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Recent eLetters

Displaying 1-10 letters out of 1428 published

  1. Re: Apple juice for rehydration.

    I am grateful to Prof Weizman for his response to my Archivist article. Like him, I was concerned that the saccharide content and high osmolality of apple juice might make diarrhoea worse, not better. However, the authors of this article did not find this. It is possible that their surveillance for this adverse effect was inadequate but this cannot be deduced from the article. Archivist can only convey what authors report: readers must make up their own minds whether or not to act on any paper's findings.

    Dr Robert Scott-Jupp

    Associate Editor, Lucina and Archivist

    Conflict of Interest:

    None declared

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  2. The challenges of communication to address Moral Distress

    We thank Dr Kraemer for his constructive response and commend his initiative to facilitate weekly staff meetings within neonatal intensive care units. We concur that communication is an essential component of addressing not only moral distress but improving workplace culture.

    As Dr Kraemer notes, finding the best forum for such discussions continues to be challenging. In our various institutions we continue to struggle to address a range of questions about when and how to communicate in ways that will be genuinely helpful. Some questions are about the nature of the discussion, such as: Do such meetings only really cater for those who are most vocal, or who have the ability to articulate their concerns? (And if so, what approaches will help those who struggle to be heard?) How do we bring the honesty and transparency of 'tea room' discussions to these more formal clinical meetings?

    Some questions are practical: How can such meetings meet the needs of both day and night time healthcare professionals? When the facilitator is the clinical lead, who will support and care for him/her as he/she seeks to support and highlight all other voices in the matter?

    Other questions are about attitudes and values: How do we turn the attitude that such discussions "don't change anything", into positive responses that both advance medicine and serve the patients and their families? At times our efforts to build trust, communicate openly and to walk a line of integrity still seem to fall short of what is needed or expected to maintain morale and a safe workplace environment.

    It is our hope that our current longitudinal study into moral distress will highlight the key time points where further interventions and debriefing meetings will be most effective in addressing healthcare professionals' valid concerns while providing a unified team that is equipped to care for the best interests of the patient and the family, no matter how challenging that may be.

    Conflict of Interest:

    None declared

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  3. Re:Hypercalcaemia and neonatal sepsis

    The purpose of our study was to document the prevalence of hypercalcaemia in children and its possible associations and we agree with the correspondent that it would be helpful to confirm these associations, such as the one highlighted for sepsis, thorough more detailed and rigorous studies.

    Conflict of Interest:

    None declared

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  4. Apple juice for rehydration.

    I read with great interest the Archivist regarding Apple juice for rehydration. It summarizes a recent study from Toronto, Canada set out to see whether dilute apple juice was as good as standard electrolyte maintenance solution for rehydration (Freedman S, et al. JAMA 2016;doi:10.1001/jama.2016.5352). They conclude that the use of half- strength apple juice may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration. The Archivist recommends to use this mode of rehydration in developed countries.

    In my opinion the authors failed to fully delineate the dangers of using fruit juice as rehydration fluid, even when diluted. Fruit juices, such as apple juice, contain usually fructose, glucose, sucrose and sometimes sorbitol, and their osmolality might reach occasionally a level of 1,070 Osm/Kg H2O. Decreased carbohydrate absorption occurs more often after ingestion of juices that contain more sorbitol, a non-absorbable sugar, and higher concentrations of fructose over glucose than after ingestion of juices which lack sorbitol and contain equal amounts of glucose and fructose. Moreover, other factors in apple juice, probably complex carbohydrates originating from the fruit skin, seem to be capable of provoking osmotic diarrhea (Hyams JS, et al. Carbohydrate malabsorption following fruit juice ingestion in young children. Pediatrics 1988;82:64- 8). Therefore, suggestions to use fruit juices as an alternative to oral rehydration solutions, even when diluted half-strength, as advised in the present study, should be accompanied by additional warnings. Recommendations to take precautions are especially relevant for very young children and infants, as efficiency of these carbohydrates absorption increases with age (Nobigrot T,et al. Carbohydrate absorption from one serving of fruit juice in young children: age and carbohydrate composition effects. J Am Coll Nutr 1997;16:152-8).

    Conflict of Interest:

    None declared

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  5. Bruising in children with bleeding disorders - Limitations

    Dear Sir,

    We would like to congratulate the authors of this excellent observational study. For paediatricians, and for medico-legal professionals, data from this study would be invaluable in their practice.

    While the authors have discussed most of the limitations of their study, we would like to point out a few more which have come to our notice.

    1) Controls were recruited only from South Wales, while cases were multi-centre. This could give rise to inter-centre variability, which needs to be looked at and accounted for.

    2) Validation of training of carers was done on children with non- bleeding disorders only. This should have been attempted on children with bleeding disorders as well, as their reporting form the basis of this study.

    3) While sexes were balanced in children with non-bleeding disorders, children with bleeding disorders were dominated by males. Differences in type or duration of activity could be a confounding factor in comparing these groups. While this is difficult to correct without introducing further bias, this needs to be considered as a factor for adjustment in models, if possible.

    Yours sincerely,

    Mallinath Chakraborty Ian Paul Morris

    Conflict of Interest:

    None declared

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  6. reflective staff meetings include attention to moral distress

    The findings of this important paper should be used to promote regular staff development meetings in neonatal intensive care units. In my experience the reason these are not more widespread is lack of availability of suitably qualified staff to facilitate such groups. Clinicians may ask for support then find the meetings disappointing.

    Over many years in a district general hospital neonatal unit a colleague and I found that staff would attend our weekly work discussions because they knew and worked with us at other times; we were their colleagues. This reduced quite understandable resistance to 'mental health' that can put people off an invitation to reflect on ethical, emotional and practical aspects of their daily work. Caring for tiny, sick and helpless human beings and their shell-shocked parents is stressful (Fischer et al 2000) and disturbing (Cohen 2003). Like soldiers at the front line, staff often manage these strains heroically - not necessarily good for morale (Braithwaite 2008). Where senior managers can support work discussion by themselves attending and expecting staff to join them, a change of culture is possible in which thinking about difficult and apparently unresolvable questions is worthwhile. Though not widely used in medical settings staff groups are a part of the weekly timetable in many helping professions and follow a flexible tradition of curiosity and reflection (Hartley & Kennard 2009). There are of course fundamental ethical questions about the consequences of ever-progressing technical advances in neonatal medicine, but also expectable tensions between staff and parents and between staff themselves, aggravated by the harsh political climate that so often prevails in expensive health services. It is not all deeply serious. Provided there is good enough basic trust in the unit, clinicians who work closely together can laugh at the irony of it all, often leading to important points that might otherwise have been missed. And there are satisfactions as well as gripes to be aired.

    Work discussion goes against the grain of protocol-driven health services. It is potentially subversive in that staff may become more aware of how undermining their working environment is. Besides the more familiar "we are far too busy for that sort of thing" and "it doesn't change anything anyway" there are many seemingly good reasons for not having meetings with no agenda or agreed outcome (Kraemer 2015), yet with courage, foresight and skill there are even better ones for doing so.

    Fischer JE, Calame A, Dettling AC, Zeier H, Fanconi S. (2000) Experience and endocrine stress responses in neonatal and pediatric critical care nurses and physicians. Crit Care Med. 28(9):3281-8.

    Cohen, M. (2003) Sent Before My Time: A Child Psychotherapist's View of Life on a Neonatal Intensive Care Unit. London: Karnac.

    Braithwaite M.(2008) Nurse burnout and stress in the NICU. Adv Neonatal Care. 8(6):343-7.

    Hartley, P. & Kennard, D. (2009). Staff Support Groups in the Helping Professions. London: Routledge

    Kraemer, S. (2015) Anxiety at the front line. In D. Armstrong & M. Rustin (Eds.) Social Defences against Anxiety: Explorations in a Paradigm. London: Karnac http://bit.ly/29FH7zg

    Conflict of Interest:

    None declared

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  7. Re:Fowl Language - a role in paediatric advocacy

    We thank Dr Williams and Mrs Scudamore for their letter. We entirely agree with the comments made and congratulate them on giving a voice to Rosie and other children and their families. We endorse the approach taken that makes children and young people central to any advocacy efforts. As we describe, and is mentioned in article 12 of the UNCRC, the first step is to listen to and engage with the children and young people themselves and developing stories, such as 'Fowl language', is a wonderful example of this. One of us (TW) has a particular interest in giving a voice to children and young people and we offer two further examples to add to the superb writing of Rosie. The first is, we believe, the first article to appear in the Archives of Disease in Childhood on child rights practice in which a young person added a commentary (Waterston T, Mann N. Child rights. Arch Dis Child 2005; 90: 171 http://adc.bmj.com/content/90/2/178.full.pdf). The second example is a publication by a group of young people in Newcastle in 1997 who carried out qualitative research among school children on health in the school setting, looking both at problems and solutions. The work was published locally under the title 'School can seriously damage your health' and was presented at an educational conference. Many other examples can be found around the country and we encourage readers both to listen to their child patients and to work with young people on making our health services more child focused.

    Delan Devakumar, Nick Spencer, Tony Waterston

    Conflict of Interest:

    None declared

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  8. Hypercalcaemia and neonatal sepsis

    Dear Sir,

    McNeilly et al. (1) recently reported the results of their 5 year retrospective study detailing frequency and aetiology of hypercalcaemia in children (defined as total calcium >2.90mmol/l). Of those with sustained hypercalcaemia (elevated levels for >2 consecutive days), neonates were over-represented (42%), and suspected sepsis was the single most common cause (24%). The authors hypothesis regarding possible mechanisms for this phenomenon included extrarenal production of 1,25(OH)2D by infiltrating macrophages (2), and release of cytokines such as interleukin 6 increasing osteoclastic activity, thus bone resorption and calcium release (3).

    It is unfortunate the authors did not clarify how many of the suspected sepsis cases were confirmed (4), if indeed this data was available to them. This is because neonatal hypercalcaemia can produce signs which mimic the stereotypical behaviour of a septic infant (5). Lack of this data limits the utility of this finding in clinical practice - if a neonate is incidentally found to be hypercalcaemic should the clinician be vigilant regarding sepsis, or even commence antibiotics? Conversely, if a neonate presents in a septic fashion, but is found to be hypercalcaemic with normal inflammatory markers, should the clinician be reassured?

    Given the difficulty in differentiating sepsis from non-infective causes of poor handling in neonates; these findings suggest hypercalcaemia may have potential as another biochemical tool to be used in conjunction with clinical judgment (6).

    References

    1. McNeilly JD, Boal R, Shaikh MG, Ahmed SF. Frequency and aetiology of hypercalcaemia. Arch Dis Child. 2016;101:344-7 doi: 10.1136/archdischild-2015-309029 archdischild-2015-309029 [pii] [published Online First: 2016/02/24]. 2. Lietman SA, Germain-Lee EL, Levine MA. Hypercalcemia in children and adolescents. Curr Opin Pediatr. 2010;22:508-15 doi: 10.1097/MOP.0b013e32833b7c23 [published Online First: 2010/07/06]. 3. Davies JH, Shaw NJ. Investigation and management of hypercalcaemia in children. Arch Dis Child. 2012;97:533-8 doi: 10.1136/archdischild-2011- 301284 archdischild-2011-301284 [pii] [published Online First: 2012/03/27]. 4. Wynn JL, Wong HR, Shanley TP, Bizzarro MJ, Saiman L, Polin RA. Time for a neonatal-specific consensus definition for sepsis. Pediatr Crit Care Med. 2014;15:523-8 doi: 10.1097/PCC.0000000000000157 [published Online First: 2014/04/23]. 5. Rodd C, Goodyer P. Hypercalcemia of the newborn: etiology, evaluation, and management. Pediatr Nephrol. 1999;13:542-7 doi: 10.1007/s004670050654 [published Online First: 1999/08/19]. 6. Ismail AQ, Gandhi A. Using CRP in neonatal practice. J Matern Fetal Neonatal Med. 2015;28:3-6 doi: 10.3109/14767058.2014.885499 [published Online First: 2014/01/21].

    Conflict of Interest:

    None declared

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  9. Fowl Language - a role in paediatric advocacy

    Any paediatrician would welcome this necessary article, which should already be a benchmark of our routine daily practice. However I wondered if it missed an opportunity on advocacy having a role in making the childrens' own voices being heard. One such example is the recently published RCPCH Research Charter [1]. We as paediatricians can bring influence to create opportunities for your patients and their siblings and thereby give children a voice. Another such example is creation of films, such as 'The First Day' which give credited roles for children with specials needs both in front of and behind the camera [2].

    Another means is the creation of stories for individual children and I give one such example. Rosie has Goldenhaar's syndrome, and is deaf, mute, has a tracheostomy and gastrostomy. Yet in spite of this she is beautiful, bright, kind and fearless. 'Fowl Language the adventures of Rosie and her 3 Legged Chicken Friend' is the first of a series of short stories about Rosie and a signing 3 legged chicken who communicate through 'Fowl Language' a version of British Sign Language.. The stories thus become a shared journey between a child and an animal, both of whom have complex disabilities and special needs. They take wing in hand and together, learn about friendship, problem solving and understanding the world [3].

    These are thus other important means by and through which we as paediatricians can advocate for children not only in the UK but abroad.

    References

    1) http://www.rcpch.ac.uk/cyp-research-charter accessed July 15th 2016

    2) https://www.youtube.com/watch?v=sZ0dWFcGONU accessed July 15th 2016

    3) http://kidshealth.wix.com/rosieandchicken accessed July 15th 2016

    Conflict of Interest:

    Mrs Nicola Scudamore is Rosie's mother

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  10. Re: Non-specific abdominal pain and appendicitis, an unespected correlation

    Dear Editor,

    We thank Dr Di Mascio and his colleagues for their interest in our study. In response we would like to point out that only a very small proportion (5.8%) of the children admitted with NSAP were subsequently hospitalised with bowel pathology (1). The increased relative risk of being diagnosed with appendicitis in the first year following a diagnosis of NSAP is clearly notable.

    Further analysis of the data shows that, considering "acute and unspecified appendicitis" (ICD10 K35 & K37) and "other appendicitis" (K36) together, of the 268 623 NSAP cohort 6274 (2%) children were admitted with appendicitis within the first year after their NSAP admission. We excluded cases where appendicitis occurred on the same admission record as the code for NSAP because this was a follow-up study based on person-days at risk. Of the 6274 children who were admitted with appendicitis within the first year following an admission with NSAP, 1926 (31% of the 6274) experienced the appendicitis admission within 1-3 days and 2505 (40%) experienced the appendicitis admission within 1-7 days of the admission with NSAP. This leaves an excess number of children who do get admitted with appendicitis some considerable time after the initial admission with NSAP, as the rate ratio remained significantly high even after 10 years (1). The small single centre study, described by Dr Di Mascio and colleagues, with just a short period of time studied between NSAP and appendicitis, is not comparable with our huge cohort constructed from linked English national hospital episode statistics with substantial follow-up.

    It is not known what pre-disposes individuals and protects others from developing acute appendicitis. One can perhaps hypothesise that a number of these children who were unwell enough to be admitted with NSAP have appendicular colic as the cause of their pain and may have some predisposition such as the luminal size or anatomical site of of their appendicular orifice which may subsequently lead to clinical appendicitis.

    Kind regards

    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

    Conflict of Interest:

    None declared

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