We have found very interesting the paper by Dr Allegaert et al. about
iv paracetamol pharmacokinetics (1) in which they referred that between-
subject variability (BSV) is explained by covariates such as size, weight,
disease characteristics or co-administration of drugs. They mentioned that
they found an unexplained variance in paracetamol clearance, and that it
remained high (39,1 per cent) even a...
We have found very interesting the paper by Dr Allegaert et al. about
iv paracetamol pharmacokinetics (1) in which they referred that between-
subject variability (BSV) is explained by covariates such as size, weight,
disease characteristics or co-administration of drugs. They mentioned that
they found an unexplained variance in paracetamol clearance, and that it
remained high (39,1 per cent) even after taking size, age and bilirubin
into account.
Regarding the co-administration of drugs as a covariate, an issue
that was not addressed in the paper, we would like to note that the
neonates included in the pooled analysis (n: 158) were from different
studies and had been administered three different iv paracetamol
formulations; one of them (Perfalgan) with a considerable amount of
mannitol (3,85g/100ml) as excipient. Thus, the
neonates in study 3 (n: 50) were administered every 6 hours a concomitant
mannitol dose of 58 mg/Kg with each paracetamol dose of 15 mg/Kg; they
received 232 mg/Kg/day of mannitol during 2 to 7 days.
The amount of mannitol included as excipient in pharmaceutical
products licensed for adults and children is considered a non-active
ingredient because it is far below the pharmacologically significant dose
for them. However, it could be enough to show an osmotic diuretic effect
in neonates, especially in low weight preterm infants. This enhanced
osmotic effect would be greater in the most immature neonates and would
decline logarithmically during the first few weeks of life(2). The osmotic
diuretic effect of the same dose of mannitol could be considerably
different in accordance with the maturation of the renal function.
In Argentina iv paracetamol is available only since last year, with
mannitol as excipient.
In 2006 we had seen that a low amount of mannitol could have some
influence on the less oliguria observed with ibuprofen compared to
indomethacin for PDA closure.(3)
Last year, a new investigation by Chiam et al. showed that the majority of
the formulations with 1g iv paracetamol also contain near 4g of mannitol
(38-39mg/ml). They explained that this low amount of mannitol was a
clinically relevant dose which might cause hypotension in critically ill
adults due to its diuretic nature even in low doses.(4)
The fact that only 1/3 of neonates (50/158) in Allegaert et als study
were co-administered a concomitant diuretic dose of mannitol should be
considered, as it could have contributed to the extensive variability and
the unexplained high variance they found in iv paracetamol clearance.
Further research is necessary to evaluate the effects of low doses of
mannitol in neonates, especially in low birth weight infants, and to
determine how iv paracetamol pharmacodynamics and pharmacokinetics are
influenced, if so, by the mannitol content of the medication.
Jorge Pisapia. Matias Lucero. Leonardo Giunta.
Clinica y Maternidad Suizo Argentina. Department of Pharmacy. SWISS
MEDICAL GROUP. Buenos Aires. Argentina.
REFERENCES
1- Allegaert K, Palmer GM, Anderson BJ. The pharmacokinetics of
intravenous paracetamol in neonates: size matters most. Arch Dis Child
2011; 96:575???580.
2- Kleinman LI, Disney TA. Renal osmotic in the neonatal and adult
dog. Am J Physiol Renal Physiol 1984; 247 Issue 3 F396-F402.
3- Pisapia J, Giunta L, Alonso MR. Mannitol influence on the less
renal side effects of ibuprofen vs indomethacin for PDA closure. Arch Dis
Child
2003;88:1135.adc.bmj.com/content/88/12/1134.full/reply#archdischild_el_1881
Jan 2006
4- Chiam E, Weinberg L, Bellomo R. Paracetamol: a review with
specific focus on the haemodynamic effects of intravenous administration.
Heart Lung Vessel 2015; 7(2):121-32.
Thyroid hormone is critical for normal growth and brain development,
and hypothyroidism in infancy is the leading cause of intellectual
impairment worldwide.
Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones
at birth.
Congenital hypothyroidism is very important clinically since severe cases
will lead to irreversible mental handicap without prompt treatment.
Thyroid hormone is critical for normal growth and brain development,
and hypothyroidism in infancy is the leading cause of intellectual
impairment worldwide.
Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones
at birth.
Congenital hypothyroidism is very important clinically since severe cases
will lead to irreversible mental handicap without prompt treatment.
The essential role of thyroid hormones in brain development during
the first 24-36 months of age is well established; thus prompt
normalization of thyroid hormone levels is essential .
The incidence of CH diagnosed by neonatal screening varies per population,
ranging from 1 in 2000 to 1 in 3000 births and is comparatively higher
than the reported incidence prior to the era of screening.
Following clinical assessment, a good venous blood sample for
measurement of free thyroxine (fT4) and TSH is mandatory, since the result
reflects the presence and severity of congenital hypothyroidism.
Compared to venous serum, the concentrations in skin puncture serum
were higher for thyroid stimulating hormone (TSH) (86.7%). Capillary TSH
dried blood spot testing on the 3rd-5th day is the most sensitive method.
In our setup we could use only venous blood TSH levels rather than
capillary blood samples reason may be having expert nursing care to
collect the blood samples but not having sufficient infrastructure and
personnel to implement the same.
In our experience 4 babies out of 1500 had transient elevated TSH
levels which on follow up normalized within 3 weeks after birth without
treatment. There was no proved case of congenital hypothyroidism was seen
probable reasons may be use of common salt fortified with iodine for
cooking and staple diet being mainly fish.
In countries that can afford newborn screening, treatment within the
first 28 days of life - so-called 'early treatment' - has transformed the
outlook for children with CH so that severe growth retardation with mental
handicap(congenital hypothyroidism) is no longer seen.
It is described as primary when the gland itself is affected and
central when the defect lies in the hypothalamo-pituitary axis;
compensated when the hypothalamo-pituitary-thyroid axis is jeopardised but
still manages to maintain normal thyroxine (T4) levels and decompensated
when normal thyroid hormone levels cannot be maintained.
Van der Sluijs Veer et al. studied 95 toddlers with CH in whom L-
thyroxine treatment had been started at a median age of 9 days, with
normalization of the serum free T4 concentration within 2.1 days and of
the serum TSH level within 18.6 days.
Cord FT4 identifies only infants with severe CH. Cord TSH is more
sensitive than cord FT4 screening. Capillary TSH dried blood spot testing
on the 3rd-5th day is the most sensitive method.
In our experience it was found that serum thyrotropin values at 2nd and
3rd day were useful in screening and early treatment of congenital
hypothyroidism.
References :
Nikolina Zdraveska, Violeta Anastasovska and Mirjana Kocova.
Frequency of thyroid status monitoring in the first year of life and
predictors for more frequent monitoring in infants with congenital
hypothyroidism. J Pediatr Endocrinol Metab 2016; aop
Ari J. Wassner and Rosalind S. Brown. Hypothyroidism in the Newborn
Period. Curr Opin Endocrinol Diabetes Obes. 2013 Oct; 20(5): 449-454. doi:
10.1097/01.med.0000433063.78799.c2
Deladoey J, Ruel J, Gigu?re Y, et al. Is the incidence of congenital
hypothyroidism really increasing? A 20-year retrospective population-based
study in Quebec. J Clin Endocrinol Metab 2011;96:2422-9.
Grosse SD, Van Vliet G. Prevention of intellectual disability through
screening for congenital hypothyroidism: how much and at what level? Arch
Dis Child 2011;96:374-9.
Corbetta C, Weber G, Cortinovis F, Calebiro D, Passoni A, Vigone MC
et al. A 7-year experience with low blood TSH cutoff levels for neonatal
screening reveals an unsuspected frequency of congenital hypothyroidism
(CH). Clin Endocrinol (Oxf). 2009 Nov;71(5):739-45. doi: 10.1111/j.1365-
2265.2009.03568.x. Epub 2009 Mar 28.
Hardy JD, Zayed R, Doss I, Dhatt GS. Cord blood thyroxine and thyroid
stimulating hormone screening for congenital hypothyroidism: how useful
are they? J Pediatr Endocrinol Metab. 2008 Mar;21(3):245-9.
Hardy JD1, Zayed R, Doss I, Dhatt GS. Cord blood thyroxine and
thyroid stimulating hormone screening for congenital hypothyroidism: how
useful are they? J Pediatr Endocrinol Metab. 2008 Mar;21(3):245-9.
Heyerdahl S. Long-term outcome in children with congenital
hypothyroidism. Acta Paediatr 2001;90:1220-2.
Falch DK. Clinical chemical analyses of serum obtained from capillary
versus venous blood, using Microtainers and Vacutainers. Scand J Clin Lab
Invest. 1981 Feb;41(1):59-62.
Dear editor,
In their study G C D Thornton and al (1) found a diagnosis of appendicitis
in 6065 children out of 268623, previously diagnosed as non specific
abdominal pain (NSAP) at the first access, who returned within one year.
According to their data, the RR to develop appendicitis in the first year
after discharge with a diagnosis of NSAP is 15.04 times higher than the
risk in the control cohort. Appendicitis is an a...
Dear editor,
In their study G C D Thornton and al (1) found a diagnosis of appendicitis
in 6065 children out of 268623, previously diagnosed as non specific
abdominal pain (NSAP) at the first access, who returned within one year.
According to their data, the RR to develop appendicitis in the first year
after discharge with a diagnosis of NSAP is 15.04 times higher than the
risk in the control cohort. Appendicitis is an acute disease with a rapid
development (2) and, as expected for an acute condition, the RR gets down
considerably after the first year (RR 3.26 at 1-4 years; 2.13 at 5-9
years).
We recently evaluated patients readmitted to our emergency department,
from March 2015 to September 2015, with a previous diagnosis of abdominal
pain without a defined cause: we had 37 patients hospitalized for
appendicitis, 23 of them were diagnosed at the first access, 6 returned
within 72 hours, other 7 cases were readmitted within 7 days, and only one
returned in more than a week.
It could be interesting to know how many patients with appendicitis in the
Thornton's series were readmitted in an acute setting (defined as
readmission within 72 hours) or in the first week after discharge. A high
number of early readmissions would strongly clarify this otherwise very
puzzling connection.
Bibliography
1- Diagnostic outcomes following childhood non-specific abdominal
pain: a record-linkage study G C D Thornton, M J Goldacre, R Goldacre, L J
Howarth Arch. Dis. Child. 2016 101:305-309
2- Appendicitis. Lewis SR, Mahony PJ, Simpson J. BMJ. 2011 Oct
6;343:d5976
In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety
netting advice and its documentation...
In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety
netting advice and its documentation in the medical notes, the authors
propose the introduction of a checklist. However, at this moment the
effective components or the best way to perform this safety netting
management still remains unknown.
A systematic review of Neill et al. states that incomplete
information on the illness of their child leaves parents still in need for
help.(1) Moreover, irrelevant information reduces parents' trust in the
intervention.(1) We know that parental knowledge and satisfaction improved
more after video discharge instructions than after written discharge
instructions alone.(2) So to proceed we think the next step is to focus on
the parental role in the decision making process. One could think of
parental monitoring of alarming signs and symptoms of their febrile child.
A study on self-referred children with fever emphasized that many parents
properly judged and acted on their febrile child's severity of illness.(3)
In England every parent is trained to recognise petechial rash,(4) we
might enlarge this knowledge to other alarming or reassuring signs and
symptoms. This could be initiated for example for respiratory rate, a
useful marker of pneumonia, one of the most frequent serious illness at
the ED.(5) We are aware of current projects on this topic. A next step is
evaluating the impact of such strategies providing improved information on
patient (re)consultation.
In addition to the recognition of deterioration, an important gap in
safety netting literature is its time frame strategy. The development of
optimal safety netting management should include clinical signs and
symptoms, but also a disease specific time frame to inform parents when
they should seek help again. This combination of safety netting
determinants may establish new starting points for improvement of care.
References:
1. Neill S, Roland D, Jones CH, Thompson M, Lakhanpaul M, group ASs.
Information resources to aid parental decision-making on when to seek
medical care for their acutely sick child: a narrative systematic review.
BMJ Open. 2015;5:e008280 doi: 10.1136/bmjopen-2015-008280 [published
Online.
2. Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to
standard written instructions improved caregivers' understanding of their
child's emergency department visit, plan, and follow-up: a randomized
controlled trial. Pediatr Emerg Care. 2013;29:699-704 doi:
10.1097/PEC.0b013e3182955480 [published Online.
3. van Ierland Y, Seiger N, van Veen M, et al. Self-referral and serious
illness in children with fever. Pediatrics. 2012;129:e643-51 doi:
10.1542/peds.2011-1952 [published Online.
4. Acutely sick kid safety netting interventions for families.
http://asksniff.org.uk/
5. Taylor JA, Del Beccaro M, Done S, Winters W. Establishing clinically
relevant standards for tachypnea in febrile children younger than 2 years.
Arch Pediatr Adolesc Med. 1995;149:283-7 Online.
Andrew Riordan writes, as ever, with excellent good sense about the
duration of courses of antibiotics. (1)
Doctors who have trained with me will have heard me talk about this.
We are falsely comforted by some numbers, which are highly likely to
themselves to be false. The "true" duration of antibiotic therapy ought
to be an awkward number - 3.4 days, or 8.7 days. It shouldn't be a neat...
Andrew Riordan writes, as ever, with excellent good sense about the
duration of courses of antibiotics. (1)
Doctors who have trained with me will have heard me talk about this.
We are falsely comforted by some numbers, which are highly likely to
themselves to be false. The "true" duration of antibiotic therapy ought
to be an awkward number - 3.4 days, or 8.7 days. It shouldn't be a neat
number like 5, 7, 10 or 14.
This leads to a second thought. Why are we comforted by 5, 7, 10,
and 14?
5 and 10 are easy. They are because we like to work in base 10.
This is because we (mostly) have ten fingers. (as an aside, it would be
much more convenient to have evolved to be interested in base 12, since 10
is only divisible by 2 and 5, whereas 12 is divisible by 6, 4, 3 and 2.
Anyone who uses this argument to advance continuing with imperial
measurements has forgotten the 16 ounces in a pound, the 14 pounds in a
stone, the three feet in a yard, and so on.)
7 and 14 are slighty less easy. The obvious answer is we like them
because the week is 7 days long. But why is the week 7 days? Biblical
answers aside, it is to do with the lunar cycle, which is actually 29.5
days but approximated to our ancestors as 28 days, breaking nicely into
four quarters.
So I give you a challenge. The next time you see some crusty old
fool (like me, for example) proclaiming on a ward round "This patient must
have 7 days of antibiotics, and not 5" do a little translation in your
head, and try to hear "This patient must have a quarter of a lunar cycle
of antibiotics, and not the same number of days as I have fingers on one
hand" instead. You'll get an interesting insight into how you need to
judge things clinically and not by silly rules.
Now, don't start me on the fact that you're "allowed" 10 white cells
in the CSF...
Ian Wacogne
Consultant Paediatrician
1. Riordan A. 5, 7, 10 or 14 days: appropriate duration of
treatment for bacteraemia or an example of 'antimicrobial bingo'?
Arch. Dis. Child. 2015 0:archdischild-2015-309132v1-archdischild-2015-
309132; doi:10.1136/archdischild-2015-309132
Conflict of Interest:
I do not believe I have any competing interests in this matter, but I am a deputy editor across the ADC group.
This editorial is a very helpful review of the current state of the
debate.
I am concerned that zoster is under diagnosed in childhood because of
lack of familiarity in both primary and secondary care. Anecdotally it is
not uncommon in a paediatric unit, in otherwise well children, but does
cause significant concern and use of resources. This needs to be
accurately captured as it may shift the economic modelling...
This editorial is a very helpful review of the current state of the
debate.
I am concerned that zoster is under diagnosed in childhood because of
lack of familiarity in both primary and secondary care. Anecdotally it is
not uncommon in a paediatric unit, in otherwise well children, but does
cause significant concern and use of resources. This needs to be
accurately captured as it may shift the economic modelling used to decide
whether to go ahead with varicella vaccination.
We read with interest the review by Amirthalingam[1] and colleagues
of the potential value of a UK varicella vaccination programme. They cite
Blumental[2] and colleagues' article in the same issue which assessed the
burden of varicella and outlined some of the known complications, such as
bacterial skin and soft tissue infections, pneumonia, and neurological
complications including meningitis and encephalitis. The Blumen...
We read with interest the review by Amirthalingam[1] and colleagues
of the potential value of a UK varicella vaccination programme. They cite
Blumental[2] and colleagues' article in the same issue which assessed the
burden of varicella and outlined some of the known complications, such as
bacterial skin and soft tissue infections, pneumonia, and neurological
complications including meningitis and encephalitis. The Blumental study
included complications occurring up to 21 days after onset of the
chickenpox rash. We wish to highlight further potential complications that
are possibly excluded from that definition but may be a significant
benefit of vaccination.
There is evidence that varicella infection is associated with an
increased risk of focal cerebral arteriopathy and arterial ischemic stroke
(AIS). In a UK study of incidence, Thomas[3] and colleagues identified 49
children with AIS following chickenpox and found that, in children, the
incidence of AIS during the following 6 months was four times that of
controls (summary incidence ratio = 4.07; 95% CI 1.96-8.45). The estimated
incidence ratio in adults was 2.13 (95% CI 1.05-4.36). Considering
varicella vaccination in a cohort of more than 3 million children, Donahue
and colleagues found no association with ischemic stroke.[4]
We believe that neurological complications of AIS, which can occur
many weeks after infection, were not considered in the review by
Amirthalingam and colleagues. Most of the complications that they reported
are transient or readily treatable, although meningoencephalitis can leave
long-term neurodevelopmental sequelae. There is a high risk of long-term
disability from childhood AIS and this places significant financial burden
on healthcare systems. We believe that this relatively uncommon but
important complication should be considered when determining the cost-
effectiveness of a varicella vaccination programme for the UK.
References
1- Amirthalingam G, Ramsay M. Should the UK introduce a universal
childhood varicella vaccination programme? Arch Dis Child. 2016
Jan;101(1):2-3.
2- Blumental S, Sabbe M, Lepage P; Belgian Group for Varicella.
Varicella paediatric hospitalisations in Belgium: a 1-year national
survey. Arch Dis Child. 2016 Jan;101(1):16-22
3- Thomas SL, Minassian C, Ganesan V, Langan SM, Smeeth L. Chickenpox
and risk of stroke: a self-controlled case series analysis. Clin Infect
Dis. 2014 Jan;58(1):61-8.
4- Donahue JG, Kieke BA, Yih WK, Berger NR, McCauley JS, Baggs J,
Zangwill KM, Baxter R, Eriksen EM, Glanz JM, Hambidge SJ, Klein NP, Lewis
EM, Marcy SM, Naleway AL, Nordin JD, Ray P, Belongia EA; Vaccine Safety
DataLink Team. Varicella vaccination and ischemic stroke in children: is
there an association? Pediatrics. 2009 Feb;123(2):e228-34.
Bronchiolitis is on rise, both in prevalence and severity in our
country due to many social and life style factors. in our hospital we
adopted a protocol named: SuProNO INCLUDE:-
- PROVIDE VITAL SIGN ASSESSMENT and close monitoring
- PROVIDE O2 AS NEEDED
- Provide IV fluid/ NGT Feeds as appropriate
-provide Hypertonic (3%) saline nebulization
-provide nasal decongestant drops/ spray and suctioning as needed
- provide anti...
Bronchiolitis is on rise, both in prevalence and severity in our
country due to many social and life style factors. in our hospital we
adopted a protocol named: SuProNO INCLUDE:-
- PROVIDE VITAL SIGN ASSESSMENT and close monitoring
- PROVIDE O2 AS NEEDED
- Provide IV fluid/ NGT Feeds as appropriate
-provide Hypertonic (3%) saline nebulization
-provide nasal decongestant drops/ spray and suctioning as needed
- provide antipyretics if needed
-NO NO NO antibiotics
NO NO NO steroids.
with this protocol, the out come is excellent even for severe cases,
with short hospitalization, and no need for high facility respiratory
support like CPAP or ventilator.
In their excellent review on the hypoglycaemia in childhood the
authors suggest that for the management of the hyperinsulinaemic
hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who
do not respond to diazoxide may respond to the octreotide but the efficacy
of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11
are associated with severe HH that is unresponsive to...
In their excellent review on the hypoglycaemia in childhood the
authors suggest that for the management of the hyperinsulinaemic
hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who
do not respond to diazoxide may respond to the octreotide but the efficacy
of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11
are associated with severe HH that is unresponsive to medical treatment
with diazoxide and octreotide. The treatment option for patients with
medically unresponsive forms of diffuse HH is a subtotal pancreatectomy,
but some patients who have undergone surgery continue to have recurrent
hypoglycemia, whereas diabetes mellitus and exocrine pancreatic
insufficiency develop in others (1).
The authors of the review make no mention of the possible use of the
mammalian target of rapamycin (mTOR) inhibitor sirolimus recently reported
to be effective and safe for the severe, diffuse form of HH that had been
unresponsive to maximal doses of diazoxide and octreotide (2-5). No major
adverse reactions were observed during the 1-year follow-up period in the
first 4 cases described (2). This finding is reinforced by the latest
cases report of others infant (3,4) and older children (5).
The suggested method of action of sirolimus includes the reduction of
beta-cell proliferation, inhibition of insulin production, and induced
peripheral insulin resistance (4). The sirolimus-sensitive mTORC1 pathway
is present in the exocrine pancreas and the relatively sirolimus-resistant
IGF1R/mTORC2/Akt pathway is overexpressed in the beta-cells, thereby
suggesting that sirolimus is effective in treating diffuse HH by reducing
the transdifferentiation of exocrine elements to insulin-producing cells
(5).
Even if further studies are needed, primarily to identify long-term
sequelae and side effects, sirolimus appears to be a promising therapeutic
option to treat children with severe HH unresponsive to diazoxide and
octreotide.
Federico Marchetti, Vanna Graziani
Department of Paediatrics, S. Maria delle Croci Hospital, Ravenna,
Italy.
48121 Ravenna, Italy
e-mail: fedemarche@tin.it
References
1. Ghosh A, Banerjee I, Morris AAM. Recognition, assessment and
management of hypoglycaemia in childhood Arch Dis Child Published Online
First: 30 December 2015 doi:10.1136/archdischild-2015-308337
2. Senniappan S, Brown RE, Hussain K. Sirolimus in severe
hyperinsulinemic hypoglycemia. N Engl J Med 2014;370(25):2448-9.
3. Abraham MB, Shetty VB, Price G, et al. Efficacy and safety of
sirolimus in a neonate with persistent hypoglycaemia following near-total
pancreatectomy for hyperinsulinaemic hypoglycaemia. J Pediatr Endocrinol
Metab 2015;28(11-12):1391-8
4. Meder U, Bokodi G, Balogh L, et al. Severe hyperinsulinemic
hypoglycemia in a neonate: response to sirolimus therapy. Pediatrics.
2015;136(5):e1369-72
5. Minute M, Patti G, Tornese G, Faleschini E, Zuiani C, Ventura A.
Sirolimus therapy in congenital hyperinsulinism: a successful experience
beyond infancy. Pediatrics. 2015;136(5):e1373-6
We agree that sirolimus may help children with Congenital
Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus
is, however, unlicensed, with little long term experience, and the
mechanism by which it reduces hypoglycaemia remains speculative. As
sirolimus is an immunosuppressant, its use in young infants has to be
carefully monitored in specialist centres under strict protocols. We are,
therefore, re...
We agree that sirolimus may help children with Congenital
Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus
is, however, unlicensed, with little long term experience, and the
mechanism by which it reduces hypoglycaemia remains speculative. As
sirolimus is an immunosuppressant, its use in young infants has to be
carefully monitored in specialist centres under strict protocols. We are,
therefore, reluctant to advocate the routine use of sirolimus in
Congenital Hyperinsulinism until more evidence has accumulated.
To the editor:
We have found very interesting the paper by Dr Allegaert et al. about iv paracetamol pharmacokinetics (1) in which they referred that between- subject variability (BSV) is explained by covariates such as size, weight, disease characteristics or co-administration of drugs. They mentioned that they found an unexplained variance in paracetamol clearance, and that it remained high (39,1 per cent) even a...
Thyroid hormone is critical for normal growth and brain development, and hypothyroidism in infancy is the leading cause of intellectual impairment worldwide. Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones at birth. Congenital hypothyroidism is very important clinically since severe cases will lead to irreversible mental handicap without prompt treatment.
The essential role of thyroid...
Dear editor, In their study G C D Thornton and al (1) found a diagnosis of appendicitis in 6065 children out of 268623, previously diagnosed as non specific abdominal pain (NSAP) at the first access, who returned within one year. According to their data, the RR to develop appendicitis in the first year after discharge with a diagnosis of NSAP is 15.04 times higher than the risk in the control cohort. Appendicitis is an a...
Dear editor,
In their letter, colleagues Jacob et al. raised further evidence of the lack of standardised safety netting. We thank them for their comments emphasizing the disparity between paediatric trainees' perception of their safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety netting advice and its documentation...
Dear Editor,
Andrew Riordan writes, as ever, with excellent good sense about the duration of courses of antibiotics. (1)
Doctors who have trained with me will have heard me talk about this. We are falsely comforted by some numbers, which are highly likely to themselves to be false. The "true" duration of antibiotic therapy ought to be an awkward number - 3.4 days, or 8.7 days. It shouldn't be a neat...
This editorial is a very helpful review of the current state of the debate.
I am concerned that zoster is under diagnosed in childhood because of lack of familiarity in both primary and secondary care. Anecdotally it is not uncommon in a paediatric unit, in otherwise well children, but does cause significant concern and use of resources. This needs to be accurately captured as it may shift the economic modelling...
We read with interest the review by Amirthalingam[1] and colleagues of the potential value of a UK varicella vaccination programme. They cite Blumental[2] and colleagues' article in the same issue which assessed the burden of varicella and outlined some of the known complications, such as bacterial skin and soft tissue infections, pneumonia, and neurological complications including meningitis and encephalitis. The Blumen...
Bronchiolitis is on rise, both in prevalence and severity in our country due to many social and life style factors. in our hospital we adopted a protocol named: SuProNO INCLUDE:- - PROVIDE VITAL SIGN ASSESSMENT and close monitoring - PROVIDE O2 AS NEEDED - Provide IV fluid/ NGT Feeds as appropriate -provide Hypertonic (3%) saline nebulization -provide nasal decongestant drops/ spray and suctioning as needed - provide anti...
Dear Editor
In their excellent review on the hypoglycaemia in childhood the authors suggest that for the management of the hyperinsulinaemic hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who do not respond to diazoxide may respond to the octreotide but the efficacy of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11 are associated with severe HH that is unresponsive to...
We agree that sirolimus may help children with Congenital Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus is, however, unlicensed, with little long term experience, and the mechanism by which it reduces hypoglycaemia remains speculative. As sirolimus is an immunosuppressant, its use in young infants has to be carefully monitored in specialist centres under strict protocols. We are, therefore, re...
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