I wonder if this brief report by Harvey et al. highlights where we are going wrong. Firstly, the lack of response to the QIP may just reflect the fact that we have such limited ability to influence outcomes when it comes to childhood obesity. If you are working in a busy CAU it seems pointless doing things that are not going to produce a positive outcome.
However my biggest concern is the statement: "How paediatricians act has a large impact on parents: we cannot expect them to prioritise their child’s obesity if we do not do the same." This appears to be the “nanny state” at work. The fact that parents are not recognising their children’s obesity, if this is really the case given the publicity this topic is receiving, is the main problem. This idea that patients are completely dependent on professionals to bring about change influences the outcome for many chronic conditions. Best results are obtained when patients (and carers) are actively involved in the management of the disease and are equipped to influence outcomes. This can only come about through education.
My personal experience is that I cannot remember ever seeing an overweight child maintain any significant weight loss. The lack of parental recognition of the fact that their child is overweight is a major problem. I am not sure how long the comment "your child is overweight" stays with parents after they leave the clinic. Do parents feel that an overweight child reflects well on them in that they are providing adequate amounts of food. The importance of food in our distant history must still have an influence. For the vast majority of the population, as recently as 100 years ago, food was often scarce and you ate whatever was put in front of you in case there was nothing for a while. That behaviour is now a problem, when food is freely available.
The only way this is going to change is when parents take the lead. The aim has to be to prevent children becoming overweight. Once it has happened it appears next to impossible to correct. This is a problem that only parents are in a position to manage and they must take responsibility for it, not medical professionals.

Thank you for your letter and for sharing your very personal experience.
We agree with you that by the time the child who is choking is attended to by advanced medical practitioners the situation is often dire and that the best hope of a good outcome rests with prompt and effective attempts to dislodge the offending object.
However, knowing that partial airway obstruction may quickly become complete airway obstruction, that (as in the cases we describe) First Aid measures may fail, and that even if the obstruction is relieved the consequences may be significant; we would also advocate that emergency services were alerted as early as possible.
The Advanced Paediatric Life Support (APLS)1 guidance in the UK gives the clear advice with regard to first aid measures to be employed in the choking child.
• If the foreign body is easily visible then carefully try to remove it.
• If the child is coughing effectively and is conscious then encourage them to cough and monitor closely.
• If the child has an ineffective cough but is still conscious then proceed as follows:
o An infant should be laid horizontally with head down, supported with airway open (on the rescuer’s forearm or lap) and five sharp back blows delivered between the shoulder blades. If this fails then the infant is turned supine, still head down, and five chest thrusts (sharp and slower compressions using the same landmarks as for CPR) commenced.
The Heimlich manoeuvre (abdominal thrusts) is not recommended in this guidance for the under 1’s since it can cause injury. However, it is well known and in extremis it would seem appropriate.
o In an older child back blows can be attempted with the child standing and leaning forward, alternated with the more traditional abdominal thrust as described by Heimlich either from behind the patient or with the patient supine and the rescuer astride.
• If the child becomes unconscious then the airway should be opened and 5 rescue breaths attempted, followed by chest compressions. Though, clearly if the airway is completely occluded the breaths will be ineffectual.
In the 3 cases we describe in the paper, we tried to outline that all episodes were witnessed by adults, promptly identified and that First Aid attempts were made to dislodge the grape at the scene by lay people and by those with training. The exact nature, timing and order of the attempts were not clear but it would appear that all appropriate manoeuvres were tried in each case.
We note that you have a question regarding the outcome of the child in our article who survived. We described this in the article but he thankfully made an excellent and complete recovery.
In conclusion, we are all too aware that by the time a child with prolonged foreign body airway obstruction reaches the Emergency Department the situation can be terminal and thank you for highlighting the importance of the dissemination of these vital First Aid skills.
Jamie Cooper and Amy Lumsden
23rd June 2017
Ref.
1. Advanced Life Support Group 2016. The choking child (section 18.4). In: Samuels M. And Wieteska S. Eds. Advanced Paediatric Life Support: a practical approach to emergencies 6th edition. Chichester UK. Wiley, pp180-185.

We are pleased to see the interest shown in our article by Drs Cheung and Lachman, but cannot agree with their assertion that our research ‘misses the point’.
Despite widespread use, there remains limited research on the effectiveness of paediatric early warning systems (PEWS) in detecting deterioration in hospitalised children. Our paper sought to establish if there were statistically significance differences in performance between 18 published systems. Trigger systems were out-performed by scoring-systems in this relevant but narrow assessment. Our conclusion emphasizes that it is unclear what factors account for these differences in performance.
Dr Cheung and others feel this observation of statistical inferiority of trigger system is not merited and the observed differences may be influenced by the scoring threshold selected. Dr Cheung illustrates this by comparison to the threshold selection of the C-reactive protein test as an indicator of inflammation. We found this to be rather confusing. The outcomes of trigger-based systems are, by their very nature, dichotomous. Whilst there is always a trade-off between sensitivity and specificity for scoring-based systems, the same does not apply to trigger-based systems. The system is either triggered or not. We note that Dr Cheung does not offer data to support his preference for trigger systems.
We agree that managing deterioration in children is complex. However it is hard to imagine how this would be improved through the use of a tool with reduced ability to discriminate children ‘at risk’ of deterioration, even if staff used this optimally. Or how the use of a tool with an unknown performance would improve the situation. Dr Cheung states “One would not recommend a new drug be widely used, regardless of its efficacy, without also evaluating whether the means of administration was reliable and acceptable.” We respectfully suggest that understanding whether an intervention is efficacious is a fundamental first step. There is no sense in evaluating the reliability and acceptability of ineffective interventions. The real world clinical effectiveness does indeed depend on many factors including human behaviour. However, clinicians are unlikely to adopt a system enthusiastically that does a poor job of categorising patients as high or low risk of deterioration.
Dr Cheung is correct in stating that score-based systems are inherently more complex to use, however this can be over-come by adopting ‘smart’ technology to automatically calculate scores, as we have done in our institution. As technology continues to develop it may be time for healthcare to work ‘smarter’ by embracing technological solutions to problems rather than demanding staff work ‘harder’. Neither quality nor its improvement should be constrained by the systems within which processes occur. While quality can be optimized within a system, improvement can be stunted.
Our paper sought to establish if there were differences in performance between differing systems and whether these were significant. Our findings indicate that differences do indeed exist and as such, this may be an important consideration for centres using a PEWS. As the editorial by Lillitos and Maconochie emphasises – it is time to focus on the evidence.

The need to improve outcomes in child health is not disputed, especially in the UK where performance lags behind the rest of Europe [1]. Mechanisms which detect, and respond, to the deteriorating child in an effective manner should be validated and shared so we welcome further research by Chapman et al. [2] which demonstrates the complexity of producing tools which do this. However, we support the concern raised by Cheung and Lachman [3] in ensuring that appropriate conclusions are drawn from this work. As a research group funded to investigate these systems, from both a quantitative and qualitative viewpoint, we would like to highlight some of the dangers in use of terminology in this area. The concept that systems may be a better paradigm than scores (i.e. the amalgamation of observations into binary or composite measures which determine pre-defined actions) is not new [4] and it is already recognised that both afferent and efferent limbs are vital in order to complete what Joffe described as the, “chain of events needed to improve response to inpatient deterioration.” We note Maconochie and Lillitos use the term PES (Paediatric Early Warning System) and differentiate trigger systems from PEWS (Paediatric early warning scores). It is not however clear why trigger systems are treated as separate from PEWS as the literature contains numerous examples of where a trigger type system has been labelled as a PEWS [5]. While we entirely agree there is a challenge in labelling both scores and systems together we are not certain that the addition of a new term, PES, will aid this clarification. The PUMA study [6] is investigating the ‘multifaceted sociotechnical system’ suggested in the recent systematic review by Lambert [5] and we, in agreement with Cheung and Lachman feel that simply comparing scoring systems against each other risks missing the point that it may be the contextual ‘system’ as a whole, and not the particular form of a tool, that has the biggest impact on patient outcomes.

1. Wolfe I, Donkin A, Marmot M, et al. UK child survival in a European context: recommendations for a national Countdown Collaboration. Archives of Disease in Childhood 2015;100:907-914.
2. Chapman SM et al. ‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems. Arch Dis Child 2017; 102:487-95
3. Cheung R and Lachman P. "Human factors matter" - Statistical analysis of performance of trigger systems misses the point. In response to: Lillitos PJ, Maconochie IK. Paediatric early warning systems (PEWS and Trigger systems) for the hospitalised child: time to focus on the evidence. Arch Dis Child 2017;102: 479-80
4. Joffe AR, Anton NR, Burkholder SC. Reduction in hospital mortality over time in a hospital without a pediatric medical emergency team: limitations of before-and-after study designs. Arch Pediatr Adolesc Med 2011;165:419–23.
5. Lambert V, Matthews A, MacDonell R, et al. Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review BMJ Open 2017;7:e014497
6. PUMA - Paediatric early warning system (PEWS): Utilisation and Mortality Avoidance. A prospective, mixed methods, before and after study identifying the evidence base for the core components of an effective PEWS and the development of an implementation package for implementation and use in the UK HS&DR 12/178/17 https://www.journalslibrary.nihr.ac.uk/programmes/hta/1217817#/ Website last accessed 20th June 2017