Displaying 1-10 letters out of 1369 published
Is there really any good evidence that rickets is associated with prolonged breast feeding?
I enjoyed this review article and found it helpful to allow me to understand how both vitamin D and calcium deficiency could both produce the same clinical picture. However I was saddened to again see it asserted that a risk factor for vitamin D defiency rickets is "prolonged breast-feeding". There is no doubt that there have been many case series showing that children presenting with rickets are predominantly breastfed. I expect that all the children had arms and legs, but that is not given as a risk factor. Breast feeding is the normal physiological state and around 80% of UK children are now at least initially breast fed. These case series also show that the majority of cases are found in dark skinned mothers who are generally much more likely to breast feed and who, if investigated, are commonly themselves vitamin D deficient (1,2). In my personal experience children presenting with rickets have also had highly limited diets. Few case reports refer to dietary intake, but one that did, found that solid feeding in cases was both delayed and inadequate(3). WHO recommend continuing to feed for at least 12 months, so when does breast feeding become prolonged? I suspect that what authors mean is that the children are subsisting largely or solely on breast milk beyond the age of 6 months, when complimentary solids are needed. Although we all pay lip service to the importance of breast feeding, it remains always under threat from the combined forces of convention - services that are not yet used to the idea of breast feeding - and commercial influences. It is of note that Danone, a major manufacturer of formula milk have been actively promoting the issue of vitamin D (see http://www.theguardian.com/healthcare-network/2014/apr/02/action-needed-on -vitamin-d). It seems clear that they at least understand that regularly linking rickets to breast feeding will increase their sales of formula milk. 1.Agarwal N, Faridi MM, Aggarwal A, Singh O. Vitamin D Status of term exclusively breastfed infants and their mothers from India. Acta Paediatr. 2010;99(11):1671-1674. 2.Madar AA, Stene LC, Meyer HE. Vitamin D status among immigrant mothers from Pakistan, Turkey and Somalia and their infants attending child health clinics in Norway. Br J Nutr. 2009;101(7):1052-1058. 3.Majid Molla A, Badawi MH, al-Yaish S, Sharma P, el-Salam RS, Molla AM. Risk factors for nutritional rickets among children in Kuwait. Pediatrics international : official journal of the Japan Pediatric Society. 2000;42(3):280-284.
Conflict of Interest:
I take great pains to avoid any sponsorship or involvement with manufacturers of formula milk, but find it hard to completely escape their long reach.
Next generation sequencing should be the first line of investigation in non syndromic deafness in people of African descent
In response to Parker and Bitner-Glindzicz's review article on Genetic investigations in childhood deafness,1 we will like to contribute to this topic with some data, that strongly question the clinical utility of GJB2 and GJB6 testing in non-syndromic hearing loss in people of African descent.
Indeed, we investigated GJB2 genes in 205 patients affected with sensorineural non-syndromic hearing loss from Cameroonian2 and South African of Xhosa ancestry.3 Subsequently, 100 patients that do not presented any mutation in GJB2 gene, were further investigated for mutation in GJB6.3 In addition to the Sanger sequencing of the coding regions of GJB2 and GJB6,3,4 detection of the most frequent deletion in European and Asian patients, del(GJB6-D13S1830), was also investigated.4
We did not found in the GJB2 gene, pathogenic variants that could explain the hearing loss in any of the 205 patients from Cameroon and South Africa.3 When comparing control Cameroonian and South African GJB2 sequences data with those extracted from the 1000 Genomes Project, there was a low level of variance amongst population groups,3 supporting the hypothesis that the prevalence of mutations in GJB2 amongst European and Asian populations affected by non-syndromic hearing loss, is due to a founder effects,5 arising after their migration out of Africa. Interestingly, in syndromic hearing loss involving GJB2 gene, the nature and frequency of mutations are likely not to be population specific; we reported in two unrelated Cameroonian individuals affected with sporadic Keratitis-Ichthyosis-Deafness (KID) syndrome, heterozygous p.Asp50Asn mutation in GJB2, in both cases;6 p.Asp50As is the most frequent mutation in KID syndrome in various World populations. The low frequency of mutation in GJB2 in non-syndromic hearing loss has been also reported in patients from Soudan and Kenya,7 Nigeria,8 in other group of South African of African descent,9 and other group of Cameroonian patients.10 The exception to this low prevalence of GJB2 mutations in African patients with non-syndromic deafness, is a specific mutation, p.R143W (c.427C>T), occurring at a high rate in the Ghanaian population from Adamarobe village.11 This could be also attributed to a founder effect, since p.R143W (c.427C>T) has not been reported in other sub-Saharan Africans, but in few African Americans,12 whose ancestors were probably brought from Ghana during the slave trade.
The study have shown that, there was no coding region variation in GJB6 associated with non-syndromic deafness among Cameroonian and Xhosa South African patients, nor GJB6-D13S1830 deletion.4 Equally, no GJB6- D13S1830 deletion was reported in patients with non-syndromic hearing loss in Nigeria,8 in another group of patients from South Africa,9 nor in African Americans and Caribbean.12
In summary, available data do not provide enough evidence to routinely investigate GJB2 and GJB6 in clinical practice in patients of sub-Saharan African ancestry with non-syndromic hearing loss. Massively parallel sequencing should be the best approach forward, and possibly the fist line of investigation to uncover the genetic aetiology of non- syndromic hearing loss among people of African descent.
Acknowledgements The research was funded by the University of Yaounde for clinical phenotyping and DNA extraction and the National Health Laboratory Services (NHLS), South Africa for recruitment of South African samples and molecular analysis.
Reference 1.Parker M, Bitner-Glindzicz M. Genetic investigations in childhood deafness. Arch Dis Child 2014, doi: 10.1136/archdischild-2014-306099. [Epub ahead of print] 2.Wonkam A, Noubiap JJ, Djomou F, Fieggen K, Njock R, Toure GB. Aetiology of childhood hearing loss in Cameroon (sub-Saharan Africa). Eur J Med Genet 2013;56:20-5. 3.Bosch J, Noubiap JJ, Dandara C, et al.Sequencing of GJB2 in Cameroonians and Black South Africans and comparison to 1000 Genomes Project Data Support Need to Revise Strategy for Discovery of Nonsyndromic Deafness Genes in Africans. OMICS. 2014 Aug 27. [Epub ahead of print] 4.Bosch J, Lebeko K, Nziale JJ, Dandara C, Makubalo N, Wonkam A. In search of genetic markers for nonsyndromic deafness in Africa: a study in Cameroonians and Black South Africans with the GJB6 and GJA1 candidate genes. OMICS 2014;18:481-5. 5.Dzhemileva LU, Barashkov NA, Posukh OL, et al.Carrier frequency of GJB2 gene mutations c.35delG, c.235delC and c.167delT among the populations of Eurasia. J Hum Genet 2010;55:749-54. 6.Wonkam A, Noubiap JJ, Bosch J, Dandara C, Toure GB. Heterozygous p.Asp50Asn mutation in the GJB2 gene in two Cameroonian patients with keratitis-ichthyosis-deafness (KID) syndrome. BMC Med Genet 2013;14:81. 7.Gasmelseed NM, Schmidt M, Magzoub MM, et al. Low frequency of deafness- associated GJB2 variants in Kenya and Sudan and novel GJB2 variants. Hum Mutat 2004;23:206-7. 8.Lasisi AO, Bademci G, Foster J 2nd, Blanton S, Tekin M. Common genes for non-syndromic deafness are uncommon in sub-Saharan Africa: A report from Nigeria. Int J Pediatr Otorhinolaryngol 2014;78:1870-3. 9.Kabahuma RI, Ouyang X, Du LL, Yan D, Hutchin T, Ramsay M, Penn C, Liu XZ. Absence of GJB2 gene mutations, the GJB6 deletion (GJB6-D13S1830) and four common mitochondrial mutations in nonsyndromic genetic hearing loss in a South African population. Int J Pediatr Otorhinolaryngol 2011;75:611- 7. 10.Trotta L, Iacona E, Primignani P, et al.GJB2 and MTRNR1 contributions in children with hearing impairment from Northern Cameroon. Int J Audiol. 2011;50:133-8. 11.Hamelmann C, Amedofu GK, Albrecht K, et al. Pattern of connexin 26 (GJB2) mutations causing sensorineural hearing impairment in Ghana. Hum Mutat 2001;18:84-5. 12.Samanich J, Lowes C, Burk R, et al. Mutations in GJB2, GJB6, and mitochondrial DNA are rare in African American and Caribbean Hispanic individuals with hearing impairment. Am J Med Genet A 2007;143A:830-8.
Conflict of Interest:
Using time and serial measurements to improve diagnostic strategies in febrile children
Response to: 1 Segal I, Ehrlichman M, Urbach J, Bar-Meir M. Use of time from fever onset improves the diagnostic accuracy of C-reactive protein in identifying bacterial infections. Arch Dis Child. Nov 2014;99(11):974-978.
We thank Segal et al. for their work and congratulate them with this interesting paper. The diagnostic value of CRP as reported by Segal et al. is very much in line with earlier work, and in keeping with the cut-off points of <20 mg/L for ruling out serious bacterial infections, and >80 mg/L for ruling in serious bacterial infections that were suggested in the meta-analysis by van den Bruel et al.2 Although the authors stated that time could be a valuable differentiating variable for interpreting the diagnostic value of CRP, their results also showed that duration in itself was not a significant predictor in multivariable analysis. This is similar to results we presented recently, showing no differentiating effect for duration of fever in a general population of febrile children, and in particular that duration of fever was not useful for deciding on using either CRP or procalcitonin (PCT) in the evaluation of febrile children.3 In our opinion the most important message of the study is that the diagnostic value of CRP increased over time. Notably, in this study children without SBI who had an early increase of CRP had early stabilization of CRP at relatively low levels, whereas CRP levels in children with SBI continued to rise and reach higher threshold values. Likewise, we found that the diagnostic value of CRP in children with a fever lasting >24 hours was better than in children with a short duration of fever.3 Others already showed an effect of using serial measurements of biomarkers on the duration of antibiotic prescribing in an outpatient setting.4 As a next step, longitudinal diagnostic strategies in the emergency department should be explored. The findings of Segal et al. support the potential use of serial measurements and of time dependent thresholds of biomarkers such as CRP and PCT at the emergency department. Taken altogether, the current cross-sectional approach of diagnostic research in febrile children may need to be replaced by a more longitudinal approach.
1. Segal I, Ehrlichman M, Urbach J, Bar-Meir M. Use of time from fever onset improves the diagnostic accuracy of C-reactive protein in identifying bacterial infections. Arch Dis Child. Nov 2014;99(11):974-978.
2. Van den Bruel A, Thompson MJ, Haj-Hassan T, et al. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ. 2011;342:d3082.
3. Nijman RG, Moll HA, Smit FJ, et al. C-Reactive Protein, Procalcitonin, and the Lab-Score for Detecting Serious Bacterial Infections in Febrile Children at the Emergency Department: A Prospective Observational Study. Pediatr Infect Dis J. Aug 4 2014.
4. Baer G, Baumann P, Buettcher M, et al. Procalcitonin guidance to reduce antibiotic treatment of lower respiratory tract infection in children and adolescents (ProPAED): a randomized controlled trial. PLoS One. 2013;8(8):e68419.
Conflict of Interest:
Peanut anaphylaxis diagnosis
The peanut allergy (PA) prevalence is about 1-2% in children. PA may account also for severe food allergy, such as anaphylaxis (1). The severity of reactions may depend on the type of allergen component sensitization. In this regard, at least 11 peanut allergen proteins have been identified and characterized. Ara h 1, 2, and 3 are the major peanut allergens and belong to the seed storage proteins family (Ara h 1 is a vicilin, Ara h 2 is a conglutin, Ara h 3 is a glycinin) (2). A very recent review pointed out the diagnostic work-up, underlining the importance of a correct diagnosis (3). We recently reported that comparing 2 groups of children with anaphylaxis to peanut (14 subjects) or peanut allergy (15 ones) a different immunological profile may be defined. Indeed, allergen-specific IgE levels to raw peanut were significantly higher in the anaphylaxis group (p=0.0044). Sensitization to either Ara h 2 or Ara h 3 was more frequently detected in the group of children with anaphylaxis than in those with PA (p = 0.0209 and p = 0.0007, respectively). Raw peanut cut-off > 2.1 kUA/L, Ara h 1 cut-off > 1 ISU, Ara h 2 cut-off > 4.7 ISU, and positivity for Ara h 3 had fair reliability to predict anaphylaxis. Therefore, we concluded that children with peanut anaphylaxis have higher IgE levels to raw peanut, Ara h 2, and Ara h 3 than children with less severe peanut allergy. Thus, molecular-based allergy diagnostics may improve the work-up pathway and provides fruitful information for prognosis and management. We suggest that all children with suspected anaphylactic reaction and possibly in all children with PA molecular diagnostic should be performed to define the allergen molecule profile involved.
References 1) Tariq SM, Stevens M, Matthews S, Ridout S, Twiselton R, Hide DW. Cohort study of peanut and tree nut sensitisation by age of 4 years. BMJ 1996;313:514-7 2) Meyling FHJ, et al. The diagnostic value of specific IgE to Ara h 2 to predict peanut allergy in children is comparable to a validated and updated diagnostic prediction model. J Allergy Clin Immunol 2013;131:157- 63 3) Anagnostou K, Clark A. The management of peanut allergy. Arch Dis Child 2015;100:68-72 4) Ciprandi G, Pistorio A, Silvestri M, Rossi GA, Tosca MA.Peanut anaphylaxis: the usefulness of molecular-base allergy diagnostics. Allergy 2015;70:129-30
Conflict of Interest:
Environmental tobacco smoke and effect on children
Dr Editor, We read with interest the publication by Feleszko Ruszczynski M, Jaworska J et al on the effect of Environmental tobacco smoke exposure and risk of allergic sensitisation in children.
As a trainer and my Paediatric ST3 in the North West deanery we write to thank you for the article referenced above. we found it very interesting read indeed and it has really enhanced the understanding of the risks of environmental tobacco smoke.
It is interesting to note that when assessing patients with asthma and other atopic conditions that parents are reluctant to admit to tobacco smoking, and if they did it is usually "I only smoke outside" or "only when he's gone to bed," and more recently (following recent legislation) "I never smoke in the car." Parents are often informed of the negative effects on their child's health, as well as on their own health. With this information it is important to now start to inform them of recent articles which are providing us with the evidence to support this. we belief that our practice and the best outcome for the patients will continue to be enhanced. We therefore have to thank you for providing this useful information.
Feleszko W, Ruszczynski M, Jaworska J et al. Environmental tobacco smoke exposure and risk of allergic sensitisation in children: a systematic review and meta-analysis Arch dis child Nov 2014: 985-992
Conflict of Interest:
Making the most of measles vaccination
We thank Bustreo, Okwo-Bele, and Kamara for a comprehensive overview of the impressive achievements by the Global Alliance for Vaccines and Immunization on reducing child mortality world wide by providing vaccines. With regard to measles vaccine, the authors note that child mortality in Niger was almost halved from 1998 to 2009, and measles vaccination contributed to this achievement. They refer to a Lives Saved Tool-based estimate of 5% of the lives saved due to measles vaccines. They add that "This impact is in addition to the non-specific effects (vaccines acting independently of other vaccines) of measles vaccination, which when provided with vitamin A or followed by DTP3 vaccination within a specified administration schedule can contribute to further mortality reduction from diseases other than measles".
We agree that the remarkable reductions in child morality can also be attributed to the non-specific effects of measles vaccine - effects, which are not yet incorporated into the cause specific-child survival projections. These non-specific effects of vaccines may indeed be modified by other interventions such as vitamin A and other vaccines. However, we find it important to point out that measles vaccine provided with vitamin A or followed by DTP3 may not be the best combinations.
First, vitamin A seems to enhance NSE of vaccines. However, the effect of measles vaccine provided together with vitamin A on overall mortality has only been the subject of one placebo-controlled randomised trial, and that trial showed that while measles vaccine provided with vitamin A may be very beneficial for females (mortality rate ratio (MMR) 0.45 [95% confidence interval (CI): 0.24-0.87]), it had the opposite effect in males (MMR 1.92 [95% CI: 0.98-3.75], p-value for same effect in females and males = 0.003). Hence, while girls may benefit from the combined treatment, males may be harmed.
Second, with respect to measles vaccination followed by DTP, this sequence has been associated with an increase in overall mortality among girls in spite of the disease-specific effects. In contrast, DTP followed by measles vaccine seems much more beneficial - e.g. in a recent trial, compared with having DTP3 as the most recent vaccination, providing measles vaccination at 4.5 months of age shortly after DTP3 was associated with strong reductions in overall mortality until the children received the usual measles vaccine at nine months of age. The sequence of vaccination has important implications for overall mortality: In a situation with herd immunity to pertussis, available evidence suggest that a policy of not providing DTP after measles vaccine would be associated with a 2-fold reduction in overall mortality for girls compared with situations where measles vaccination was followed by DTP.
Hence, to make the most of the beneficial non-specific effects of measles vaccine, it should be given after DTP3 and it should not be followed by DTP vaccination.
1 Bustreo F, Okwo-Bele J-M, Kamara L. World Health Organization perspectives on the contribution of the Global Alliance for Vaccines and Immunization on reducing child mortality. Arch Dis Child 2015;100 Suppl 1:S34-7. doi:10.1136/archdischild-2013-305693
2 Fox MJ, Martorell R, van den Broek N, et al. Assumptions and methods in the Lives Saved Tool (LiST). Introduction. BMC Public Health 2011;11 Suppl 3:I1. doi:10.1186/1471-2458-11-S3-I1
3 Amouzou A, Habi O, Bensa?d K, et al. Reduction in child mortality in Niger: a Countdown to 2015 country case study. Lancet 2012;380:1169-78. doi:10.1016/S0140-6736(12)61376-2
4 Jensen KJ, Ndure J, Plebanski M, et al. Heterologous and sex differential effects of administering vitamin A supplementation with vaccines. Trans R Soc Trop Med Hyg 2015;109:36-45. doi:10.1093/trstmh/tru184
5 Fisker AB, Bale C, Rodrigues A, et al. High-dose vitamin A with vaccination after 6 months of age: a randomized trial. Pediatrics 2014;134:e739-48. doi:10.1542/peds.2014-0550
6 Aaby P, Benn C, Nielsen J, et al. Testing the hypothesis that diphtheria-tetanus-pertussis vaccine has negative non-specific and sex- differential effects on child survival in high-mortality countries. BMJ Open 2012;2. doi:10.1136/bmjopen-2011-000707
7 Aaby P, Aaby P, Martins CL, et al. Non-specific effects of standard measles vaccine at 4.5 and 9 months of age on childhood mortality: randomised controlled trial. BMJ 2010;341:c6495.
Conflict of Interest:
Use of Carbamazepine in the Treatment of Childhood Rolandic Epilepsy
Authors Maria Moran1, Nikolina Docheva2, William Whitehouse 1,2 1. Nottingham Children's Hospital, 2. University of Nottingham
We were interested to read the article by Mellish et al.(1) which reports preference for carbamazepine first line for UK paediatricians treating Benign Rolandic Epilepsy (also known as Benign Epilepsy with Centrotemporal Spikes), perhaps better called Childhood Rolandic Epilepsy (CRE), an archetypal Genetic Focal Epilepsy (GFE). As described in their article, and in NICE guidance, carbamazepine may worsen seizures in a significant minority of children with CRE which perhaps makes it a questionable first-line choice. We have had local experience of a few cases evolving into Atypical Benign Partial Epilepsy of Childhood (ABPEC or pseudo-Lennox syndrome) temporarily while on carbamazepine.
A systematic literature search revealed case reports describing onset of new atonic/absence seizures and continuous spike and wave discharges in sleep on EEG (2,3). A worsening of epileptic negative myoclonus has also been described (4,5). In a retrospective study of 98 cases of CRE, Corda et al describe 40 patients who received carbamazepine (35 as monotherapy) (6). Only 2 experienced deterioration in seizures (5%; 95% CI -1.7% to 11.7%).
In a recent local retrospective clinical audit, epilepsies worsened on carbamazepine in 8/44 (18%), and on sodium valproate in 5/40 (13%). However only 4 (9%) on carbamazepine had a GFE.
It seems that carbamazepine can aggravate CRE but this is perhaps not specific to CRE, or even any GFE, nor frequent enough to caution this practice. However prescribers do need to be aware of this property, and must be prepared to withdraw carbamazepine promptly if seizures worsen.
This question would be best resolved by including carbamazepine in a multicentre prospective trial of treatment na?ve children with GFE (including CRE) with EEG and clinical outcome assessments designed not only to ascertain clinical effectiveness but also worsening of the epilepsy and EEG.
References 1. Mellish L, Dunkley C, Ferrie C, Pal D. Antiepileptic drug treatment of rolandic epilepsy and Panayiotopoulos syndrome: clinical practice survey and clinical trial feasibility Arch Dis Child 2015;100:1 62-6
2. Lerman P. Seizures induced or aggravated by anticonvulsants. Epilepsia 1986:27:706-10
3. Nanba Y, Maegaki Y. Epileptic negative myoclonus induced by carbamazepine in a child with BECTS. Pediatr Neurol 1999;21(3):664-7
4. Parmeggiani L, Seri S, Bonanni P, Guerrini R. Electrophysiological characterization of spontaneous and carbamazepine-induced epileptic negative myoclonus in benign childhood epilepsy with centro-temporal spikes. Clin Neurophysiol. 2004;115(1):50-8
5. Corda D, Gelisse P, Genton P, Dravet C, Baldy-Moulinier M. Incidence of drug-induced aggravation in benign epilepsy with centrotemporal spikes. Epilepsia 2001; 42(6):754-759.
Conflict of Interest:
Shape of Training and Integrated Child Health
Thank you for your response to our article on Shape of Training, and for sharing your interesting and innovative programme for GP registrars in Northumbria, UK.
We know of a number of different innovative 'integrated child health' programmes that are emerging across the UK and would encourage clinicians and educators innovating in this area to continue to evaluate programmes and to share learning. Your experience is an interesting challenge to the idea that hospital-based 6 month placements are the only possible way to train GP trainees in paediatrics and child health. While we would be very supportive of the expansion of the GP training programmes so that all trainees experience placements in paediatrics and child health, we would encourage this to be done in a way that supports the progression of a much more integrated approach to paediatrics and child health.
If we are to produce the best child health work force possible, it is crucial that the training experience of all doctors on non-paediatric training programmes (e.g. GP, Anaesthetics, Emergency Medicine etc) in paediatric placements is thoughtfully catered to their specific training needs. This requires adaptability in rota design, and care and attention from the clinicians and educators who supervise and support these trainees.
Conflict of Interest:
Competing interests as per the original article
REPTILE-ASSOCIATED SALMONELLOSIS: TIME FOR A NEW PUBLIC HEALTH APPROACH
To the Editor
We read with interest the recent report by Murphy and Oshin regarding reptile-associated salmonellois (RAS) in children aged <5 years in South West England . We agree that further work is required to better inform the public of the potential risks pet reptiles pose for infants and young children. Ireland, as elsewhere, has seen an increase in ownership of exotic pets, particulary reptiles, and with them cases of RAS in young infants  . From 2009-12, an average of 22 cases/year of exotic pet (predominantly reptile associated) salmonellosis were identified in Ireland. Pet reptiles and amphibians included: bearded dragons; lizards; snakes; terrapins; tortoises and turtles.
While active media campaigns led to a decrease in RAS cases elsewhere, current public health information does not appear to be reaching its target audience  . Despite 2011 Health Protection Surveillance Centre health information which recommends reptiles not be kept as pets in households with children aged < 5 years under any circumstances, the incidence of RAS doubled in 2012 (10 of 28 cases in young children, with 5 aged < 6 months of age), with a further 19 cases in 2013 . Many parents were unaware that pet reptiles pose a potential risk to young infants. While parents "always washed their hands after handling them," in some cases, reptiles were washed in the family bathtub, or roamed the house freely.
We conducted a national telephone survey of information provided by pet shops to potential purchasers of reptiles and enquired about their suitability as pets in households with young infants. Only 4 of 10 pet shops provided information of the potential risk of RAS to small children. Six of 10 pet shops were unaware of any potential health-risks from keeping reptiles in households with young infants. One pet shop owner described reptiles as "perfectly clean pets".
The Centre for Disease Control and Prevention recommends that pet shops provide health-related information to owners and potential purchasers of reptiles prior to the point of purchase and not at the cash register . If public education is the approach chosen to reduce RAS rather than import restriction or regulation, which have proved effective elsewhere, we suggest that health-related information campaigns that target potential purchasers of reptiles at point of sale should be explored .
1 Murphy, D. and F. Oshin, Reptile-associated salmonellosis in children aged under 5 years in South West England. Arch Dis Child Online First 22 December 2014. http://adc.bmj.com/content/early/2014/12/18/archdischild-2014-306134
2 Al-Assaf, N., P. Gavin, and R. Manning, Reptile-associated salmonellosis: an under-recognised problem in Ireland. Arch Dis Child 2010; 95: A34.
3 de Jong, B, Y. Andersson, and K. Ekdahl, Effect of regulation and education on reptile associated salmonellosis. Emerging Infectious Diseases, 2005. 11(3): 398-403.
4 Health Protection Surveillance Centre. Reptiles and Turtles and Infectious Diseases. 2011 [cited 2014 22/01//2015]; http://www.hpsc.ie/A -Z/Zoonotic/ReptilesandRisksofInfectiousDiseases/File,14381,en.pdf.
5 Centres for Disease Control and Prevention, 2013 [cited 2014 26 January 2015]. http://www.cdc.gov/salmonella/small-turtles-03-12/advice- consumers.
Conflict of Interest:
A response to 'Shape of Training: the right people with the right skills in the right place'
We welcome Kalber et al's article on the 'Shape of Training', particularly in relation to the needs of primary care clinicians and wish to share with the authors our experience of innovative primary care training.
Paediatric rheumatology is an exemplar of a paediatric subspecialty focussed on the management of specific diseases, such as Juvenile Idiopathic Arthritis, by multidisciplinary care. One of the challenges faced by our specialty is identification of appropriate patients requiring our care, amongst the many children who may present to primary care. Musculoskeletal complaints are common; the busy primary care doctor requires skills and knowledge in order to identify which children require on-going referral and those who can be managed in primary care.
Paediatric training is not mandatory in primary care training, and paediatric subspecialty training may not be viewed as useful. However, we were fortunate to be involved with the Northumbria GP vocational training scheme and piloted an integrated training programme (ITP) involving paediatric rheumatology. ITPs offer registrars within the Northumbria GP vocational training scheme the opportunity to spend half their working week in general practice, and the remaining time in a hospital or community specialty. The placement, for one year, also offers a place on the Certificate of Clinical Education programme run by Newcastle University, with formal tutoring on the principles and practice of teaching, regular opportunities to teach medical student in the paediatric setting with feedback from experienced physicians, as well as teaching and assessment of students when in primary care. Three years later this scheme is still in place and has been of enormous benefit to all involved: the GP registrar, the GP trainers and training practice, the paediatric rheumatology multidisciplinary team (MDT) and patient care.
Our approach to GP registrars based with us in paediatric rheumatology has been in keeping with the ethos of this article; the 'themed area' that trainees are exposed to is that of chronic disease in childhood, how this affects the child and family unit, and how the MDT operates to support the child and family. The learning experience within paediatric rheumatology offers many transferable messages to paediatrics as a whole - clinical assessment, approach to investigations, managing children with chronic disease, MDT working, safeguarding and transitional care. In addition, in new patient clinics, the GP registrar is encouraged to reflect on the referral process and how this can be improved, including training and feedback to referrers where appropriate. We believe that this opens channels of communication between the primary care and hospital based care interface that can only benefit patient care. The scheme has been of great benefit to the hospital team, learning about the challenges of assessing children from the primary care perspective and how to optimise our communication with the health care providers in the community to support families.
The GP registrars report improved confidence in assessing children with musculoskeletal presentations, as well as recognising red flags of when to be concerned, knowledge of the referral process and when to consider referral to orthopaedic or rheumatology, and identifying those children who can be managed through community-based occupational or physiotherapy. Furthermore the knowledge and skills gained by the GP registrar are shared with primary care colleagues in clinical and supervisory meetings, thus cascading knowledge at a local level, improving awareness of musculoskeletal presentations and how to manage them. GP trainers report increasing confidence amongst GP registrars with regard to patient assessment in primary care and communication at the primary / hospital care interface. Overall, the scheme has been a successful exemplar of a novel approach to training for primary care registrars with mutual benefit to all concerned; this echoes the views of the authors on integrated primary care and paediatric training posts as a way forward to improve the care of children.
Conflict of Interest: