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Recent eLetters

Displaying 1-10 letters out of 1378 published

  1. Use of digital multimedia may bolster both patient and investigator recruitment into randomised controlled trials

    Dear Sir/Madam,

    We read the paper by Tait and colleagues with interest [1]. The authors advocate digital media for delivering participant education in randomised controlled trials (RCTs) involving children. We agree and propose that this strategy may offer broader benefits beyond those discussed by the authors.

    Patient recruitment to clinical trials is difficult, with many failing to achieve their expected recruitment targets [2]. In an executive report by the Health Technology Assessment (HTA) programme, uncertainty over consent and delivery of information was described as a major barrier to patient participation in RCTs [3]. Education using accessible digital media devices may facilitate a renewed culture and enthusiasm to participate in clinical research. To maximise utility, educational information should be tailored and provided on multiple platforms, with links to social media [4]. Development should be guided closely by stakeholder patient representative groups to maximise user accessibility [5].

    Expanding the delivery and quality of digital media based education may also bolster recruitment and retention of other groups involved in conducting clinical research. The Student Audit and Research in Surgery (STARSurg) Collaborative has previously demonstrated the value of online educational video and social media interaction in recruiting collaborating investigators to large-scale, multicentre audit projects [6]. This provided a cost-effective strategy to promote timely dissemination of academic projects across a national setting.

    We endorse routine provision of patient-centred education in clinical research, and suggest others consider expanding this to include its use in recruiting collaborating investigators.

    References

    1)Tait AR. Voepel-Lewis T. Levine R. Using digital multimedia to improve parents' and children's understanding of clinical trials. Arch Dis Child. 2015 Jun;100(6):589-93.

    2)McDonald AM, Knight RC, Campbell MK, et al. What influences recruitment to randomised controlled trials? A review of trials funded by two UK funding agencies. Trials 2006;7:9.

    3)Prescott RJ. Counsell CE. Gillespie WJ. et al. Factors that limit the quality, number and progress of randomised controlled trials. Health Technol Assess 1999;3(20)

    4)Ryan GS. Online social networks for patient involvement and recruitment in clinical research. Nurse Res. 2013;21(1):35-9.

    5)Mapstone J, Elbourne D, Roberts I. Strategies to improve recruitment to research studies. Cochrane Database Syst Rev. 2007 Apr 18;(2):MR000013. Review. Update in: Cochrane Database Syst Rev. 2010;(1):MR000013.

    6)Khatri C. Chapman SJ. GLasbey J et al. Social Media and Internet Driven Study Recruitment: Evaluating a New Model for Promoting Collaborator Engagement and Participation. PloS One 2015;10:e0118899.

    Acknowledgements: This letter was created through discussion within the monthly meeting of the Student Audit & Research in Surgery (STARSurg) twitter journal club (#JCApril).

    Conflict of Interest:

    None declared

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  2. Re:Justifications for the value of good developmental assessment

    Dear Editor,

    Adrian Sutton expresses concern about the use of the term "human capital" in our recent article entitled "Child Development Assessment Tools in Low and Middle Income countries: how can we use them more appropriately?" [1]

    The main focus of the article was to review the structure and methodology for development of child developmental assessment tools (CDATs) for use in low and middle-income countries (LMIC), with particular emphasis on how to adapt and apply western CDATs outside their population of construction. We agree that children's emotional and adaptive needs are as important as their physical and educational needs. We agree that judgment of future productivity on an economic basis should not influence allocation of resources or be the impetus for developmental assessments. We are also obliged to recognize that societal evaluation of the capabilities of a child depends on many factors, particularly in settings where educational provision is neither universal nor equal, and when definitions of, and attitudes towards, disability vary. In LMIC settings, economic constraints clearly impact on access to education, as well as on provision of services for the disadvantaged, and social participation and interaction for marginalized groups,

    CDATs do not have the ability to judge future productivity, economic or otherwise. However, highlighting the importance of developmental assessment within the framework of early childhood programmes should encourage early interaction with parents prior to formal schooling, thereby facilitating evaluation and intervention for individuals with difficulties as well as promoting discussion of the rights of the child, gender issues, and the importance of considering socio-emotional development as well as physical needs. Early inclusion of children with disabilities into the community is also one way to try to limit potential stigmatization of these individuals in later life.

    The term "human capital" is already well established within the lexicon of the child development literature. As an example the Saving Brains campaign states that their mission is to "develop sustainable ways to promote and nurture healthy child and brain development in the first 1000 days at scale with lasting impact on human capital in low-resource settings" and it is the "waste of human capital that leaves the next generation ill equipped to solve the enormous challenges that lock individuals, communities and societies in poverty."[2] Whatever objections here may be to this terminology, surely the point is that as paediatricians working in LMIC we have an obligation to raise awareness of these issues and do whatever we can to influence resource allocation and prioritization of public health funding to support the needs of children with disabilities.

    As a final point we would like to highlight that research into quality of life measures and patient reported outcomes in LMIC are needed through participatory methods; as we discussed "the relationship between future employability, quality of life measures and performance on a CDAT before the age of 5 years, is not known. Longitudinal research is needed to evaluate these relationships."

    1. Sabanathan S, Wills B, Gladstone M. Child development assessment tools in low-income and middle-income countries: how can we use them more appropriately? Archives of disease in childhood 2015 doi: 10.1136/archdischild-2014-308114[published Online First: Epub Date]|. 2. Canada GC. Saving Brains: Unlocking the Potential for Development. Secondary Saving Brains: Unlocking the Potential for Development. http://www.grandchallenges.ca/saving-brains/.

    Conflict of Interest:

    None declared

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  3. Too many digits

    The article by TJ Cole will be very helpful for authors and readers. Authors should always keep in mind that we are reporting information about data, and not just numbers. The following statement by Carl Friedrich Gauss (1777-1855) is reported: "Lack of mathematical education does not become more evident than by excessive precision in numerical calculation."

    Conflict of Interest:

    None declared

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  4. Justifications for the value of good developmental assessment

    Sabanathan et al state in their abstract that "Optimum early childhood experience is believed to allow children to benefit fully from educational opportunities resulting in improved human capital." Am I alone in wondering why the term "human capital" features so prominently when the lived experience in emotional terms - the suffering and satisfactions - of the children do not?

    "Human Capital is defined in the Oxford English Dictionary as 'the skills the labor force possesses and is regarded as a resource or asset.' It encompasses the notion that there are investments in people (e.g., education, training, health) and that these investments increase an individual's productivity."(Goldin, 2014, 1) This is an economic proposition with potentially far-reaching consequences if used as a basis for valuing human beings, assessing the usefulness of diagnostic tools and defining policy.

    An appreciation of a child's developmental potential, attainments and the specific needs which flow from these will enable well-adapted care (including in the educational environment). Well-adapted care is founded on the admixture of emotional attunement and the provision of primary physical needs. Good-enough attunement will provide any child with a better experience of life which in turn will facilitate her / his learning within her capabilities. However, for some children, well-adapted care will not ultimately mean they become economically productive individuals - but surely they are as worthy of the benefits of good developmental assessment as any other child?

    We must not by-pass or pre-empt the debate which belongs in the literature of medical ethics by allowing terminology such as this to silently sneak through into the paediatric literature without adequate explanation and justification for its use in this particular context. Let's not make medicine simply a tool of those with an economic rather than a humanitarian agenda. Reference: Goldin C. (2014) http://scholar.harvard.edu/files/goldin/files/human_capital_handbook_of_cliometrics_0.pdf

    Conflict of Interest:

    Member of the BMJ Ethics Committee

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  5. Re: Using time and serial measurements to improve diagnostic strategies in febrile children

    We thank Dr. Nijman et al. for their thoughtful comments, and agree with their observations.

    Our study, as well as their work , highlight the need to take fever duration into account when interpreting CRP results in febrile children. Future longitudinal studies ,enrolling large numbers of subjects, may focus on generating "CRP curves" , similar to those used for example in interpreting bilirubin levels in neonates . Such curves, stratified by fever duration,may provide clinicians the calculated post-test probability for bacterial infection for every given CRP level and contribute to the clinical decision process even when only one CRP measurement is avaiable

    Conflict of Interest:

    None declared

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  6. Re: Use of Carbamazepine in the Treatment of Childhood Rolandic Epilepsy

    Thanks to Moran and colleagues for pointing out another controversy surrounding the use of carbamazepine in idiopathic focal epilepsy. There has been concern, voiced mainly in paediatric neurology forums, of worsening of seizures (e.g. myoclonus) or of the development of electrical status epilepticus on the EEG in this situation. The risk is highlighted by the case reports cited in their letter, but this risk might not be specific and has not been quantified, and thus there is insufficient evidence on which to make a reasoned choice of anti epileptic medication. We agree with the correspondents that the question of electroclinical worsening deserves to be addressed in the proposed clinical trial.

    Conflict of Interest:

    None declared

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  7. Context matters in children's experiences of napping and night-time sleep

    Given the media headline in response to this paper--that "Daytime naps 'should stop at the age of two'" (http://www.dailymail.co.uk/health/article-2957907/Daytime-naps-stop-age- two.html)--we would like to emphasise that napping can be an effective strategy for children to achieve sufficient amounts of sleep. This is particularly important when children experience inconsistent nighttime sleep arrangements, in which they are unable to achieve recommended amounts of sleep at nighttime alone; and for children from more socio- economically deprived backgrounds, who are already at a health disadvantage.

    In interviewing parents of over 80 three-year-old children about their child's sleep, we were struck by the many households in which sleep hygiene behaviours were not, and probably could not, be implemented, for reasons including household crowding, irregular schedules, fluctuating sleep environment, lack of parental knowledge, support or motivation. 21% of children did not have a regular bedtime implemented by their parents on all or most nights, and 23% did not fall asleep in their own bed each night with some children sleeping in multiple households every week (e.g. mother's home, father's home, grandparents' homes)1. These children, more commonly from socio-economically deprived areas, had significantly shorter nighttime sleep: but not shorter sleep over 24 hours. This suggests that napping compensates for shorter nighttime sleep in some children without 'healthy' nighttime sleep behaviours, preventing these children from experiencing insufficient sleep duration.

    There is a lack of high quality evidence on whether consolidated nighttime sleep versus combined nighttime sleep and daytime napping is better for health. Furthermore, as the authors point out, there is insufficient evidence to conclude whether napping results in delayed nighttime sleep onset and shorter nighttime sleep, or whether short nighttime sleep results in daytime napping (we suspect both are at play in different groups of children, depending on their home environment).

    Given the lack of high quality evidence, discouraging naps in those children with corresponding shorter nighttime sleep duration could unnecessarily penalise children who rely on daytime napping to achieve sufficient sleep amounts. In the context of crowded, perhaps chaotic, households, preventing naps where nighttime sleep is unlikely to be improved would lead to a reduction in 24 hour sleep duration, thereby negatively impacting health and development and increasing health-related inequalities.

    It should not be assumed that one approach fits all children. Blanket recommendations about the suitability of napping might increase inequalities in outcomes. Children's sleep behaviours and sleep environments are diverse. For some, regular and early bedtimes, in a quiet, dark room, enable them to achieve sufficient sleep through nighttime sleep alone. However others operating under more constrained contexts exhibit different strategies, including irregular, later bedtimes combined with napping, to achieve similar sleep amounts over 24 hours. Until there is good evidence that there are negative consequences to this second strategy, and that preventing napping will not result in decreased, insufficient sleep for some children, then napping should not be dismissed.

    1Jones CHD & Ball H (2014) Exploring socioeconomic differences in bedtime behaviours and sleep duration in English preschool children. Infant and Child Development, DOI: 10.1002/icd.1848

    Conflict of Interest:

    We are the authors of one of the papers included in this systematic review.

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  8. Re:Environmental tobacco smoke and effect on children

    Dear Editor,

    We thank Dr Williamson and Dr Odeka for their nice comments.

    Indeed, starting point of our research was my concern of chronically sick children exposed to parental smoking and developing asthma. Moreover, these children often seek for professional immunological care, while the explanation for their sickness is rather different from expectations of their parents.

    In fact, the parents in our practice, admit to smoke only "on the balcony" or "under the kitchen hood" and therefore we felt obliged to provide more scientific arguments to explain detrimental effects of ETS exposure in children (including recurrent bronchitis, chronic cough and eventually atopic dermatitis or asthma).

    We are happy to read, that our report will support your everyday pediatric practice. We also do believe, that our article will influence current legislation procedures aiming at limiting passive smoking of conventional cigarettes in children.

    We allow ourselves to take this opportunity and to suggest, that presumably electronic nicotine delivery systems (ENDS) may offer an interesting alternative to nicotine-addicted parents of children with chronic respiratory conditions. Probably ENDS may soon be offered also in the routine pediatric work. The studies are ongoing...

    Conflict of Interest:

    None declared

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  9. Positioning Early Child Development in the Post-2015 Agenda

    The Archives of Disease in Childhood series on the progress achieved towards attaining the Millennium Development Goals (MDG) draws attention to significant progress globally. Requejo and Bhutta [1] report the progress for MDG 4 (reduce by two-thirds, between 1990 and 2015, the under -five mortality rate). The number of child deaths has been reduced by half to around 6.3 million. Keeping attention on child survival is necessary if we are to end the preventable deaths of 17, 000 children who still die each day; however, a sole focus on survival ignores the reality of the quality of life for the children who survive. More than 200 million children under 5 years of age are at risk of not reaching their full developmental potential [2]. These children are largely concentrated in the same countries with poor survival rates as the risks for survival and development are largely the same, namely malnutrition, poverty, disease, neglect and a lack of learning opportunities.

    The long term impact of adversity in early childhood includes lower educational attainment and economic productivity, poorer health outcomes, increased risks of chronic conditions such as obesity and cardiovascular diseases, and increased risks of mental health problems and violence[3-4]. Mechanisms underlying many of these poor life outcomes operate through compromised early brain development. Interventions in early life that protect and promote cognitive and social-emotional functioning are as critical as efforts to protect and promote survival and physical health. Interventions to mitigate risks such as malnutrition and preventable illnesses improve children's health, growth and development, but alone they do not enable children to catch up to cognitive levels of healthy nourished children.

    Children also require stable, nurturing and responsive care, opportunities to learn, and safe and healthy environments. Without strategies to address both the survival and development of children, the lost potential and long term costs to individuals and society remain high. The 2014 special series in the 'Annals of the New York Academy of Sciences' on child development and nutrition reported that low cost interventions to promote early learning, care and development are effective, including when integrated with health and nutrition services. Since then, important evidence has emerged about the long-term effects of care for development intervention on educational attainment and long-term productivity[5].

    Inequalities between children precede birth and grow wider in environments that fail to support their development. Interventions in early childhood have the potential to reduce these inequalities. Early child development (ECD) programmes for young children and families are among the most promising approaches to alleviating poverty and achieving social and economic equity. The UN Secretary General synthesis report on the post-2015 agenda 'The Road to Dignity by 2030: Ending Poverty, Transforming All Lives and Protecting the Planet' (Documents\post-- 2015\synthesis report\N1467001.pdf) presents a transformational approach that builds around 6 elements that will help us deliver on the Sustainable Development Goals. ECD is part of this new agenda as a clear strategy for investment in 'People.' The acknowledgement of ECD in a global development framework recognizes the early years as the foundation for human development and life-long learning.

    The child health community has an obligation to ensure that all children survive and thrive. Efforts to reduce mortality and improve health must be accompanied by investments to promote children's optimal social-emotional, cognitive and linguistic development as a foundation for a sustainable development.

    The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or the stated policies of WHO or of UNICEF.

    1.Requejo JH, Bhutta ZA (2015). The post-2015 agenda: staying the course in maternal and child survival. Archives Disease in Childhood; 100 (Suppl 1):s76-s81.

    2.Grantham-McGregor SM Grantham-McGregor SM, Cheung Y, Cueto S, Glewwe P, Richter L, Strupp B. (2007). Developmental potential in the first 5 years for children in developing countries. Lancet; 369:60-70.

    3.Walker SP, Chang SM, Vera-Hernandez M, Grantham-McGregor S (2011). Early childhood stimulation benefits adult competence and reduces violent behavior. Pediatrics; 127(5):849-57.

    4.Campbell F, Conti G, Heckman JJ, Moon SH, Pinto R, Pungello E, et al (2014). Early childhood investments substantially boost adult health. Science; 343(6178):1478-85.

    5.Gertler P, Heckman J, Pinto R, Zanolini A, Vermeersch C, Walker S, Change SM, Grantham-McGregor S (2014). Labor market returns to an early childhood stimulation intervention in Jamaica. Science, 344; 998-1001

    Conflict of Interest:

    None declared

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  10. 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.

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