specialist Community Trust
(1) Unsworth DJ. Adrenaline syringes are vastly over prescribed. Arch
Dis Child 2001;84:410-411.
This article was written expressly with the general paediatrician in
mind and attempts to provide a succinct approach to the problem. It in no
way presumes to be a definitive treatise on the metabolic investigation of
renal stones in children. For this reason the term “uric acid stones”
was used to help simplify the figure and table. Edvardsson et al are
absolutely correct in pointing ou...
This article was written expressly with the general paediatrician in
mind and attempts to provide a succinct approach to the problem. It in no
way presumes to be a definitive treatise on the metabolic investigation of
renal stones in children. For this reason the term “uric acid stones”
was used to help simplify the figure and table. Edvardsson et al are
absolutely correct in pointing out that APRT deficiency is a disorder of
purine metabolism and that the scientific classification should be
entitled as such, with separate subdivisions of “Uric Acid Stones”,
“Dihydroxyadenine Stones” and “Xanthine Stones”.
Similarly, my comments on idiopathic hypercalciuria attempt to
summarise extensive literature and controversy on this topic. Many
investigators have abandoned characterising hypercalciuria as absorptive
or renal and my choice of wording the article was careful to highlight
this, i.e. “the distinction between these two forms MAY be considered
relevant”.
Finally, I have no wish to adopt a dogmatic approach to the
evaluation of children with possible renal stones and would encourage all
physicians reading this article to use their clinical acumen when
investigating their patients. For this reason I do not believe that
plain abdominal radiography needs to be performed in every single patient
and I would certainly disagree with Edvardsson et al that intravenous
pyelography, with its attendant risks, should be done on a regular basis
as part of the investigation.
Following recent correspondence [1,2], we agree that lumbar
puncture (LP) should be avoided in children with unstable meningococcal
septicaemia, but would strongly caution against its abandonment in all
meningococcal disease (MCD).
The sensitivity of PCR for diagnosing MCD, in two prospective studies
investigating clinically diagnosed cases, was 47% [3] and recently has
increased to 87% (Hac...
Following recent correspondence [1,2], we agree that lumbar
puncture (LP) should be avoided in children with unstable meningococcal
septicaemia, but would strongly caution against its abandonment in all
meningococcal disease (MCD).
The sensitivity of PCR for diagnosing MCD, in two prospective studies
investigating clinically diagnosed cases, was 47% [3] and recently has
increased to 87% (Hackett et al. Proceedings of Paediatric Research
Society 2000), not 100% as Nadel claims [2]. In the latter study, in
patients admitted to PICU, blood PCR confirmed MCD in 92% (44/48). All
four PICU patients with negative blood PCR had clinical signs
predominantly of meningitis. In two a positive cerebrospinal fluid (CSF)
PCR was the only confirmatory test, the third was confirmed on serology
and the fourth remains unconfirmed. In fact 16% of children with MCD
present with meningitis, without a rash or positive blood cultures [4].
Secondly, precise diagnosis aids management. Four patients, each with
a CSF confirmed diagnosis of meningococcal meningitis, remained febrile
(> 38ºC), despite adequate antibiotic coverage, for 7-10 days after
admission; fever settled between 11 to 20 days. The diagnosis of
meningococcal meningitis obviated further investigations and an
unnecessary change to “second line” antibiotics.
Thirdly, in infants under 3 months of age presenting with signs of
meningitis, a bacteriological diagnosis is crucial to allow accurate
therapy, as the organism may be Escherichia coli, Listeria monocytogenes,
Neisseria meningitidis, Streptococcus agalactiae, Streptococcus pneumoniae
or Haemophilus influenzae.
We agree that LP is unnecessary in the majority of patients with MCD,
particularly those admitted to PICU. However it is clinically helpful in
some children and essential in others. Since simultaneous detection of
Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus
influenzae is now possible by CSF PCR [5] a deferred LP that may not yield
culture results may still aid clinical management.
SCOTT HACKETT
Meningococcal Research Fellow
ENITAN CARROL
Specialist Registrar
ALISTAIR THOMSON
Honorary Consultant Paediatrician
1. Sam WI. The role of lumbar puncture in meningococcal disease. Arch Dis Child 2000;83(4):370.
2. Nadel S. Lumbar puncture should not be performed in meningococcal
disease. Arch Dis Child 2001;84(4):373.
3. Carrol ED, Thomson AP, Shears P, Gray SJ, Kaczmarski EB, Hart CA.
Performance characteristics of the polymerase chain reaction assay to
confirm clinical meningococcal disease. Arch Dis Child 2000;83:271-3.
4. Riordan FA, Marzouk O, Thomson AP, Sills JA, Hart CA. The changing
presentations of meningococcal disease. Eur J Pediatr 1995;154:472-4.
5. Corless CE, Guiver M, Borrow R, Edwards-Jones V, Fox AJ, Kaczmarski EB.
Simultaneous Detection of Neisseria meningitidis, Haemophilus influenzae,
and Streptococcus pneumoniae in Suspected Cases of Meningitis and
Septicemia Using Real-Time PCR. J Clin Microbiol 2001;39(4):1553-8.
Dear Dr Wacogne,
We intend to apply the same stringent rules to advertising as we do already in the paper version of the journal.
Thank you for your positive feedback to our decision to allow free access to developing countries.
Harvey Marcovitch
Dear Editor,
I applaud the decision of ADC Online to allow free internet access to readers of the journal in the developing world. You have clearly thought about the problems regarding access in these places. However, I would like to draw to your attention another problem; that of advertising.
I strongly feel that you should vet very carefully the advertisements that you carry in the context of the...
Dear Editor,
The two publications on fertility preservation for children [1,2] raise important issues but several issues need to be clarified.
Specifically, ICSI is not a method to reverse male infertility in whatever circumstance. ICSI provides an effective solution to severe male infertility problem but, offspring and partner issues need to be considered carefully [3-6]. The suitability of pre-pu...
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Dear Editor,
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This short report by Cunningham et al [1], describes changes in FEV1 following nebulised Colistin in cystic fibrosis (C.F.). The authors report that out of 58 children studied, 34 showed a greater than 10% reduction in FEV1 and conclude that this is of some significance. The study in its conclusions can be criticised on a number of grounds.
The choice of cut-off value at 10% change from baseline F...
Dear Editor,
We read with interest the paper by Unsworth [1] regarding the over prescribing of adrenaline syringes. We are sure we are not the only community paediatric team who have similar concerns, although perhaps from a different perspective. Dr Unsworth writes of the safety issues. We have more experience of the practical problems.
Thanks to the availability of prompt training for school staff by comm...
Dear Editor,
This article was written expressly with the general paediatrician in mind and attempts to provide a succinct approach to the problem. It in no way presumes to be a definitive treatise on the metabolic investigation of renal stones in children. For this reason the term “uric acid stones” was used to help simplify the figure and table. Edvardsson et al are absolutely correct in pointing ou...
Dear Editor,
Following recent correspondence [1,2], we agree that lumbar puncture (LP) should be avoided in children with unstable meningococcal septicaemia, but would strongly caution against its abandonment in all meningococcal disease (MCD).
The sensitivity of PCR for diagnosing MCD, in two prospective studies investigating clinically diagnosed cases, was 47% [3] and recently has increased to 87% (Hac...
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