We write to draw attention to two problems with the recent study on a
scoring system for bruising by Dunstan et al. [1].
Firstly, the authors did not publish confidence intervals for the
Likelihood Ratios (LRs) derived from different score threshold values
(Table 3), thereby not allowing readers to judge whether the Likelihood
Ratios are statistically, let alone clinically, significa...
We write to draw attention to two problems with the recent study on a
scoring system for bruising by Dunstan et al. [1].
Firstly, the authors did not publish confidence intervals for the
Likelihood Ratios (LRs) derived from different score threshold values
(Table 3), thereby not allowing readers to judge whether the Likelihood
Ratios are statistically, let alone clinically, significant.
Secondly, the authors neglect the phenomenon of Spectrum Bias. This
is a well described feature of many tests, whereby Sensitivity and
Specificity (and hence derived LRs) of a test vary with disease severity
or prevalence. Examples of Spectrum Bias have been described with several
tests including exercise stress testing[2] and UTI diagnosis[3].
The study population had a prevalence of physical abuse of 40%, much
higher than the general paediatric population. Since test performance
(i.e. LR) is not independent of the pre-test probability, the LRs
generated by a study done on this population cannot necessarily be used in
a population with a much lower prevalence of abuse, as the authors have
done in Table 4. Since Spectrum Bias tends to reduce test performance as
the pre-test probability falls [4], the LR for any given score threshold
would be smaller than that quoted when applied to a population with a
lower prevalence of physical abuse. Since most settings would expect to
have a lower prevalence of physical abuse than the study, this reduces the
value of the proposed scoring system as a clinical tool.
Yours Sincerely,
Dr. M. Williams MRCP Intensive Care Unit, Charing Cross Hospital,
London, W6 8RF
Dr. B. Krishnan MRCPCH Dept. of Paediatrics, Guys Hospital, London
SE1 9RT
References:
(1) Dunstan FD, Guildea ZE, Kontos K, Kemp AM, and Sibert JR. A scoring
system for bruise patterns: a tool for identifying abuse Arch Dis Child
2002;86;330-333.
(2) Okin PM, Kligfield P. Gender-specific criteria and performance of
the exercise electrocardiogram Circulation 1995;92(5);1209-16.
(3) Lachs MS Nachamkin I, Edelstein PH, Goldman J, Feinstein AR and
Schwartz JS. Spectrum bias in the evaluation of diagnostic tests: lessons
from the rapid dipstick test for urinary tract infection Annals of
Internal Medicine 1992;117(2);135-40
(4) Hlatky MA, Pryor DB, Harrell FE Jr, Califf RM, Mark DB and Rosati
RA Factors affecting sensitivity and specificity of exercise
electrocardiography. Multivariable analysis. American Journal of Medicine
1984 77(1):64-71.
We read with interest the article by Duke et al[1] regarding hypoxaemia in
acute respiratory and non-respiratory illnesses in infants and children in
developing countries published recently in the ADC.[1] The authors have
rightly pointed out the limited availability of published data on the
incidence, significance or clinical signs predicting hypoxaemia in infants
less than three months of age. With...
We read with interest the article by Duke et al[1] regarding hypoxaemia in
acute respiratory and non-respiratory illnesses in infants and children in
developing countries published recently in the ADC.[1] The authors have
rightly pointed out the limited availability of published data on the
incidence, significance or clinical signs predicting hypoxaemia in infants
less than three months of age. With similar concerns we had conducted a
study in infants less than two months, a part of which was published in
the Archives[2] . We found that tachypnoea, defined as RR>60/min,
predicted hypoxia with 80% sensitivity and 68% specificity[2]. In that study
we had also examined six functional and behavioural responses as
predictors of hypoxemia (Table 1). Five of these six variables had a
very good sensitivity to detect hypoxaemia.
Table 1: Sensitivity and positive predictive value of six behavioural and
observation variables to detect hypoxaemia in a cohort of 200 infants < 2
months attending Pediatric Emergency.
Variable*
Number of infants with
Sensitivity
Positive Predictive value
Sign
positive
SpO2<90%
Poor Spontaneous activity
142
67
87.0%
47.2%
Abnormal cry
136
67
87.0%
49.3%
Poor-paradoxical Consolability
123
60
77.9%
48.8%
Poor/decreased responsiveness or Consciousness level
134
66
85.7%
49.3%
Abnormal colour
131
68
88.3%
51.9%
Increased respiratory efforts
146
75
97.4%
51.4%
*Definitions : Abnormal Spontaneous Activity : Reduced or
less than normal activity, or not playful, or not active. Abnormal cry:
whimpering, or sobbing, or weak, or moaning or not crying at al. Poor or
paradoxical consolability: Irritable, or cries off and
on, or continued cry for longer period. Poor or decreased responsiveness0r consciousness level: less alert than usual, or opens eyes off
and on, or wakes up with difficulty, or obtunded, or does not wake up, or coma. Abnormal
colour: Not usual pink, or pale, or ashen-pale, or cyanotic. Increased
respiratory efforts: fast breathing, or laboured breathing.
A very high prevalence of hypoxaemia in the population studied by Duke et
al1 is rather intriguing. Out of total 257 sick neonates and children 52%,
were hypoxaemic. Among children with Acute Lower Respiratory Infection
(ALRI) 73% and those with non-ALRI - 32% were hypoxaemic. In an ongoing
study we have measured oxygen saturation (by Nellcore® oximeter) in a
prospective cohort of 683 children 2-59 months brought to Pediatric
Emergency Department (ED) with any respiratory symptom. Oxygen saturation
using a fingertip sensor in these children at the time of arrival to ED
ranged from 78% - 99%. The overall prevalence of hypoxaemia defined as
SpO2 <_90 was="was" _4.5="_4.5" table="table" _2.="_2." additional="additional" _5.1="_5.1" children="children" had="had" borderline="borderline" hypoxaemia="hypoxaemia" i.e.="i.e." a="a" spo2="spo2" value="value" of="of" _90.="_90." this="this" is="is" similar="similar" to="to" prevalence="prevalence" _5.9="_5.9" defined="defined" as="as" _90="_90" in="in" gambian="gambian" _2-33="_2-33" months="months" age="age" reported="reported" by="by" usen="usen" et="et" al3.="al3." even="even" our="our" previous="previous" study="study" _200="_200" infants="infants" less="less" than="than" two="two" only="only" _38.5="_38.5" the="the" sick="sick" attending="attending" ed="ed" were="were" hypoxaemic2.="hypoxaemic2." p="p"/>
Table 2 : Prevalence of hypoxaemia (SpO2 < 90%, or SpO2< 90%) in 683 children, 2-59 months of age, presenting with a
respiratory illness in Pediatric Emergency, PGIMER, Oct. 2001- Feb. 2002.
Total Number
Mean Age (In mon)
SpO2 Range
Number with
SpO2 <90%
SpO2=90%
SpO2< 90%
Upper Resp. Infection
257
20.6
94-99%
0
0
0
Non severe pneumonia
60
15
90-98%
0
1(1.5%)
1(1.5%)
Severe Pneumonia
82
10.3
90-98%
2(2.4%)
8(9.7%)
10(12.2%)
Very severe pneumonia
42
7.3
78-95%
25(59.5%)
11(26.2%)
36(85.7%)
Bronchiolitis
52
7.1
90-98%
0
2(3.8%)
2(3.8%)
Laryngotracheitis/Laryngitis
15
22.9
92-98%
0
0
0
Acute Asthma
113
32.8
90-99%
2(1.9%)
2(1.9%)
4(3.8%)
Others*
62
26.8
82-99%
2(4.1%)
11(15.3%)
14 (19.4%)
Total
683
-
-
31(4.5%)
35(5.1%)
66(9.6%)
*Includes: Acute tonsillo-pharyngitis- 12, Foreign body aspiration –19,
Pertussis like illness-7, Pulmonary tuberculosis-7, Empyema-7, Pleural
effusion-4, Infectious mononucleosis-2, Diphtheria-2, Pneumothorax and Lung
cyst- 1 each.
A systematic review of studies on prevalence and predictors of
hypoxemia in children by Lozano et al[4] found that the prevalence of
hypoxia was dependent upon a number of factors including the setting of
the study. The prevalence ranged from 6-9% in outdoor setting to 31-43% in
emergency departments to a maximum of 47% in hospitalized children. Yet,
in our study, which represents the situation near sea level (Chandigarh
being a plain topographically) and the setting of an emergency department,
the prevalence of hypoxaemia is much lower than that reported at heights.
In light of our data and published literature. We believe that either the
definition of hypoxemia used by Duke et al[1] is too liberal or the children
with respiratory symptoms living at high altitude decompensate more
frequently to develop hypoxia. More information is needed in this respect
to formulate guidelines for general use.
The cumulative data clearly suggest that hypoxaemia is more frequent in
children living at high altitude. Interestingly most studies including
that of Duke et al on this subject in children 2 to 59 months have been
from high altitudes. It is most likely that geographic location, 1600m
above sea level is responsible for the high frequency of `hypoxaemia' in
their patient population. This, however, may not necessarily reflect the
need for oxygen therapy. If definition of hypoxemia suggested by Duke et
al[1] were to be applied as a guideline to oxygen therapy almost half of
their patients would need oxygen therapy. We need to answer as to whether
oxygen therapy makes any difference to outcome of patients labeled as
hypoxaemic using cut-off limits proposed by Duke et al1.
It may also be worthwhile to conduct studies with a large sample size at
see-level (plains) and in various settings before reaching a conclusion
about SpO2 cut-off for hypoxia at heights.
SUNIT SINGHI
Professor of Pediatrics
BHAVNEET BHARTI
Assistant Professor
Department of Pediatrics, Advanced Pediatrics Centre,
Postgraduate Institute of Medical Education & Research,
Chandigarh-160 012,INDIA
References
(1) Duke T, Blaschke AJ, Sialis S, Bonkowsky JL. Hypoxaemia in acute
respiratory and non-respiratory illnesses in neonates and children in a
developing country. Arch Dis Child 2002;86:108-112.
(2) Rajesh VT, Singhi S, Kataria S. Tachypnoea is a good predictor of
hypoxia in acutely ill children. Arch Dis Child 2000;82:46-49.
(3) Usen S, Weber M, Mullholland K et al. Clinical predictors of
hypoxaemia in Gambian children with acute lower respiratory infection:
prospective cohort study Brit Med J 1999;318:86-91.
(4) Lozano JM. Epidemiology of hypoxaemia in children with acute lower
respiratory infection. Int J Tuberc Lung Dis 2001;5:496-504.
Dr Casano describe a case refractory pulmonary hypertension with
severe Bordetella pertussis infection. Their description of the
literature is incomplete. We described a further 4 cases of fatal
pulmonary hypertension (PHT)
in a series of 13 critically ill infants with B. pertussis[1]. The cases
that developed PHT all presented with severe hyperleukocytosis (WCC>100 x 10(9)/l)which was unresponsive...
Dr Casano describe a case refractory pulmonary hypertension with
severe Bordetella pertussis infection. Their description of the
literature is incomplete. We described a further 4 cases of fatal
pulmonary hypertension (PHT)
in a series of 13 critically ill infants with B. pertussis[1]. The cases
that developed PHT all presented with severe hyperleukocytosis (WCC>100 x 10(9)/l)which was unresponsive to all currently available modalities
including extra-corporeal membrane oxygenation. Hyperleukocytosis was an
independent predictor of death when corrected for presentation severity of
illness. We suggested, in line the existing histological evidence[2], that
such extreme leukocytosis prediposes to the formation of lymphocyte
aggregates in the pulmonary vasculature and increased pulmonary vascular
resistance via obstruction rather than hypoxic vasoconstriction.
Therefore Dr Casano's recommendation for the early use of pulmonary
vasodilators is unlikely to be sufficient in context. We are assessing the
impact of strategies aimed at reducing lymphocyte numbers and adhesion in
addition to standard treatments for pulmonary hypertension.
References
(1)Pierce C, Klein N, Peters M. Is leukocytosis a predictor of
mortality in severe pertussis infection? Intensive Care Med 2000
Oct;26(10):1512-4
(2) Williams GD, Numa A, Sokol J, et al. ECLS in pertussis: does it
have a role? Intensive Care Med 1998;24:1089–92
We write with regard to the article by Astrom and Soderhall [1] which
demonstrates the symptomatic benefit of intravenous bisphosphonates in
children with osteogenesis imperfecta. While we have great enthusiasm for
the benefits of these drugs, we feel that some concern for the side effect
profile, in particular on liver function, is warranted.
As experienced by Astrom and Soderhall, bisphos...
We write with regard to the article by Astrom and Soderhall [1] which
demonstrates the symptomatic benefit of intravenous bisphosphonates in
children with osteogenesis imperfecta. While we have great enthusiasm for
the benefits of these drugs, we feel that some concern for the side effect
profile, in particular on liver function, is warranted.
As experienced by Astrom and Soderhall, bisphosphonate administration
is often associated with pyrexia and rigors. Other reported side effects
include GI upset and rarely renal problems, thrombophlebitis and
hypersensitivity reactions.[2]
However, as with many relatively new therapies in paediatric
patients, little is known of their biochemical effects. Our own personal
experience suggests that liver function may also be affected by
bisphosphonates.
A retrospective study of eight children undergoing intravenous
pamidronate treatment for bone disease was undertaken in Glasgow’s Royal
Hospital for Sick Children, to assess whether there was a difference in
AST and ALT levels before and after pamidronate treatment. (Dosage 3mg/kg
over 3 consecutive days every 3 months)
Of the eight, post treatment results were available for 6 patients.
All showed an increase in serum AST following treatment and 4 of the 6 had
mean post treatment AST above the upper limit of normal (45iu/l). Five
children had a post treatment increase in ALT, the mean post treatment
value was above the upper limit of normal(40iu/l) for two of them. We
detected no abnormality in serum bilirubin associated with pamidronate
treatment
It seems that I.V. pamidronate, is associated with a derangement in AST
which is likely to reflect hepatocellular or muscle cell damage.
While we accept that this observation is only a small number of
children, and that the changes may be transient, we would urge caution in
administering pamidronate to children. We acknowledge the reported
reduction in morbidity afforded by these drugs, but would advocate
continued vigilant monitoring of adverse effects in all children
undergoing bisphosphonate treatment.
References
(1) Astrom E, Soderhall S, Beneficial effect of longterm intravenous
bisphosphonate treatment of osteogensis imperfecta. Arch Dis Child 2002;
86: 356-64.
(2) Masud T, Francis RM, Adverse effects of Drugs for bone disease.
Adverse Drug Reaction Bulletin 1992, No.155.
J.P. Renton (B.Sc)
Medical Student
University of Glasgow
Glasgow
G12 8QQ
Dr S.C. Ling
Consultant Paediatric Gastroenterologist
Royal Hospital For Sick Children
Yorkhill
Glasgow
G3 8SJ
Dr. S.F. Ahmed
Consultant Paediatric Endocrinologist
Royal Hospital For Sick Children
Yorkhill
Glasgow
G3 8SJ
Email: gcl328@clinmed.gla.ac.uk
We read with interest the paper from Carrol and coworkers who have
demonstrated for the first time that procalcitonin (PCT), even it cannot
be presented as a gold standard (7 % of false negative), is a promising
marker of meningococcal disease (MCD) in children presenting with fever
and rash.[1] Carrol et al. also observed that PCT level was significantly
higher (p = 0.001) in children with...
We read with interest the paper from Carrol and coworkers who have
demonstrated for the first time that procalcitonin (PCT), even it cannot
be presented as a gold standard (7 % of false negative), is a promising
marker of meningococcal disease (MCD) in children presenting with fever
and rash.[1] Carrol et al. also observed that PCT level was significantly
higher (p = 0.001) in children with severe MCD (37/64: 57.8 %) and higher
but not significantly (p = 0.299) in those who died (7.8 %).[1] This
confirms the findings from Karabocuoglu et al. who reported that PCT level
was higher in children with severe meningococcemia (fever, petechia or
purpura, and hemodynamic instability) than in children with systemic
meningococcal infection without shock (291.29 ± 167 vs. 19.7 ± 23 ng/ml;
p <0.001). [2]
Unfortunately, regarding the children with severe MCD reported by
Carrol et al.,[1] several information are missing: a clear definition of severe
MCD (defined in their paper as a Glasgow Meningococcal Septicaemia
Prognostic Score ³8), median PCT values of survivors and non-survivors
and comparison in term of prediction of outcome between PCT level and
generic or specific severity scoring systems. Thus, we would like to
highlight that admission PCT level is an accurate predictor of mortality
in the subgroup of children with meningococcal septic shock (MSS).
We have prospectively compared in 35 children (median age: 16 months;
Q1: 9-Q3: 45) with MSS [defined as ecchymotic or necrotic purpura with
shock needing fluid expansion (median for the first 24 hrs : 90 ml/kg; Q1-
Q3: 48-120) and catecholamine infusion] admitted in our PICU between July
1999 and May 2002 the accuracy in predicting death of the PCT
(immunoluminometric assay) and C reactive protein (CRP: nephelometry) [3]
levels at admission, and the Pediatric Risk of Mortality (PRISM) score[4] within 24 hrs of admission or at the time of death.
Sensitivity, specificity, positive and negative predictive values, and
percentage of well-classified children were calculated at the following
cutoff values: PCT > 130 ng/ml [the best cutoff value of the PCT level
was determined by c2 optimisation (Fisher's test: p=0.0004)], CRP <
100 mg/l 3, PRISM value > 20 and PRISM probability of death > 50 %.[5]
For each severity index, we calculated the area under the ROC curve (AUC)
and the standard error (SE) [6] and determined the significance of
comparisons.[7]
Eleven of 35 children died (31 %) while predicted mortality with the
PRISM score was 15.6 (standardised mortality ration: 0.71; 95 % confidence
interval: 0.35-1.26). The median (Q1-Q3) PCT and CRP levels and PRISM
value and probability of death were the following: (survivors vs.
nonsurvivors) PCT 73 (15-210) vs. 277 (208-606) ng/ml (p = 0.001); CRP 92
(44-160) vs. 72 (41-109) mg/l (p = 0.25); PRISM value 17 (8-22) vs. 33 (26
-37) (p <10-3); PRISM probability 19 (4-42) vs. 88 (63-95) % (p <
10-3). Performance characteristics of PCT, CRP and PRISM score are given
in the table.
In this study, the PCT level at admission was as accurate as the
PRISM value and PRISM probability of death calculated within 24 hrs of
admission or at the time of death, and more accurate than the CRP level
for classifying survivors and nonsurvivors of MSS. These results are in
accordance with those from Hatherill et al. who observed in 37 children
with MSS that admission PCT level (values not indicated) was higher in
nonsurvivors (11 %) than in survivors (p=0.04) and related to the severity
of organ failure (p=0.02); however, in the whole group of children with
septic shock whatever the causative organism, the admission PCT functioned
worse than the PRISM score [AUC 0.73 (0.59-0.88) vs. 0.83 (0.71-0.93);
statistical comparison not performed].[8]
The PRISM score is accepted worldwide in PICUs and has been reported
to accurately predict outcome of meningococcal disease. [9, 10] However, as
it needs a 24 hour observation period, it cannot be used as inclusion
criterion for clinical trials. Admission PCT could represent a good
alternative tool if further studies confirm its ability to predict
mortality.
References
(1) Carrol ED, Newland P, Riordan FAI, Thomson APJ, Curtis N, Hart CA.
Procalcitonin as a diagnostic marker of meningococcal disease in children
presenting with fever and a rash.
Arch Dis Child 2002;86: 282-5.
(2) Karabocuoglu M, Kaya O. Plasma procalcitonin levels correlated
with the severity of systemic meningococcal disease in children. Crit Care
Med 2000;28(Suppl.): A170.
(3) Leclerc F, Chenaud M, Delepoulle F, et al. Prognostic value of
C-reactive protein level in severe infectious purpura: a comparison with
eight other scores. Crit Care Med 1991;19:430-2.
(4) Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality
(PRISM) score. Crit Care Med 1988;16:1110-6.
(5) Mok Q, Butt W. The outcome of children admitted to intensive care
with meningococcal septicaemia. Intensive Care Med 1996;22:259-63.
(6) Hanley JA, McNeil BJ. The meaning and use of the area under a
receiver operating characteristic (ROC) curve. Radiology 1982;143:29-36.
(7) Hanley JA, McNeil BJ. A method of comparing the areas under
receiver operating characteristic curves derived from the same cases.
Radiology 1983;148:839-43.
(8) Hatherill M, Tibby SM, Turner C, Ratnavel N, Murdoch IA. Crit Care
Med 2000;28: 2591-4.
(9) Castellanos-Ortega A, Delgado-Rodriguez M. Comparison of the
performance of two general and two specific scoring systems for
meningococcal septic shock in children. Crit Care Med 2000; 28: 2967-2973.
(10) Leteurtre S, Leclerc F, Martinot A et al. Can generic scores
(Pediatric Risk of Mortality and Pediatric Index of Mortality) replace
specific scores in predicting the outcome of presumed meningococcal septic
shock in children? Crit Care Med 2001; 29: 1239-1246.
Table Performance characteristics of PCT, CRP and PRISM score in 35
children with MSS
I read with interest the article. I recently had an experience when a
2-month-old infant, born term, 3.3 kg was admitted with clinical diagnosis
of Bronchiolitis. Since we do not have facilities for virology we cannot
claim microbiological confirmation. This infant had severe respiratory distress
and wheeze with low-grade fever. She was given IVF,Cont.Oxygen at 3.5 l/mt
as well as antibiotics. On th...
I read with interest the article. I recently had an experience when a
2-month-old infant, born term, 3.3 kg was admitted with clinical diagnosis
of Bronchiolitis. Since we do not have facilities for virology we cannot
claim microbiological confirmation. This infant had severe respiratory distress
and wheeze with low-grade fever. She was given IVF,Cont.Oxygen at 3.5 l/mt
as well as antibiotics. On the 4th day in hospital I noticed a pansystolic
murmur in the tricuspid area as well as hepatomegaly of 4 cm. The chest was
too noisy to aid any meaningful clinical finding. Color Doppler Echo showed
Pulmonary Hypertension with Tricuspid regurgitation. She was treated with
Digoxin,Lasix and Continuous humidified Oxygen. She gradually improved and
was discharged on day 10. She was readmitted once after a month,for 2 days,when she continued to have mild pul HT. After a month she was
readmitted with respiratory distress. CDE showed complete resolution of
Pul.HT. But she developed a sudden respiratory arrest from which she could
not be resuscitated.
I am sending this letter since it appears similiar to the one described. [1]
Dr Santhosh R.Gopal,DCH,DNB*
Paediatrician
District Hospital
Trichur, South India
References
(1) P Casano, M Pons Odena, F J Cambra, J M Martín, and A Palomeque. Bordetella pertussis infection causing pulmonary hypertension. Arch Dis Child 2002;86:453.
We welcomed the study of family-based cognitive behaviour therapy
(CBT) for young people with Chronic Fatigue syndrome (CFS) by Chalder et
al., as we too have found that the family approach to rehabilitation
beneficial in this condition.
Although there has been little research into the effectiveness of
family therapy with patients with CFS, there is evidence that support by
family...
We welcomed the study of family-based cognitive behaviour therapy
(CBT) for young people with Chronic Fatigue syndrome (CFS) by Chalder et
al., as we too have found that the family approach to rehabilitation
beneficial in this condition.
Although there has been little research into the effectiveness of
family therapy with patients with CFS, there is evidence that support by
family members for individuals with a range of other chronic conditions is
of major importance to good outcomes [1,2,3] and, conversely, that in some
instances the family can inadvertently reinforce illness behaviour.[4]
In our outpatient program for adolescents with CFS, we added family
sessions to other elements including activity scheduling, school
reintegration and establishing appropriate sleep routines. Our aims were:
(i) to establish whether this form of treatment was beneficial, and (ii) to
identify whether there were family factors/arrangements that might be more
or less helpful in promoting recovery from CFS. We varied the frequency
and number of family sessions with the wants and needs of the family, and
dovetailed family meetings with medical and/or physiotherapy appointments.
Family sessions for each subject were an hour in duration and were not
limited in number or duration over time.
We used a structural family therapy approach informed by a
biopsychosocial systems perspective.[5] The goal of the family work is a
return to full-time education with the ancillary aim, particularly for
socially isolated young people, of increased social and leisure
activities.
To date, we have offered family work to 36 young people with CFS and
their families, of whom 30 engaged with the work. Of these, over 80 % have
shown significant improvement.
Although there are clear similarilites in terms of the family focus
between our program and that described by Chalder et al., our program has
not included CBT. This raises the question as to whether it is a
particular therapeutic technique or the family approach that is important
for recovery in CFS?
References
(1) Kinsella G. Psychosocial issues in recovery following severe head
injury. Proceedings of the 13th Annual Brain Impairment Conference,
Besthesda Hospital, 1989,248-67.
(2) Shepherd G. Psychiatric Rehabilitation in the 1990s. In: Theory and Practice of Psychiatric
Rehabilitation Watts F,
Bennet D, Shepherd G, (Eds).1990. Chicester: John Wiley.
(3) Brooks DN. The head injured family. J Clin Exper Neuro-Psychol
1991;13:155-88.
(4) Brace MJ, Scott Smith M, McCauley E, Sherry DD. Family reinforcement of illness behavior: a comparison of adolescents with chronic fatigue syndrome, juvenile arthritis, and healthy controls. J Dev Behav Pediatr 2000 Oct;21(5):332-9.
(5) Doherty W, McDaniel S, Hepworth J. Medical family therapy: an
emerging arena for family work. J Fam Therapy 1994;16(1).
As an academic pediatrician interested in the treatment of cough, I
read the recent review by Schroeder and Fahey [1] with great interest.
However, I feel that this review, like others published recently, [2,3]
are incomplete with regards to the data describing the use of
dextromethorphan for acute cough due to upper respiratory tract infection
(URTI). In addition to the study that was cited by Tay...
As an academic pediatrician interested in the treatment of cough, I
read the recent review by Schroeder and Fahey [1] with great interest.
However, I feel that this review, like others published recently, [2,3]
are incomplete with regards to the data describing the use of
dextromethorphan for acute cough due to upper respiratory tract infection
(URTI). In addition to the study that was cited by Taylor et al,[4] there
are three additional subjective placebo controlled trials evaluating the
efficacy of dextromethorphan that were not described in the review and one
recent manuscript describing objective data in adults.
The first paper from 1961 by Gruber and Carter [5] was a placebo
controlled trial using inmates of a home for children with cough due to
URTI. Dextromethorphan, propoxyphene derivatives, or placebo were given
to these children who over several days subjectively rated the antitussive
and antiexpectorant effect of the medications. The authors found a
significant improvement in cough for those children given dextromethorphan
compared with placebo. They also reported a dose response effect with
greater improvement seen with a 30 mg dose compared with 15 mg. The age,
weight, sex and other descriptive or demographic variables were
unfortunately not reported in this investigation.
Two years later a similar study by Carter [6] found similar results.
The medications and placebo were combined with acetylsalicyclic acid (ASA)
in this investigation. The age range of the children was 1 to 15 years
with a mean of 4.1 years. Dextromethorphan plus ASA was superior to ASA
for numerous variables including cough frequency, cough severity,
frequency of expectoration, amount expectorated, and duration of cough.
The children given dextromethorphan also reported that they were less
bothered by their cough.
More recently, a Scandanavian group led by Korppi [7] compared
dextromethorphan with and without salbutamol to placebo for cough due to
URTI. These results differed from the two described above by showing a
large placebo effect. Alone or in combination with the beta agonist,
dextromethorphan was not superior to placebo for cough symptoms or general
condition.
Finally, there is no objective pediatric data in existence comparing
dextromethorphan alone to placebo for the treatment of cough due to URTI.
Alternatively, the recent paper by Pavesi et al.[8] describes six adult
double-blind, parallel-group, single-dose, placebo controlled trials
comparing dextromethorphan to placebo in 710 patients. The trials
demonstrated that dextromethorphan reduced cough bouts, components,
effort, and intensity with an increase in cough latency. This group
described their computerized cough acquisition and analysis system in
detail while providing their results.
In summary, it appears that these data combined with those described
in the review by Schroeder and Fahey still leave doubt regarding the
efficacy of over-the-counter cough medications for the treatment of cough
due to URTI. While the older data may contain methodologic flaws, the
results are still relevant to reviews on the topic and should have been
included. As a practicing pediatrician in the United States, I will
continue to follow the guidelines put forth by the American Academy of
Pediatrics [9] that concluded that there is no current indication for
dextromethorphan as an antitussive. However, these data clearly show a
need for further investigations using dextromethorphan to settle this
debate over its efficacy once and for all.
Ian M. Paul, M.D.
Penn State College of Medicine
Department of Pediatrics
Division of General Pediatrics
Hershey, PA
USA
References
(1) Schroeder K, Fahey T. Should we advise parents to administer
over the counter cough medicines for acute cough? Systematic review of
randomised controlled trials. Arch Dis Child 2002;86:170-5.
(2) Schroeder K, Fahey T. Systematic review of randomised controlled
trials of over the counter cough medicines for acute cough in adults. BMJ
2002;324:1-6.
(3) Schroeder K, Fahey T. Over-the-counter medications for acute cough in
children and adults in ambulatory settings. Cochrane Database Syst Rev
2001;(3):CD001831.
(4) Taylor JA, Novack AH, Almquist JR, Rogers JE. Efficacy of cough
suppressants in children. J Pediatr 1993;122:799-802.
(5) Gruber CM, Carter CH. A measure of the effectiveness of propoxyphene
antitussives in children. Am J Med Sci 1961;242:443-6.
(6) Carter CH. A clinical evaluation of the effectiveness of novrad and
acetylsalicylic acid in children with cough. Am J Med Sci 1963;245:713-7.
(7) Korppi M, Pietikainen M, Laurikainen K, Silvasti M. Antitussives in
the treatment of acute transient cough in children. Acta Paediatr Scand
1991;80:969-71.
(8) Pavesi L, Subburaj S, Porter-Shaw K. Application and validation of a
computerized cough acquisition system for objective monitoring of acute
cough: A meta-analysis. Chest 2001; 120: 1121-8.
(9) American Academy of Pediatrics, Committee on Drugs. Use of codeine- and dextromethorphan-containing cough remedies in children. Pediatrics
1997;99:918-20.
We share a similar experience to the one detailed in Watura’s study.[1] We
have gone a step ahead and actually evaluated our own training programme
provided to school staff. The anaphylaxis training programme in now
running in its sixth year in Birmingham. It has two nurse co-ordinators
that visit each school once every year. There are 175 schools in
Birmingham with children who have had food related all...
We share a similar experience to the one detailed in Watura’s study.[1] We
have gone a step ahead and actually evaluated our own training programme
provided to school staff. The anaphylaxis training programme in now
running in its sixth year in Birmingham. It has two nurse co-ordinators
that visit each school once every year. There are 175 schools in
Birmingham with children who have had food related allergic reaction. 203
children have an EPIPEN and 76 children have oral medication in school in
case of an emergency.
Our survey revealed that there was significant improvement in
theoretical knowledge pre and post training. However the teacher’s ability
to correctly use the EPIPEN remains unchanged suggesting this is the area
that needs attention. With this in mind more frequent training was
introduced to some schools lat year. A practice EPIPEN and 2-minute
resuscitation video from the anaphylaxis society were also provided to the
participating schools apart from the annual training session. There was
considerable improvement in teacher’s ability to correctly use the EPIPEN
subsequently.
We suggest that community child health departments that are involved
with anaphylaxis training in schools bear this in mind when designing
their training package. The frequency of the training rather than the
method employed seemed to be a more crucial point.
Reference
(1) Watura JC. Nut allergy in school children: a survey of schools in the Severn NHS trust. Arch Dis Child2002;86:240-4.
Dr R Singhal
Specialist Registrar
Community Paediatrics
Birmingham Heartlands Hospital
Dr D Simkiss
Consultant Community Paediatrician
Bacchus Road
South Birmingham Primary Care Trust
In response to the review article by Shaw and Pal [1] we would like to
contribute our experience of rickets in children in a inner city
population over the last 24 months. During this period 14 children were
seen fulfilling clinical/radiological and biochemical criteria for vitamin
D deficient rickets.
The children were between the ages of 5-36 months(mean age 15.3
months)
In response to the review article by Shaw and Pal [1] we would like to
contribute our experience of rickets in children in a inner city
population over the last 24 months. During this period 14 children were
seen fulfilling clinical/radiological and biochemical criteria for vitamin
D deficient rickets.
The children were between the ages of 5-36 months(mean age 15.3
months)
4 were white children, 3 British Asians/Asians, 2 middle eastern and
5 African/Afro-Caribbean. These children presented in various ways.
Delayed walking
1
Bow legs
6
Hypocalcemic fits
3
Cough-Xray changes noted
3
Incidental finding on blood test
1
The most important dietary factor was prolonged exclusive breast
feeding. 7 children (50 %) were breast fed for more than 12 months at the
time of diagnosis, 3 were breast-fed for 6-12 months, and 2 for 3-6
months. None of the mothers received vitamin D during pregnancy. Only one child had clear evidence of failure to thrive. 8/14 children
had iron deficiency.
All had a good clinical response to vitamin D therapy . 8/14 children
were treated with alfacalcidol, 4 were treated with ergocalciferol, and 1
child with cholecalciferol. 2 babies were given multivitamins only. All
families received specialist dietetic advice. Treatment was continued for a
mean of 3.6 months(range 2-6 months).
We strongly agree with Shaw and Pal that there should be increased
awareness of this condition, which has lapsed from attention to some
extent. Our experience suggests that all ethnic groups in inner London
have high levels of vitamin D deficiency especially Asian and African
groups. Vitamin D should be offered to high-risk groups during pregnancy
and a vitamin D containing multivitamin given to their infants. The
message to introduce a mixed diet from 4-6 months of age needs to be re-enforced.
Reference
(1) Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating
a new concern. Arch Dis Child 2002;86:147-9.
Dear Editor,
We write to draw attention to two problems with the recent study on a scoring system for bruising by Dunstan et al. [1].
Firstly, the authors did not publish confidence intervals for the Likelihood Ratios (LRs) derived from different score threshold values (Table 3), thereby not allowing readers to judge whether the Likelihood Ratios are statistically, let alone clinically, significa...
Dear Editor
We read with interest the article by Duke et al[1] regarding hypoxaemia in acute respiratory and non-respiratory illnesses in infants and children in developing countries published recently in the ADC.[1] The authors have rightly pointed out the limited availability of published data on the incidence, significance or clinical signs predicting hypoxaemia in infants less than three months of age. With...
Dear Editor
Dr Casano describe a case refractory pulmonary hypertension with severe Bordetella pertussis infection. Their description of the literature is incomplete. We described a further 4 cases of fatal pulmonary hypertension (PHT) in a series of 13 critically ill infants with B. pertussis[1]. The cases that developed PHT all presented with severe hyperleukocytosis (WCC>100 x 10(9)/l)which was unresponsive...
Dear Editor
We write with regard to the article by Astrom and Soderhall [1] which demonstrates the symptomatic benefit of intravenous bisphosphonates in children with osteogenesis imperfecta. While we have great enthusiasm for the benefits of these drugs, we feel that some concern for the side effect profile, in particular on liver function, is warranted.
As experienced by Astrom and Soderhall, bisphos...
Dear Editor
We read with interest the paper from Carrol and coworkers who have demonstrated for the first time that procalcitonin (PCT), even it cannot be presented as a gold standard (7 % of false negative), is a promising marker of meningococcal disease (MCD) in children presenting with fever and rash.[1] Carrol et al. also observed that PCT level was significantly higher (p = 0.001) in children with...
Dear Editor
I read with interest the article. I recently had an experience when a 2-month-old infant, born term, 3.3 kg was admitted with clinical diagnosis of Bronchiolitis. Since we do not have facilities for virology we cannot claim microbiological confirmation. This infant had severe respiratory distress and wheeze with low-grade fever. She was given IVF,Cont.Oxygen at 3.5 l/mt as well as antibiotics. On th...
Dear Editor
We welcomed the study of family-based cognitive behaviour therapy (CBT) for young people with Chronic Fatigue syndrome (CFS) by Chalder et al., as we too have found that the family approach to rehabilitation beneficial in this condition.
Although there has been little research into the effectiveness of family therapy with patients with CFS, there is evidence that support by family...
Dear Editor
As an academic pediatrician interested in the treatment of cough, I read the recent review by Schroeder and Fahey [1] with great interest. However, I feel that this review, like others published recently, [2,3] are incomplete with regards to the data describing the use of dextromethorphan for acute cough due to upper respiratory tract infection (URTI). In addition to the study that was cited by Tay...
Dear Editor
We share a similar experience to the one detailed in Watura’s study.[1] We have gone a step ahead and actually evaluated our own training programme provided to school staff. The anaphylaxis training programme in now running in its sixth year in Birmingham. It has two nurse co-ordinators that visit each school once every year. There are 175 schools in Birmingham with children who have had food related all...
Dear Editor
In response to the review article by Shaw and Pal [1] we would like to contribute our experience of rickets in children in a inner city population over the last 24 months. During this period 14 children were seen fulfilling clinical/radiological and biochemical criteria for vitamin D deficient rickets.
The children were between the ages of 5-36 months(mean age 15.3 months)
4 were white...
Pages