Displaying 1-10 letters out of 1351 published
Vitamin D supplementation - The North Tyneside Experience
The Department of Health (DoH) recommends universal vitamin D supplementation for non-formula-dependent children aged 6 months to 5 years . Following the report by Jamieson et al. , we share similar data from North Tyneside, showing that few children are being supplemented with vitamin D and that parental awareness of current recommendations is poor.
We distributed questionnaires to consecutive parents and carers of children aged 6 months to 5 years, presenting acutely to the Children's Assessment Unit at North Tyneside General Hospital earlier this year. We defined children at high-risk of vitamin D deficiency as those receiving less than 500 ml formula milk per day. The hospital serves a predominantly White British population at risk of vitamin D deficiency owing to the negative impact of reduced sunlight exposure in the higher latitudes of Northeast England.
The median age of the surveyed population was 27 months. Overall 10.5% (4/38) took Vitamin D supplements or 15.4% (4/26) in the high risk group. Only 18.5% (7/38) of carers were aware of current DoH recommendations with regard to vitamin D supplementation.
In view of the resurgence of vitamin D deficiency and its paediatric manifestations [3-4], we support the suggestion that a health promotion campaign to raise public awareness of DoH recommendations on supplementation is indicated and argue for universal vitamin distribution for children from birth to 5 years in primary care.
1.National Institutes of health. July 2014.<http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional />
2.Jamieson K, Braha N, Gritz A, et al. Vitamin D deficiency: are we preventing the preventable? Arch Dis Child 2014;99(5):486-7.
3.Ladhani S, Srinivasan L, Buchanan C, et al. Presentation of Vitamin D deficiency. Arch Dis Child 2004;89(8):781-4.
4.Pearce SH, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ 2010;340:b5664.
Conflict of Interest:
Is litigation an indispensable form of protection against error
I read with great interest, Dr Rosenbloom's recent article. He discusses how difficult issues are raised involving blame when a medical error is discovered but the process may offer families restitution and compensation. 'Parental responsibility' is a term used to describe the legal duty that a parent has to their child (1). Parents act, therefore, as surrogate decision makers on the basis of what they believe to be in the child's best interests. This responsibility includes making decisions to pursue litigation that may have an effect on their child's future and weighing up the harms and benefits of pursuing litigation.
Existing regulations and legislation are designed to afford protection to children receiving medical care. However, in today's climate, litigation can be viewed as an indispensable form of protection or compensation against medical carelessness or error. Almost every hospital and clinician have full insurance coverage which are skyrocketing annually. Yet, there is no evidence that medical litigation has resulted in improved healthcare.(2) Studdert et al found that claims which found no evidence of medical error were often denied compensation but substantial expenditures go toward litigation over errors and payment of them. The overhead costs of medical litigation is spiralling (3).
Wood states that 'the law confuses error with negligence and error should not be the basis for litigation'(4). Litigation based on error is therefore counter-productive to improving quality of care. Surely, the ultimate aim of our healthcare system is to enhance safety and quality, not reduce insurance premiums
1.Children's Act 1989, section 3(1). 2. Morris JA Jr, Carrillo Y, Jenkins JM, Smith PW, Bledsoe S, Pichert J, White A. Surgical adverse events, risk management, and malpractice outcome: morbidity and mortality review is not enough. Ann Surg. 2003 Jun;237(6):844-51 3. Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006;354:2024-33. 4. Wood C.The misplace of litigation in medical practice. Aust N Z J Obstet Gynaecol. 1998 Nov;38(4):365-76.
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Anxiety disorders in children with tics
We read with great interest the recent review article by Creswell, Waite and Cooper on 'Assessment and management of anxiety disorders in children and adolescents'. The article brought to the forefront the importance of accurately identifying and treating anxiety disorders during development, with an encouraging discussion of new treatment strategies and delivery approaches to increase access to psychological therapies for children with anxiety disorders. We are keen to add to these discussions by raising awareness of the common co-occurrence and interaction between anxiety symptomatology and tics for children with Tourette syndrome or other chronic tic disorders (CTD). Psychiatric diagnoses are commonly reported for children with CTD , with approximately 50% of children meeting criteria for at least one anxiety disorder. Obsessive compulsive disorder (OCD), social phobia and generalised anxiety disorder are most commonly reported, though separation anxiety may also co- occur. Interestingly, for children with CTD, behavioural difficulties (e.g. Attention Deficit Hyperactivity Disorder) are most commonly reported during the primary school years whilst anxiety disorders are more prevalent during the teenage years, thus a reduction in externalising behaviours are associated with an increase in internalising behaviours. Findings from our own clinical population support this trajectory and indicate that for children with CTD quality of life is more closely related to anxiety symptomatology than tic severity. In addition, in our clinical experience, the effective management of anxiety disorders with evidence based cognitive-behavioural strategies (as advocated by Creswell and colleagues) often results in improved in tic control and reduced interference from tics on day to day life. Thus, there is a complex interaction between anxiety and tics during development. This highlights the need for the careful evaluation of anxiety disorders in children with CTD to ensure that their broader mental health needs are not overlooked, as for many children often it is not the tics that need managing but the co-morbid psychiatric conditions.
1. Specht, M. W., Woods, D. W., Piacentini, J., Scahill, L., Wilhelm, S., Peterson, A. L., ... & Walkup, J. T. Clinical characteristics of children and adolescents with a primary tic disorder. Journal of Developmental and Physical Disabilities 2011;23(1):15-31.
2. Rizzo, R., Gulisano, M., Cal?, P. V., & Curatolo, P. (2012). Long term clinical course of Tourette syndrome. Brain and Development 2012;34(8):667-673.
3. Woods, M., Robinson, S., Brennan, H, Bunton, P., & Hedderly, T. A Comparison of Clinician and Self-Report Measures of Tics, Co-morbid Difficulties and Quality of Life [abstract p48]. European Society Study of Tourette Syndrome, 25-26 April 2014, Pitie-Salpetriere Hospital, Paris
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Re: Epidemiology of Paediatric Firearm Injuries
We appreciate the response from Murch(1) and colleagues as it highlights the dramatic difference in firearm injury rates between the United Kingdom and the United States. Great Britain's firearm regulation is among the strictest in the world while there is significant state to state variability in the United States (2, 3). A study by Fleegler (3), et al. demonstrated that greater statewide firearm regulations are associated with a lower rate of firearm fatalities within the state both for suicides and homicides, which may partially account for the differences in rates between the countries.
Other factors that may contribute to the differing rates between the two countries include the differences in firearm availability and ownership. It has been shown that large cities with more federal firearms licensees (individuals or stores licensed by the federal government to sell firearms) have higher rats of gun homicide (4). Additionally, a recent study demonstrated that countries with higher numbers of guns per capita had higher rates of firearm-related deaths(5).
These studies along with our own (6) support the notion that the United States has far to go in terms of improving firearm regulations and safety. By looking to other countries, we can learn which legislative models and injury prevention strategies have been most successful in reducing firearm-related injuries worldwide.
1. Murch H, Heatman B, Naughton A, Sibert JR. Epidemiology of paediatric firearm injuries. Arch Dis Child. 2014; doi: 10.1136/archdischild-2014-306861 [published Online First: 2014/06/22].
2. Firearms-Control Legislation and Policy: Great Britain. Washington, D.C.: The Law Library of Congress.
3. Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R. Firearm legislation and firearm-related fatalities in the United States. JAMA Intern Med. 2013;173:732-40 doi: 10.1001/jamainternmed.2013.1286 [published Online First: 2013/03/08].
4. Wiebe DJ, Krafty RT, Koper CS, Nance ML, Elliott MR, Branas CC. Homicide and geographic access to gun dealers in the United States. BMC Public Health. 2009;9:199 doi: 10.1186/1471-2458-9-199 [published Online First: 2009/06/25].
5. Bangalore S, Messerli FH. Gun ownership and firearm-related deaths. Am J Med. 2013;126:873-6 Online.
6. Srinivasan S, Mannix R, Lee LK. Epidemiology of paediatric firearm injuries in the USA, 2001-2010. Arch Dis Child. 2014;99:331-5 doi: 10.1136/archdischild-2013-304642 [published Online First: 2013/12/18].
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At the threshold
The question asks would a rapid PCR test on blood alter management in a febrile infant by way of discontinuing antibiotic therapy if found to be negative.
The multiplex PCR offered would not alter management in a "hot, grumpy, 2 month old" even if it offered 100% certainty that the infant did not have bacteraemia. Bacteraemia implies bacterial infection directly in the blood and is only one of a number of potential sources of bacterial infection in this clinical scenario. Limiting multiplex PCR tests to blood would not eliminate the need for CSF, urine and chest-xray analysis in identifying the source of the pyrexia. The question fails to acknowledge the fact that an infant may have a serious bacterial infection in the absence of bacteraemia. In fact, traditional methods of bacterial blood culture are often negative despite positive urine/CSF culture, or infective changes on a chest xray/ultrasound.
Therefore, in reality, antibiotics would continue irrespective of the accuracy and "evidence" associated with the multiplex PCR test described in your article. It would simply be another tool for rapidly assessing a sick infected infant.
Conflict of Interest:
Malawi trial is included
The second paragraph of this brief note is entirely incorrect, as the trial from Malawi is indeed included in the BMJ meta-analysis. It is included as reference #34 and mentioned explicitly by name in Tables 1 and 2 and Figures 2 and 3. That trial in fact provided approximately 2/3 of the participants included in the meta-analysis.
Conflict of Interest:
Re: Cultural awareness; small volumes of blood for culture cause under-detection of invasive infections
We support Drs. Munro and Flanagan's recommendations to increase awareness of the need for larger volumes of bloods for culturing in children,1 and additionally recommend larger volumes of cerebrospinal fluid during lumbar puncture, given the increasing availability of molecular diagnostic tests for viruses causing meningitis. However, we believe that the findings of their recent audit identifying similar blood volumes being taken from 14 year-olds as 1 month-olds (mean 1.92ml vs. 1.00ml respectively) most likely reflect standard practice in most National Health Service hospitals in England, which allows us to compare our positivity rates with historical studies with more confidence. At the same time, though whilst it is true that the sensitivity of paediatric blood cultures remains limited, it has improved substantially with recent automated microbiological culturing processes, such as those used in the trusts within our study. Moreover, our low positivity rates are in keeping with other studies of bacteraemia in industrialised countries with established national immunisation programmes,2-5 including the UK.6,7 In particular, we are not aware of any hospitals in England that recommend the collection of 40-60mL of blood volume in older children; these recommendations from the IDSA/ASM are based on expert opinion extrapolated from adult blood volumes rather than actual observations.8 The recommendations also advocate much lower blood volumes in infants and toddlers who have the highest burden of infection, in keeping with other recent studies reporting higher culture positive rates with larger blood volumes (?0.5 mL for <1 month-olds, ?1.0 mL 1-36 month-olds and ?4.0 mL for ?36 month-olds).5 Therefore, whilst we need to increase awareness for reasonable age-appropriate blood and CSF volumes to be taken for culture and molecular testing in children, the audit by Drs. Munro and Flanagan does not change our findings of low childhood invasive bacterial infection rates. We now need to this information to develop and implement strategies to reduce childhood hospitalization rates and manage low-risk febrile children at home.
AUTHORS: Kirsty LeDoare, Adam Irwin, Mike Sharland, Shamez Ladhani Paediatric Infectious Diseases Research Group, St. George's Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK E-mail: email@example.com
1. Munro APS, Flanagan P. Cultural awareness; small volumes of blood for culture cause under-detection of invasive infections. Arch Dis Child 2014 xxx 2. Haddon RA, Barnett PL, Grimwood K, et al. Bacteraemia in febrile children presenting to a paediatric emergency department. Medical J Aust. 1999 May 17;170(10):475-8. 3. Sard B, Bailey MC, Vinci R. An analysis of pediatric blood cultures in the postpneumococcal conjugate vaccine era in a community hospital emergency department. Pediatr Emerg Care. 2006 May;22(5):295-300. 4. Bressan S, Berlese P, Mion T, et al. Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review. Acta Paediatr. 2012 Mar;101(3):271-7. 5. Connell TG, Rele M, Cowley D, Buttery JP, Curtis N. How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children's hospital. Pediatrics. 2007 May;119(5):891 -6. 6. Martin, NG Sadarangani M, Pollard AJ, Goldacre MJ. Hospital admission rates for meningitis and septicaemia caused by Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae in children in England over five decades: a population-based observational study. Lancet Infect Dis. 2014 Mar 13. pii: S1473-3099(14)70027-1. 7. Irwin, A., Community-acquired bacteraemia presenting to the Alder Hey Children's Hospital Emergency Department, BPAIIG winter meeting oral presentation, 13/12/2013. 8. Baron E, Miller J, Weinstein M, et al. A guide to utilization of the microbiology?laboratory for diagnosis of infectious diseases: 2013 recommendations by?the Infectious Diseases Society of America (IDSA) and the American Society?for Microbiology, Clinical Infectious Diseases, 2013 Aug; 57 (4) : e22-?e121.
Conflict of Interest:
Epidemiology of Paediatric Firearm Injuries
We were interested in the paper by Srinivasan and colleagues1 as it brings into focus the differences in the epidemiology of firearm injuries in children and young people between the USA and the United Kingdom and the importance that gun control has had in child and adolescent safety here. Through the Child Death Review in Wales we have previously reviewed deaths from firearm injuries in the UK. This followed the death in Wales of a young person by his own hand using a shotgun. This prompted us to examine the problem of firearm deaths to children and young persons in Great Britain2. We hoped to search for common themes that underpin the causes of childhood firearm deaths and investigate the scope for prevention.
In the paper from America1, the incidence of fatal firearm injuries attending emergency rooms was 0.4/100,000 (CI -02-1.0) with a non-fatal rate of 23.5 (CI 14.1 to 32.9). The fatal rate quoted is for children presenting dead or dying to emergency departments and the overall rate of firearm injuries deaths is much larger 3.2/100,000 children3 in 2010. Of the injuries in Emergency Room study, 64% were unintentional. Some of these unintentional shootings may occur when children are unsupervised in a home, find a loaded gun and accidentally fire it. There are also youth suicides. In our study between 2005 and 2010, 41 children were killed by firearms: 1 in Scotland, 4 in Wales and 36 in England. Looking at England and Wales the incidence in children 0-18 years is 0.057/100,000/ year. The age range was 18 months to 17 years, with a majority (32) aged 15-17 years. There were 8 accidental deaths, 6 suicides and 27 murders. 8 deaths involved air rifles. Notably of the murders, 24 children were of Afro-Caribbean origin and 4 were female. There was a geographical variation, with 16 murders occurring in London and 6 in Manchester. 19 cases of murder were linked to criminal gangs. The incidence of deaths from firearms based on figures from Children's Defense Fund (from U.S. Centers for Disease Control and Prevention) is approximately 56 times more common per 100,000 population in America than England and Wales. This provides important lessons for the United States but there are lessons also for us in Britain with reducing of violent youth crime in big urban centres and reducing the exposure of children to air rifles and shotguns.
1. Srinivasan S, Mannix R, Lee L K Epidemiology of paediatric firearm injuries in the USA, 2001-2010. 10.1136/archdischild-2013-304642
2. Murch H et al. Review of child deaths from firearms in Great Britain 2005-2010. Is there scope for prevention? Welsh Paediatric Journal 2012; 37:17-20
3. Protect Children not Guns 2013. Children's Defense Fund. 25 E Street, N.W., Washington, DC 20001
Conflict of Interest:
Interveening in childrens' health
Mitch Blair's article is an important commentary on the relationship between academic enquiry and changes which affect child health, and justifies some amplification. The two examples he relies on are very different and obscure a third. The benefit of antenatal steroids in reducing R.D.S. was based on research but occurred as a result of a steady increase in collaboration of paediatricians (responsible for treatment of R.D.S. ) and obstetricians (responsible for prescribing steroids). This started in the 1970's and allowed the agnostics to gradually convert, rather than by a sudden watershed in 1990.
The cot death story obscures the major alteration in infant care which aroused little comment in this country ,although it did in the Netherlands. Clear evidence that preterm infants benefited from lying prone led to a major change, instigated mainly by midwives who felt that 'normal' babies should not be excluded from the benefits given to those in 'Special Care'. Both midwives and mothers noted that some babies slept more soundly when prone.
Ruth Gilbert has documented how evidence for the adverse effect of prone sleeping was accumulating, but the studies were observational , of small numbers and with confidence limits which nobody judged sufficient to advise changing the sleeping position of what had become the majority of infants.
In 1989 F.S.I.D. recognised that the search for medical diagnoses had only been successful in a few cases, and Risk Related Intervention was not practical for the whole population. I set up a working group, including leading professionals , to advise on the most promising measures which might reduce deaths and could be advised for virtually all babies.Sufficient evidence from intervention studies was lacking, although there were documented initiatives advising locally on issues such as overheating and prone sleeping.
Early in 1991 Ed Mitchell published results of the New Zealand intervention study which reached a wider community at a meeting in Rouen that summer. This was judged sufficient for action; a campaign was swiftly prepared based on the recommendations of the working party and F.S.I.D. launched the "Reduce the Risk " campaign in October. The delay in acting on evidence was in months not 20 years. The D.O.H. followed with television advertisements ,a temporary leaflet('Back to Sleep') and funding for the C.E.S.D.I. study.
To make significant improvements one needs more than well founded research; the data and the arguments for change must be easily available and understandable., and robust enough to prevent calls for more research before action. The benefits should be major and the risks minimal. The agents of change , parents, nurses and midwives, and medical staff all have individual needs in the way information is presented, and while the state needs to take ultimate responsibility a bureaucratic response could bring its own disadvantages including a lack of motivation .
Conflict of Interest:
Former Trustee; Foundation for the Study of Infant Death
Evidence based medicine and research activities in the developing world
Dear Sir, We read with interest the work by Duke et Fuller (1) demonstrating an increase in the publication of randomized controlled trial (RCT); total: 1553) in 76 low- and middle income countries (LMIC) over a 11-year period. Of note, studies of nutrition (366 publications, 23.6%) and malaria (336 publications, 21%) predominated. Trials of infectious diseases - most importantly malaria involved a comprehensive range of both treatment and preventive strategies with the implementation of new interventions as routine health strategies, and reductions in malaria. The authors demonstrated that there have been a relatively small number of trials of interventions for treatment or prevention of acute respiratory infection (98 publications, 6.3%), neonatal health (64 publications, 4.1%) and tuberculosis in children (26 publications, 1.7%). Interestingly, in the last 5 years there has been increasing focus on non-communicable diseases such as asthma and allergy, obesity, diabetes and cardiac disease, and behavioural-developmental disorders while mental health conditions have received little attention (21 publications, 1.4% of publications) (1).
While Duke et Fuller. (1) are to be congratulated for their systematic analysis, there is an ongoing lack of up-to-date, systematic reviews that critically assess the role and potential limitations of evidence-based medicine (EBM) and systematic Cochrane reviews in particular originating in LMIC. Undoubtedly, EBM has contributed substantially to improving the quality of medicine in general, and in neonatology and pediatrics in particular (2). Cochrane reviews are systematic reviews/meta-analyses of primary research in the medical and health policy fields. They are considered the highest standard in EBM. Thus, the Cochrane database may prove particularly beneficial for LMIC with limited resources. However, most published clinical research has been conducted in highly industrialised Western countries, and it remains unclear how the results gained from these RCTs will translate into changes in medical care in the developing world. Thus, it is important that LMIC themselves get involved in research activities based on their specific medical problems and needs - as demonstrated by Duke et Fuller ?1? - but also in the process of generating of Cochrane reviews as well.
Hence, we would like to share our data analysis on this topic (3). We performed a systematic literature review of all Cochrane reviews published between 1996 and 2010 by the Cochrane Neonatal Review Group (CNRG) and in the field of neuropediatrics. The main outcome parameter of our review was the assessment of the percentage of reviews that originated in developing countries and the number of reviews that provided conclusive/ inconclusive data. In total, 262 reviews were performed in the field of neonatology and 112 in the field of neuropediatrics. Only a small fraction (15/262 (5.7%) in neonatology and 16/112 (14.3%) in neuropediatrics) originated in developing countries. Only seven of those 15 reviews in the field of neonatology provided conclusive recommendations (six negative, one positive) while in neuropediatrics 9 reviews provided conclusive recommendations (five negative and four positive), while six were inconclusive. One report provided conditional recommendations.
This is of concern, for worldwide the vast majority of neonates and children are born and raised in these countries. Moreover, the recommendations issued in Cochrane reviews performed in highly industrialised countries are largely applicable to the fields of neonatology and neuropediatrics as practised in industrialised countries and will potentially exclude the majority of neonates, infants, and children being born and cared for in the developing world. However, recently, efforts (through initiatives such as the Effective Health Care Alliance and the SEA-orchid consortium) have been undertaken to disseminate knowledge from the CNRG to low- and middle-income countries to ensure that care practices are evidence-based and that scarce resources will be used and allocated appropriately (2, 4). These programs target generators as well as users and teachers of evidence in order to ultimately ensure the implementation of effective interventions (2, 4). Moreover, and of note, our study also demonstrated that a substantial percentage of systematic Cochrane reviews from developing countries were inconclusive and failed to provide any recommendation with regard to a specific intervention.
Based on our findings and the work by Duke et Fuller (1), we conclude that there is an ongoing need for high-quality research that addresses specific issues that are most relevant to the medical care of children in developing countries. Funding and research agencies will play a pivotal role in selecting the most appropriate research programs for the developing world. Given the limited financial and human resources that are available in the medical arena in the developing world, future emphasis must be on long-term outcomes that are vital to infants and children and their families, as well as to healthcare workers. Importantly, in the future the effects of interventions not only on survival, but also on long -term morbidity, must be considered (5). This change in paradigm is particularly important in perinatal medicine. In doing so, the realization and implementation of the Millennium Development Goals as defined in 2000 will become realistic, thus reducing child mortality rates worldwide (6, 7). In the future, it will be important to assess effectiveness of interventions that will have been put in place following the publication of high quality RCTs - as shown by Duke et Fuller (1) - and systematic reviews in LMIC.
References 1. Duke T, Fuller D. Randomised controlled trials in child health in developing countries: trends and lessons over 11 years. Arch Dis Child. 2014 Mar 10. doi: 10.1136/archdischild-2013-305702. [Epub ahead of print] 2. Davis, P.G. 2006. "Cochrane Reviews in Neonatology: Past, Present and Future." Seminars in Fetal & Neonatal Medicine 11: 111-16 3. Meyer S, Willhelm C, Girisch W, Gottschling S, Gr?ber S, Gortner L. The role of developing countries in generating Cochrane meta-analyses in the field of pediatrics (neonatology and neuropediatrics): a systematic analysis. World Health Popul. 2013;14(2):24-32 4. Henderson-Smart, D.J., P. Lumbiganon, M.R. Festin, J.J. Ho, H. Mohammad, S.J. McDonald et al. 2007. "Optimising Reproductive and Child Health Outcomes by Building Evidence-Based Research and Practice in South East Asia (SEA-Orchid): Study Protocol." BMC Medical Research Methodology 7: 43;doi: 10.1186/1471- 2288-7-43 5. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic review for 2010 with time trends since 2000. Lancet 2012;379(June 9):2151-61. 6. UNICEF. Committing to child survival: a promise renewed. New York: United Nations Children's Fund, 2012. Ref Type: Report 7. Willhelm, C., W. Girisch, L. Gortner and S. Meyer. 2012. "Role of Cochrane Reviews in Pediatric Neurology." Acta Paediatrica 101(4): 352-3. d
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