Displaying 1-10 letters out of 1303 published
Response to: "Capillary refill time: Time to fill the gaps!"
Thank you for your response to our research 'The agreement of fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue perfusion in a simple and timely manner and continue to extrapolate that in shock, blood is usually diverted from the skin in an attempt to perfuse vital organs. Current practice and guidance assumes that CRT is a reflection of this (1-7). We were not expecting to find fingertip CRT to be faster than sternum CRT, although we did not find it strange. We agree and also suspect that different sites have different refill times because of the complex and intricate relationships involved, which are not practical or possible to record prior to carrying out the CRT (such as arteriolar resistance, venular resistance etc. as discussed in Carcillo (1)). There is a substantial amount of research in CRT in vascular medicine which we decided not to include in our literature review prior to this study, although our findings might indicate it would be more appropriate to examine this area in more detail. We do know that the fingertip pulp is rich in arterio-venous anastomoses which may explain why it had the quickest CRT and that vascular resistance is increased in peripheral beds and this may explain why it also had the slowest CRT.
We agree that there needs to be standardisation of the technique, greater awareness of CRT limitations and it should be analysed in conjunction with other haemodynamic markers. We suggested that guidance provided by the Resuscitation Council (RC) (2-4), amongst others, be reviewed for exactly these reasons. The RC highlight CRT as one of the five parameters to observe when examining circulation, giving it equal weighting to heart rate, pulse volume, blood pressure and end organ perfusion status. The RC guidance does advise to consider CRT with other cardiovascular signs but importantly does not consider the fingertip site or variables such as inter and intra observer reliability and skin colour.
Carcillo's editorial is interesting; however this purposive review is not balanced or systematic and does not provide a comprehensive overview of the literature relating to CRT. Interestingly although Carcillo is discussing sick children we are informed that CRT is age dependant and rightly references the study that discovered this in 1988, there is no evidence that tells us otherwise, yet we can find no guidance by the RC or other group that utilises an age dependant model, why is that?
Our study did not set out to examine the usefulness of the test, but led us to question the way CRT is conducted in current clinical practice. In an era where we try to practice evidence based medicine, if this test is recommended for use in practice (something our research cannot answer) then we have a duty to generate the evidence to support the way in which it is conduced.
1. Carcillo JA. Capillary refill time is a very useful clinical signin early recognition and treatment of very sick children. Editorial on Pediatr Crit Care Med 2012; 13:136 -140
2. Resuscitation Council. Medical Emergencies and Resucitation-- Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice. http://www.resus.org.uk/pages/MEdental.pdf (accessed May 2013):24.
3. Resuscitation Council. European paediatric life support (EPLS). 3rd edn. London:
4. Resuscitation Council 2011:12. Resuscitation Council. A systematic approach to the acutely ill patient, adapted from the ALERTTM. http://www.resus.org.uk/pages/alsABCDE.htm (accessed May 2013).
5. Jevon P. Measuring capillary refill time. Nurs Times 2007;103:26- 7.
6. Lima A, Jansen TC, Van Bommel J, et al. The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients. Crit Care Med 2009;37:934-8.
7. Graham C, Parke T. Critical care in the emergency department: shock and circulatory support. Emerg Med J 2005;22:17-21.
Conflict of Interest:
Re: The importance of a preschool booster for children born to hepatitis B-positive mothers
We are grateful to Dr Ladhani and Dr Ramsay  for their thoughtful editorial that accompanied the publication of our paper . We would agree that, despite discrepant observational data in the UK regarding the waning of antibody titres [2, 3], there is now a large body of evidence  demonstrating that, even where antibody titres have waned, booster doses are not required if an adequate primary schedule has been completed.
As discussed in the editorial, the pragmatic priority is to ensure that all children complete the course and receive at least one further dose after their initial (accelerated) schedule at 0, 1, 2 months.
Routine immunisation visits are a convenient time to do this, and the pre-school booster presents one such opportunity. However, as Dr Ladhani and Dr Ramsay have noted elsewhere, almost all UK children diagnosed with chronic hepatitis B infection acquire this through vertical transmission . Having a named clinician responsible for delivery of the 0, 1, 2 month schedule can improve its delivery , and the 12 month routine vaccine visit is more timely than the pre-school booster for ensuring its completion.
1. Ladhani SN, Ramsay ME. The importance of a preschool booster for children born to hepatitis B-positive mothers. Arch Dis Child. 2013; 98: 395-396. 2. Yates TA, Paranthaman K, Yu LM, et al. UK vaccination schedule: persistence of immunity to hepatitis B in children vaccinated after perinatal exposure. Arch Dis Child. 2013; 98: 429-433. 3. Boxall EH, A Sira J, El-Shuhkri N, et al. Long-term persistence of immunity to hepatitis B after vaccination during infancy in a country where endemicity is low. J Infect Dis. 2004; 190(7): 1264-9. 4. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. Clin Infect Dis. 2011; 53(1): 68-75. 5. Flood J, Amirthalingam G, Ramsay ME, et al. The diagnosis of chronic Hepatitis B infection among children born in England after introduction of universal antenatal HBV screening programme. Poster presented at the European Society of Paediatric Infectious Disease Meeting, The Hague, June 2011. http://www.kenes.com/ espid2011/cd/pdf/P774.pdf.
Conflict of Interest:
Our study was supported by the NIHR Oxford Biomedical Research Centre and GlaxoSmithKline Biologicals. SL has undertaken paid work for vaccine manufacturers for provision of travel health training and attendance at advisory group meetings. AJP and MDS have conducted clinical trials on behalf of Oxford University sponsored by manufacturers of vaccines. AJP and MDS do not accept any personal payments from vaccine manufacturers: grants for support of educational activities are paid to an educational/administrative fund held by the Department of Paediatrics, Oxford University. MDS has received support from vaccine manufacturers to attend academic conferences. ED, SBW, SJH, KP and TAY declare no conflicts of interest besides funding received for the study.
Capillary refill time:Time to fill the gaps!
We read with great interest the article on capillary refill time (CRT) in children. Crook J and Taylor RM have carried out a simple and yet very relevant study on CRT in children.CRT is almost universally checked by child care providers particularly in emergency room or intensive care setting and is taken as a surrogate of the perfusion status. However, two issues have plagued this simple bedside test:
(i) There seems to be no uniformity in the way this test is carried out across the world. We recently published a letter to editor (1) describing the variations in eliciting CRT amongst the various standard texts and references. After analysis of all the references, it seemed prudent to follow the Pediatric advanced life support(PALS )guideline for CRT in children (finger tip) and the WHO guideline for CRT in young infants (finger tip and sternum) with a pressure application of at least 3 seconds. There continue to be issues with eliciting CRT from the peripheries in neonates (2).In the current article ,the authors have rightly suggested a uniform practice for assessing CRT though it wasn't in the purview of their study.
(ii) There have been various studies questioning the utility of CRT .Even the APLS manual suggests use of caution in interpreting CRT as a standalone measure of shock. Another recent article suggests poor inter- rater reliability and poor correlation with cardiac output in non-acutely ill children (3).The confusion with respect to studies on CRT perhaps stems from the lack of a simple gold standard for assessing perfusion status of the tissues. It could be the pulse pressure, skin temperature gradient, central venous oxygen saturations (ScVO2), lactate , near infra red spectroscopy (NIRS) etc or a mixture of such variables. It is also important to remember that in an attempt to perfuse the vital organs in shock , the blood is usually diverted from the skin and hence the delay in CRT is supposed to reflect the degree of shock. As pointed out by Carcillo JA in an excellent editorial(4) ,there are numerous studies supporting the use of CRT and hence it is a useful tool for evaluation of the hemodynamic status in children.
The authors of this current study have carried out both sternal and finger tip CRT in normal children and found that there was a poor correlation between the two. Another interesting finding was that the finger tip CRT was faster than the sternal CRT.This finding is rather strange and seems difficult to fit in despite the complex and intricate relationship between arteriolar resistance, venular resistance, viscosity, microvessel patency, polycythemia etc involved in the capillary refill. It was also premature on part of the authors to consider resuscitation council(RC) to re-evaluate their recommendations on CRT.
It is important for us to ensure that the CRT is carried out with some uniform method by all child care providers and that studies on CRT should consider assessing its utility against a set of surrogate variables of perfusion in the normal and sick children. One must be aware of the limitations of CRT and analyse it in conjunction with the other markers of hemodynamic status. A normal CRT in a sick child except perhaps in warm shock has a good negative predictive value. One could consider inventing a simple device akin to a ball point pen with a stopwatch which delivers a standard pressure for appropriate time on the skin surface so as to make the process of eliciting CRT more uniform. It would be even better if the refill measurement could be digitized to avoid any subjective error. Irrespective of the technique used, a resource limited country is likely to use only clinical signs or low cost devices for assessment of perfusion in sick children with shock.
1. Pandey A,John BM.Capillary refill time:Is it time to fill the gaps.Medical Journal Armed Forces India 2013;69:97-98.
2. Gale C.Is capillary refill time a useful marker of hemodynamic status in neonates? Arch Dis Child 2010; 95:395-397
3. Lobos A,Lee S,Menon K. Capillary refill time and cardiac output in children undergoing cardiac catheterization. Pediatr Crit Care Med 2012; 13:136 -140
4. Carcillo JA. Capillary refill time is a very useful clinical sign in early recognition and treatment of very sick children. Editorial on Pediatr Crit Care Med 2012; 13:136 -140
Conflict of Interest:
Should we use linear splines to model complex growth processes?
Fairley et al(1) describe differences in growth between White and Pakistani infants in the BiB study using mixed effects linear splines, an approach becoming popular in the analysis of serial anthropometry. Linear splines were used because they summarize noisy data in meaningful parameters: an intercept and linear slope terms (connected by knots) governing different age sections. Adding an exposure obtained estimates of differences between ethnicities in size at the intercept and in rate of change for each age section. Linear splines are an appealing analytical choice, but their biological and statistical limitations are often overlooked.
Growth follows a complex pattern of age related change and linear splines (by their very nature) have limited ability to describe this process. A traditional structural growth model (e.g., Berkey-Reed 1st order(2)) may be a better choice to "describe the growth pattern". Careful selection of knots might have improved matters (e.g., given neonatal weight loss, a knot at age two weeks would make sense). Instead, knots developed in the ALSPAC study were used, thereby assuming that the growth process was the same for BiB infants (with different defining characteristics) compared to ALSPAC infants. Further, when investigating the effects of an exposure on growth, does it make sense to impose the same inflection points (i.e., knots) on each response of that exposure? A major assumption of the mixed effects linear splines used by Fairley et al(1) was that all individuals shared the same inflection points. Applying conventional regression to hierarchical data produces incorrect standard errors(3) and linear spline specification that does not account for between individual variation may have similar consequences.
Methods in other disciplines(4) have extended the flexibility of linear splines to incorporate individual level inflection points at knots that do not need to be specified a priori, but instead are data driven. A promising avenue of research is to extend mixed effects linear splines for growth modelling to include individual level inflection points; this could be done in existing Bayesian modelling framework software(5).
1. Fairley L, Petherick ES, Howe LD, Tilling K, Cameron N, Lawlor DA, et al. Describing differences in weight and length growth trajectories between white and Pakistani infants in the UK: analysis of the Born in Bradford birth cohort study using multilevel linear spline models. Archives of Disease in Childhood 2013;98:274-9. 2. Berkey CS, Reed RB. A model for describing normal and abnormal growth in early childhood. Human Biology 1987;59:973-87. 3. Goldstein H. Efficient statistical modelling of longitudinal data. Annals of Human Biology 1986;13:129-41. 4. van den Hout A, Muniz-Terrera G, Matthews FE. Change point models for cognitive tests using semi-parametric maximum likelihood. Computational Statistics & Data Analysis 2013;57:684-98. 5. Lunn DJT, A. Best, N. Spiegelhalter, D. WinBUGS - a Bayesian modelling framework: concepts, structure, and extensibility. Statistics and Computing 2000;10:325-37.
Conflict of Interest:
Issues relating to basilar artery strokes in children
The timely commentary on basilar artery stroke(1) serves as an opportunity to highlight the importance of a high index of suspicion for posterior circulation transient neurological episodes(TNAs)(2), especially in the presence of risk factors for vertebral artery dissection(3). It is also a reminder of the underuse of magnetic resonance imaging(utilised in only 44.3% of 97 children in one review)(4), notwithstanding the fact that it is the modality of choice for distinguishing between transient ischaemic attack(including TNAs) and iscahemic stroke, the distinguishing characteristic of the latter being its assocation with infarction of brain tissue(5). The recognition of the diagnostic and prognostic import of TNAs leaves considerable room for improvement, not only in adults(2), but also in children(4).In the former age group one study reported that 45 out of 275 patients(ie 16%) with brainstem strokes had experienced antecedent TNAs, and that only ten of those patients with TNAs had sought medical attention at the time. More to the point, a vascular cause was suspected by the doctor in only one of those cases(2). Given the higher prevalence of brainstem TNAs among children(43% of 97 patients with eventual basilar artery strokes in one study)(4), even greater use should be made of MRI to establish the distinction between TNA and brainstem stroke. The index of suspicion for attributing brainstem TNA to vertebral artery dissection should also be high if there is an antecedent history of trauma to the neck or head region, as was the case in 50% of 68 childhood instances of vertebral artery dissection reviewed in one publication(3).Although MRI does establish the distinction between TNA and stroke within the therapeutic time window for thrombolysis it is still uncertain whether or not children with stroke should receive thrombolytic therapy(6)(7). Good outcomes were reported in 24 children with basilar artery stroke who did not receive thrombolysis(6), and it has been argued that the benefit vs risk profile of thrombolysis(for basilar artery occlusion) might be different in children as opposed to adults(7). Nevertheless, in one review, 17 of the 97 children with basilar strokes received thrombolysis. One criticism that has been levelled is that, in the rare event of administration of thrombolytic therapy to children to with stroke, dose regimens vary widely, and treatment is often given outside the time intervals recommended for adults(8). These observations reinforce the view that clinical trials to evaluate dose and safety of thrombolytic therapy are needed in childhood stroke(8). References
(1) Archivist Basilar artery stroke Arch Dis Child 2013;98:334 (2)Paul N., Simani M., Rothwell PM Transient isolated brainstem symptoms preceding posterior circulation stroke; a population-based study Lancet Neurology 2013;12:65-71 (3) Hasan I., Wapnick S., Tenner MS.,Couldwell WT Vertebral artery dissection in children: A compreshensive review Pediatric Neurosurgery 2002;37:168-177 (4)Simonetti BG., Ritter B., Gautschi M et al Basilar artery stroke in childhood Developmental Medicine and Child Neurology 2013;55:65-70 (5)Easton JD., Saver JL., Albers GW et al Definition and evaluation of transient ischemic attack. A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Council; Council on Cradiovascular surgery and anesthesia;Council on cardiovascular radiology and intervention;Council on cardiovascular nursing; and Interdisciplinary council on peripheral vascular disease Stroke 2009;40:2276-2293 (6)Langman-Bartolome M., Pontigon A-M., Moharir M et al Basilar artery strokes in children: good outcomes with conservative medical treatment Develomental Medicine doi: 10.1111/dmen.12092 (7)Deveber G Childhood basilar artery thrombosis: reassuring outcomes in younger patients Developmental Medicine and Child Neurology 2013;55:7-14 (8) Amlie-Lefond C., deVeber G., Chan AK Use of alteplase in childhood artrial ischaemic stroke; a multicentre observational cohort study Lancet 2009;8:530-536
Conflict of Interest:
To the editor of Archives of Disease in Childhood.
I read the article by Nick J Shaw, M Zulf Mughal. Arch Dis Child 2013; 98: 368-372 with great interest and I would like to comment on some items of the summary which I quote: "Factors responsible for worldwide resurgence of rickets among infants and adolescents are complex and include: residence in northern or southern latitudes, voluntary avoidance of exposure to solar ultraviolet B (UVB) radiation,..."
I wonder if
1. Are these factors responsible for or associated with?
2. If residence in "northern or southern latitudes" is "responsible for worldwide resurgence of rickets" Equator would be the best latitude to reside?
3. Is Involuntary avoidance not a risk? "82% of infants living in the Arab Emirates had rickets" .... J Pediatr 2003;142:169-73
In the summary the word supplement is found thrice but never the word sunlight, when sun is all we need.
Conflict of Interest:
Re:What about Pere'z Reflex.
We appreciate the interest shown and the comments on our article by Dr. Carlos Loeda.
Bladder stimulation techniques and some primitive reflexes of the newborn,(1,2) may favor the onset of urination. There are few reports on its application in the collection of urine, and results are very heterogeneous.(3,4) Stimulation maneuvers such bladder percussion are long known, and are used routinely in neurogenic bladder.(5)
As stated by Dr. Loeda, J. Boehm et al described in 1966 that they applied Perez reflex for collection of urine samples in 55 newborns. Perez reflex consists on the normal response of an infant when held in a prone position and pressed with a finger along the spine from the sacrum to the neck. The response is described as crying, flexion of the limbs and head elevation and pelvis. It can also trigger urination and defecation. Boehm did not describe any standardized technique, but used the voiding associated to reflex to collect urine. In the paper, there is no report of time to sample collection or success rate.
The main contribution of our study is to design a technique based on a protocolized sequence of fluid intake, use of percussion manoeuvres bladder and lumbar massage. The three points are relevant. Steps and time spent on every step are defined to facilitate reproducibility. We reflected the success rate (86%) and the average time until sample collection (57 seconds). We believe that our group has gone a step further by creating a sequence simple, fast, effective and reproducible. It is associated with a high degree of acceptance by parents and health professionals.
Its utility has been recognized by dozens of compliments we have received from pediatricians from all around the world. We would like to take this opportunity to show our gratitude to all.
1. Carbonell JM, Perez del Pulgar Marx J. Contribucion al estudio de los reflejos del recien nacido y prematuro: complejo por friccion digital vertebral. Rev Espan Pediat 1955;11:317.
2. Vollmer H. A new reflex in Young infants. Amer J Dis Child 1958; 95:481.
3. Davies P, Creenwood R, Benger J. Randomised trial of a vibrating bladder stimulator the time to pee study. Arch Dis Child 2008;93:423-4.
4. Morris B, Vince JD, Ripa P, Tefuarani N. The clean cath technique for urine collection in infants and young children. Trop Doct 2007;37(2):125.
5. Prasad RS, Smith SJ, Wright H. Lower abdominal pressure versus external bladder stimulation to aid bladder emptying in multiple sclerosis: a randomized controlled study. Clin Rehabil 2003;17:42-7.
Conflict of Interest:
Protracted bacterial bronchitis in a reference center
I have read with high interest the article Craven and Everard(1) about protracted bacterial bronchitis (PBB) and the necessity in the better recognized of this disease. In our service of Pediatric Allergy and Immunology we receive patients with persistent cough daily. Sometimes is very difficult to differentiate PBB from asthma, due to the similarity of symptoms and to numerous of these patients have personal and familiar allergic antecedents. Because these considerations all children that look for our unit with a history six weeks cough or more associate with "wet" characteristic, without free days of cough, and the cough that worse just after lying down in bed and first thing in the morning, before perform any lab investigation, receive orientations around PBB and the difficulties in perform the fibreoptic bronchoscopy with bronchoalveolar lavage, that's necessary for a definitive diagnosis. After that we suggest the use of azythromycin 12mg/kg per 7 days(2). I do not have the exact data around our routine but I really believe that this procedure treating PBB reduce the number of patients that starts asthma treatment to try to control the persistent cough.
Reference 1.Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013;98(1):72-6.
2.Mulholland S, Gavranich JB, Gillies MB, Chang AB. Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children. Cochrane Database Syst Rev. 2012;9:CD004875. doi:10.1002/14651858.
Conflict of Interest:
What about Pere'z Reflex.
This article describes what seems to be a very useful method for infant's urine clean catch. But the procedure is not entirely original. In 1966 Boehm and Haynes had proposed a similar method for eliciting reflex urination in infants ("Midstream Catch" Urines Studies in Newborn Infants JOHN J. BOEHM, MD; JAMES L. HAYNES, AB Am J Dis Child. 1966;111(4):366-369). In that paper, the lumbar area stimulation was slightly different, as trying to get a "lower" Perez's reflex.
Carlos Loeda MD Staff Pediatritian HGU Alicante Spain
Conflict of Interest:
inspection of the rib cage should have been the first strategy
Given the fact that "a large swelling was[still] present after aspiration"(1), how is it that the swelling was not evident on clinical examination during the period(amounting to 1 month) when the patient was diagnosed as having a lower respiratory tract infection? The reason, I suspect, is that it is no longer routine practice to inspect the rib cage(ie the chest) for asymmetry, localised swellings, and diminished movement when a patient presents with respiratory symptoms. A "snapshot" of what now passes for routine practice is represented by the photograph of a patient being examined for suspected community acquired pneumonia on page 60 of the BMJ article entitled "Community-acquired pneumonia management: new guidelines"(2). Ironically, without stressing the importance of inspecting the rib cage to rule out mimics of pneumonia(such as hepatic abscess), the caption to the photograph goes on the read"establishing whether the patient has pneumonia and identifying the pathogen are key factors"(2). A photograph of a child having her chest examined whilst she had her top garments on appeared in a later issue of the same journal with the caption"respiratory rate for diagnosing serious infection", and, again, the irony was lost on the authors that examination of the chest cannot be complete if the patient has not stripped to the waist. What I fear is that in this high-tech age clinical standards have slipped, with the consequence that misdiagnosis of serous diseases, exemplified by hepatic abscess(1), will become more commonplace. References (1) Hegarty RM., Sanka S., Bansal S Hepatic abscess presenting in a previously healthy teenager Arch Dis Child 2013;98:145 (2) Mandell L Community-acquired pneumonia BMJ 2010;341:59-60
Conflict of Interest: