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Recent eLetters

Displaying 1-9 letters out of 1361 published

  1. 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 [1]. 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 [2] . 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 [3] . 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 [4]. 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 [5]. 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 [3].

    References

    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:

    None declared

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  2. 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:

    None declared

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  3. Developmental influences on the pharmacokinetics and pharmacodynamics of midazolam

    I have read with great interest the systematic review to determine the extent of inter-individual variation in clearance of midazolam in children and to establish which factors are responsible for this variation (1). The authors found that the coefficient of clearance in plasma was greater in critically ill patients than non-critically ill patients. Furthermore, there is also a large inter-individual variation in midazolam clearance in critically ill children and neonates. The degree in variation is far greater than the variation in doses administered. Several factors that affect midazolam metabolism were discussed, particularly factors related to critical illness.

    Recently, a systematic review summarized current concepts about developmental influences on the pharmacokinetics and pharmacodynamics of midazolam (2). Based on current available studies it appears that with the rising of age, the pharmacokinetics of intravenously administered midazolam alter, resulting in a shorter half-life due to a higher hepatic clearance in older children as compared to newborn. It was found that bodyweight-normalised clearance increases with age from approximately 0.06 l/kg/h in preterm neonates to 0.6 l/kg/h in children around 5 years of age before decreasing to 0.4 l/kg/h in adult patients. Also, with the rising of age, the pharmacodynamics of intravenously administered midazolam may alter due to a decrease in density of receptors, possibly leading to a decreased clinical response. These findings implicate opposite effects and it is uncertain which of these effects are predominant and how this evolutes over time. It seems, however, that the clinical response to midazolam is the lowest in young children, aged approximately 6 months to 6 years, who need higher midazolam dosing to achieve the same clinical response (3).

    Further research is indeed needed to elucidate the different factors contributing to the observed age-related differences in the effects of midazolam. With more information on the pharmacokinetics and pharmacodynamics in different age groups and patient populations it may be possible to give dosing guidelines based on the required level of sedation and individual parameters, such as (gestational) age and illness parameters. It remains, however, remarkable that despite it's widespread use, high quality evidence to support the use of midazolam in critically ill children is lacking.

    References

    1.Altmamimi MI, Sammons H, Choonara I. Inter-individual variation in midazolam clearance in children. Arch Dis Child 2015;100:95-100

    2.Swart EL, Slort PR, Plotz FB. Growing up with midazolam in the neonatal and paediatric intensive care unit. Curr Drug Metab 2012;13:760-6

    3.Gast-Bakker DAH de, van der Werff SD, Sibarani-Ponsen RD, Swart EL, Plotz FB. Age is of influence on midazolam requirements in a pediatric intensive care unit. Acta Paediatrica 2007;96:414-7

    Conflict of Interest:

    None declared

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  4. Cardioinversion for supraventricular tachycardia

    There is not much new under the sun, and this includes headstands as a treatment for supraventricular tachycardia (SVT). In 1995 I reported this technique as an effective method of converting SVT to sinus rhythm [1]; details of this safe and simple technique were published widely in the medical press at the time [2]. The manoeuvre had been discovered by the father of a patient in desperation when his son suffered a prolonged episode of SVT in a remote part of New Zealand and far from medical care. In the case of my patient he found the technique was ineffective when he performed a handstand by himself. I recommend that the assistance of another person may enhance the likelihood of success.

    References

    1] Supraventricular tachycardia; response to cardioinversion Heaton Paul A.J, Med J Aust 1995;163;595-6 2] Supraventricular tachycardia; response to cardioinversion Yearbook of Pediatrics 1995 ed James A.Stockman: 458-9

    Conflict of Interest:

    None declared

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  5. International Charter for Ethical Research Involving Children (ERIC) 2013

    Professor Modi's excellent review has a curious omission that of the International Charter for Ethical Research Involving Children (ERIC) 2013.

    http://childethics.com/ accessed November 2nd 2014

    Its project partners include, amongst others, the UNICEF Office for Research and Childwatch International Research Network.

    This Charter addresses the issues raised in her review about moving forward the ethical foundation on which research in children is undertaken. It provides a crucial resource for any institution/individual considering undertaking such research and also for the parents/carers of such children, as well as the children who may be subject to it.

    Conflict of Interest:

    I was an expert reviewer and contributor to the International Charter for Ethical Research Involving Children (ERIC) 2013.

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  6. Re: Clarifying the diagnosis of PBB

    Authors: Francis J Gilchrist1,2 ,Mark G Pritchard1, Warren Lenney1,2.

    1. Academic Department of Child Health, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, United Kingdom

    2. Institute for Science and Technology in Medicine, Keele University, Guy Hilton Research Centre, Thornburrow Road, Stoke-on-Trent ST4 7QB, United Kingdom

    Correspondence Dr Francis J Gilchrist, Academic Department of Child Health, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, United Kingdom. Tel: 01782 675289 Email: francis.gilchrist@uhns.nhs.uk

    We thank Professors Chang and Grimwood for their response to our letter. Only 10 years ago, protracted bacterial bronchitis (PBB) was not considered an entity by many of our Paediatric Respiratory colleagues. Although most now recognise PBB as a cause of wet cough in children, there is variation in the diagnostic criteria and treatment regimens used across the world. We wholeheartedly agree that there is an urgent need for prospective longitudinal studies to inform clinical practice.

    In response to their specific comments. Of the ten children that did not fully respond to the initial course of antibiotics; three subsequently had complete resolution of their cough after further antibiotic courses. Suppurative lung disease was considered in the remaining seven and when clinically indicated a CT scan was undertaken. All of these were reported as normal. With regards to the use of prophylactic antibiotics; these were only started in children who had multiple relapses, especially when these relapses occurred very quickly after stopping treatment. Anecdotally these children have done very well but we refer again to the need for prospective studies to investigate the best treatment regimen.

    Conflict of Interest:

    None declared

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  7. Clarifying the diagnosis of PBB

    We congratulate Dr Pritchard and colleagues for reporting on a retrospective follow-up of their patient cohort with protracted bacterial bronchitis (PBB) and thank them for acknowledging the importance of PBB as a cause of chronic cough. The diagnostic criteria of PBB do however need clarification as the 10 children whose wet cough failed to resolve with antibiotics do not have PBB. Instead, they may have bronchiectasis, chronic suppurative lung disease or another cause of wet cough. Recently we showed (in a retrospective cohort of 144 children) that children whose wet cough did not improve after 4-weeks of antibiotics are significantly more likely to have radiolographically-proven bronchiectasis (adjusted odds ratio 5.86; 95%CI 1.20-28.5) [Arch Dis Child 2014; 99:522-5]. This observation supports published statements [Pediatr Pulmonol 2008;43:519- 31] that children whose wet cough does not respond to 4-weeks of antibiotics should undergo further investigation. Importantly, the clinical diagnosis of PBB is based upon three criteria (a) presence of a chronic (>4-weeks) wet cough; (b) resolution of the cough following 2- weeks of antibiotics; and (c) absence of other symptoms and signs suggestive of an alternative cause of wet cough [Med J Aust 2006;184:398- 403].

    In Prichard and colleagues' study, 33 children did have PBB and some had recurrent episodes. Anecdotally, we find that ~50% of children with PBB have recurrent (>3) episodes, some of whom are found to have bronchiectasis. While prescribing prophylactic antibiotics is arguably justified in children with >3 episodes per year, we remain uncertain whether prophylactic antibiotics are warranted when these are less frequent and especially now with ongoing concerns over increasing antibiotic resistance. Clearly, a prospective longitudinal study is required to follow-up children with PBB to help inform clinical practice and is something we are pursuing currently.

    Prof Anne B Chang and Prof Keith Grimwood

    Conflict of Interest:

    AC has potential intellectual competing interest as an author of many papers on PBB

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  8. Distinction between bronchopneumonia, acute bronchiolitis, and asthma

    Acute bronchiolitis and asthma come under the category of obstructive airway disease while bronchopneumonia does not. The main clinical manifestation of an obstructive airway disease would be hyperinflation that would have the clinical features of viscero-ptosis (upper border of liver pushed down), and loss of cardiac dullness on chest percussion.The other clinical feature of obstructive airway disease is prolonged expiration that can be recognized both from careful clinical observation and auscultation. Acute bronchiolitis can be excluded in children older than 18 - 24 months. Recurrent attacks, family history, history of atopy, response to broncho- dilators, and recognized trigger factors help strengthen the diagnosis of asthma, but we need to understand that bronchiolitis can be recurrent due to causation by viruses other than respiratory syncitial virus. A practical method of distinguishing between bacterial and viral infection can be based on the presence of fever, runny nose, cough - the cardinal features of a viral upper respiratory tract infection. A chest x-ray is neither desirable nor required for the diagnosis of any of the three conditions unless complications are suspected. It would be expensive and lead to unnecessary exposure of children to radiation. Health workers can be trained to recognize prolonged expiration by holding their hand before them and have it follow the upward and downward movement of the infant or child's chest. Observation of the movement of their own hand would make recognition of prolonged expiration much easier. All three groups of patients would have fast breathing that health workers are trained to recognize.

    Conflict of Interest:

    None declared

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  9. Management of chronic hepatitis B infection - will NICE guidance lead to over investigation?

    We were pleased to read Dr Davison's review of the two recently published guidelines for managing chronic Hepatitis B infection in children [1]. We have recently audited our practice against both of these guidelines. As Dr Davison points out; "The level of Alanine transaminase (ALT) at which treatment should be considered highlights a fundamental difference between the guidelines". NICE suggests that ALT in males above 30 IU/L and in females above 19 IU/L is considered abnormal [2]. The ESPGHAN guidelines suggest a threshold of more than 1.5 times the upper limit of normal (or more than 60 IU/L) [3]. In our cohort of 12 children with chronic hepatitis B, all the children had an abnormal ALT using NICE guidance, but only 7 had abnormal ALT by ESPHGAN criteria, of which only 4 remain abnormal 6 months later. The number of children in our audit is small, but suggests that using the NICE criteria for abnormal ALT could lead to over investigation for children with chronic hepatitis B. NICE guidance extrapolated adult ALT values to children. We agree that "further research is needed to review the appropriateness of these values in children and young people when making decisions to start treatment".

    References

    1. Davison S. Management of chronic hepatitis B infection. Arch Dis Child. 2014 May 8. doi: 10.1136/archdischild-2013-304925. [Epub ahead of print]

    2. National Institute for Health and Care Excellence (NICE). Diagnosis and management of chronic hepatitis B in children, young people and adults, 2013. guidance.org.uk/cg165.

    3. Sokal EM, Paganelli M, Wirth S, et al. Management of chronic hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus of an expert panel on behalf of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Hepatol 2013;59:814-29.

    Conflict of Interest:

    Dr Davison comes to do a Hepatitis clinic with me once a year.

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