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Recent eLetters

Displaying 1-10 letters out of 1413 published

  1. Re:Holes in the net: safety netting in Emergency Departments needs to improve

    Dear editor,

    In their letter, colleagues Jacob et al. raised further evidence of the lack of standardised safety netting. We thank them for their comments emphasizing the disparity between paediatric trainees' perception of their safety netting practice and their documentation in the medical notes.

    To overcome the lack of information on the difference of given safety netting advice and its documentation in the medical notes, the authors propose the introduction of a checklist. However, at this moment the effective components or the best way to perform this safety netting management still remains unknown.

    A systematic review of Neill et al. states that incomplete information on the illness of their child leaves parents still in need for help.(1) Moreover, irrelevant information reduces parents' trust in the intervention.(1) We know that parental knowledge and satisfaction improved more after video discharge instructions than after written discharge instructions alone.(2) So to proceed we think the next step is to focus on the parental role in the decision making process. One could think of parental monitoring of alarming signs and symptoms of their febrile child. A study on self-referred children with fever emphasized that many parents properly judged and acted on their febrile child's severity of illness.(3) In England every parent is trained to recognise petechial rash,(4) we might enlarge this knowledge to other alarming or reassuring signs and symptoms. This could be initiated for example for respiratory rate, a useful marker of pneumonia, one of the most frequent serious illness at the ED.(5) We are aware of current projects on this topic. A next step is evaluating the impact of such strategies providing improved information on patient (re)consultation.

    In addition to the recognition of deterioration, an important gap in safety netting literature is its time frame strategy. The development of optimal safety netting management should include clinical signs and symptoms, but also a disease specific time frame to inform parents when they should seek help again. This combination of safety netting determinants may establish new starting points for improvement of care.

    References: 1. Neill S, Roland D, Jones CH, Thompson M, Lakhanpaul M, group ASs. Information resources to aid parental decision-making on when to seek medical care for their acutely sick child: a narrative systematic review. BMJ Open. 2015;5:e008280 doi: 10.1136/bmjopen-2015-008280 [published Online. 2. Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to standard written instructions improved caregivers' understanding of their child's emergency department visit, plan, and follow-up: a randomized controlled trial. Pediatr Emerg Care. 2013;29:699-704 doi: 10.1097/PEC.0b013e3182955480 [published Online. 3. van Ierland Y, Seiger N, van Veen M, et al. Self-referral and serious illness in children with fever. Pediatrics. 2012;129:e643-51 doi: 10.1542/peds.2011-1952 [published Online. 4. Acutely sick kid safety netting interventions for families. http://asksniff.org.uk/ 5. Taylor JA, Del Beccaro M, Done S, Winters W. Establishing clinically relevant standards for tachypnea in febrile children younger than 2 years. Arch Pediatr Adolesc Med. 1995;149:283-7 Online.

    Conflict of Interest:

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  2. Treatment of Bronchiolitis in a Poor- Resourced Settings

    Bronchiolitis is on rise, both in prevalence and severity in our country due to many social and life style factors. in our hospital we adopted a protocol named: SuProNO INCLUDE:- - PROVIDE VITAL SIGN ASSESSMENT and close monitoring - PROVIDE O2 AS NEEDED - Provide IV fluid/ NGT Feeds as appropriate -provide Hypertonic (3%) saline nebulization -provide nasal decongestant drops/ spray and suctioning as needed - provide antipyretics if needed -NO NO NO antibiotics NO NO NO steroids.

    with this protocol, the out come is excellent even for severe cases, with short hospitalization, and no need for high facility respiratory support like CPAP or ventilator.

    Conflict of Interest:

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  3. Holes in the net: safety netting in Emergency Departments needs to improve

    Safety netting in the Emergency Department (ED) is key to the practice of safe medicine. Following the article by de Vos-Kerkhof (1), we present further evidence to suggest that there is a lack of standardised safety netting. In addition, we found a disparity between paediatric trainees' perception of their safety netting practice and what they actually documented in the medical notes.

    In a retrospective case notes review of 100 consecutive ED attendances to our hospital seen by the paediatric team and discharged from ED, only 16% had documentation that the families had been told about the existence of uncertainty around the diagnosis and the course of the illness. This compares unfavourably with the fact that 73% of surveyed paediatric trainees reported that they routinely mentioned this to families. Furthermore, the signs and symptoms to look for had only been documented in 27% of cases, though 88% of trainees reported discussing this with the family. 39% of the notes reviewed had no specific safety netting documentation of any kind.

    It is clear that for non-consultant paediatricians, who are the clinicians seeing most referred children in ED, a gap exists between the safety netting that they report undertaking and what is documented. This may be in part because they provided verbal safety netting advice without documenting it but it also suggests that safety netting procedures are poor, despite the clinical and medico-legal imperative for adequate safety netting and documentation advocated by the National Institute for Health and Care Excellence(2).

    Clearly training for junior doctors on safety netting and its documentation needs to improve. A safety netting checklist and more high quality patient information leaflets may help clinicians to offer adequate advice and information to families at the time of discharge. (297 words)

    1. de Vos-Kerkhof E, Geurts DH, Wiggers M, Moll HA and Oostenbrink R. Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care. Archives of Disease in Childhood. 2016; 101: 131 -9.

    2. Fields E, Chard J, Murphy MS and Richardson M. Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance. BMJ (Clinical Research Ed). 2013; 346: f2866.

    Conflict of Interest:

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  4. Point of care lactate testing in resource-poor settings

    Khan et al. make a strong case for investment in point-of-care lactate testing in low and middle income countries (LMICs) (1). They believe that this would identify children at high risk of death, and would save lives because these children could receive earlier resuscitation. Unfortunately the optimal management of children with hyperlactataemia in LMICs is far from clear. Although Khan et al. extrapolate from findings in well-resourced settings to suggest that early fluid resuscitation would be beneficial, this is contrary to the findings of the FEAST study in which bolus fluid resuscitation in African children with signs of shock produced an increase in mortality (2). Of note, this effect was also observed in the subgroup of children with hyperlactataemia.

    Not only is hyperlactataemia a consequence of sepsis, but it is also a defining feature of severe malaria which is a common cause of death in many LMICs (3). Unlike the situation in sepsis, the pathophysiology of hyperlactataemia in malaria is thought to involve microvascular obstruction by parasitized red blood cells, microvascular dysfunction, and anaemia (4,5). Aggressive fluid resuscitation is discouraged in severe malaria, and detailed physiological studies in adults with severe malaria showed that fluid resuscitation failed to reduce microvascular obstruction and lactate concentrations (5). However, when hyperlactataemia is associated with severe malarial anaemia, blood transfusion can be lifesaving (3).

    It is likely that point of care lactate testing in LMICs would achieve the goal of identifying children at higher risk of death, but it is far from certain whether this would be accompanied by the improved outcomes that would be needed to justify the investment. Amongst children with malaria it may identify the need for parenteral artesunate or blood transfusion, but in children with sepsis further research is needed to define the optimal management strategies when intensive care is limited or unavailable.

    1. Khan M, Brown N, Mian AI. Point-of-care lactate measurement in resource-poor settings. Arch Dis Child 2016;101(4):297-8. 2. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364(26):2483-95. 3. World Health Organization. Guidelines for the treatment of malaria. Third edition, 2015. 4. Miller LH, Ackerman HC, Su XZ, et al. Malaria biology and disease pathogenesis: insights for new treatments. Nature medicine 2013;19(2):156- 67. 5. Hanson JP, Lam SW, Mohanty S, et al. Fluid resuscitation of adults with severe falciparum malaria: effects on Acid-base status, renal function, and extravascular lung water. Crit Care Med 2013;41(4):972-81.

    Conflict of Interest:

    None declared

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  5. Re: Treatment of the hyperinsulinaemic hypoglycaemia unresponsive to diazoxide and octreotide: sirolimus should be considered

    We agree that sirolimus may help children with Congenital Hyperinsulinism who do not respond to diazoxide or octreotide. Sirolimus is, however, unlicensed, with little long term experience, and the mechanism by which it reduces hypoglycaemia remains speculative. As sirolimus is an immunosuppressant, its use in young infants has to be carefully monitored in specialist centres under strict protocols. We are, therefore, reluctant to advocate the routine use of sirolimus in Congenital Hyperinsulinism until more evidence has accumulated.

    Arunabha Ghosh Indraneel Banerjee Andrew Morris

    Conflict of Interest:

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  6. Re:Invertase is an alternative to Sucraid in the treatment of CSID

    My child also has CSID. She is about to be 8 yrs old and has been on Sucraid for the last 6-7 yrs. I am looking for an alternative to this medication as sometimes we cannot get the medication and have to go a strict diet until we can get some again. I will look into this alternative and post results later.

    Conflict of Interest:

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  7. Varicella vaccination in the UK: reduced risk of stroke might be another advantage

    We read with interest the review by Amirthalingam[1] and colleagues of the potential value of a UK varicella vaccination programme. They cite Blumental[2] and colleagues' article in the same issue which assessed the burden of varicella and outlined some of the known complications, such as bacterial skin and soft tissue infections, pneumonia, and neurological complications including meningitis and encephalitis. The Blumental study included complications occurring up to 21 days after onset of the chickenpox rash. We wish to highlight further potential complications that are possibly excluded from that definition but may be a significant benefit of vaccination.

    There is evidence that varicella infection is associated with an increased risk of focal cerebral arteriopathy and arterial ischemic stroke (AIS). In a UK study of incidence, Thomas[3] and colleagues identified 49 children with AIS following chickenpox and found that, in children, the incidence of AIS during the following 6 months was four times that of controls (summary incidence ratio = 4.07; 95% CI 1.96-8.45). The estimated incidence ratio in adults was 2.13 (95% CI 1.05-4.36). Considering varicella vaccination in a cohort of more than 3 million children, Donahue and colleagues found no association with ischemic stroke.[4]

    We believe that neurological complications of AIS, which can occur many weeks after infection, were not considered in the review by Amirthalingam and colleagues. Most of the complications that they reported are transient or readily treatable, although meningoencephalitis can leave long-term neurodevelopmental sequelae. There is a high risk of long-term disability from childhood AIS and this places significant financial burden on healthcare systems. We believe that this relatively uncommon but important complication should be considered when determining the cost- effectiveness of a varicella vaccination programme for the UK.

    References

    1- Amirthalingam G, Ramsay M. Should the UK introduce a universal childhood varicella vaccination programme? Arch Dis Child. 2016 Jan;101(1):2-3.

    2- Blumental S, Sabbe M, Lepage P; Belgian Group for Varicella. Varicella paediatric hospitalisations in Belgium: a 1-year national survey. Arch Dis Child. 2016 Jan;101(1):16-22

    3- Thomas SL, Minassian C, Ganesan V, Langan SM, Smeeth L. Chickenpox and risk of stroke: a self-controlled case series analysis. Clin Infect Dis. 2014 Jan;58(1):61-8.

    4- Donahue JG, Kieke BA, Yih WK, Berger NR, McCauley JS, Baggs J, Zangwill KM, Baxter R, Eriksen EM, Glanz JM, Hambidge SJ, Klein NP, Lewis EM, Marcy SM, Naleway AL, Nordin JD, Ray P, Belongia EA; Vaccine Safety DataLink Team. Varicella vaccination and ischemic stroke in children: is there an association? Pediatrics. 2009 Feb;123(2):e228-34.

    Conflict of Interest:

    None declared

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  8. The sensitivity of non-invasive clinical examination to detect dehydration has been questioned without any evidence

    The ADC Archivist recently reported that Freedman et al had revealed that "old-fashioned clinical examination" missed about 20% of cases of significant dehydration in children.[1] Their assessment of this work was not surprising because the meta-analysis in the Journal of Pediatrics carries the headline message that even the "most accurate, noninvasive" methods could only "identify dehydration suboptimally", and it was a high quality analysis which only included studies that had accurately quantified the degree of dehydration by serial weighings.[2] However, Freedman et al's conclusions are misleading because they only selected papers for analysis that had evaluated a rapid triaging tool, and none which had undertaken standard full clinical examinations.

    The four papers that qualified for Freedman et al's statistical reanalysis had used the 'Clinical Dehydration' and 'Gorelick' scores to detect dehydration secondary to gastroenteritis. The individual components of these tests were not mentioned in their meta-analysis paper, but either can be performed quickly on a fully-clothed infant in less than a minute. They rely on scoring (a) the child's general appearance (seeking signs of thirst, restlessness, lethargy and irritability, drowsiness, limpness, cold, sweatiness, or coma), (b) whether the eyes look sunken, (c) if the tongue feel moist, and (d) if tears are reduced or absent, all on simple scales. They do not include any of the following components of routine clinical examinations: capillary refill time, pulse rate and volume, respiratory pattern, peripheral coolness, or skin turgor. As such, these authors are not entitled to list their triage-type scoring as being the "most accurate, noninvasive" clinical tests for dehydration. By presenting their data as they did, Freedman et al may have produced a false- impression among paediatricians about the sensitivity of full, careful clinical examinations for evaluating fluid-balance status, and by reviewing it as they did the ADC Archivist may have inadvertantly perpetuated this confusion.

    References

    1. Archivist. Assessing dehydration. Archives of Diesease in Childhood 2015;100:999. 2. Freedman SB, Vandermeer B, Milne A, Hartling L. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. Journal of Pediatrics 2015;166:908- 16.

    Conflict of Interest:

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  9. Imaging in suspected child abuse

    Monika Bajaj and Amaka Offiah are to be commended for their thoughtful and helpful review of the benefits and risks of skeletal imaging in cases of suspected child abuse.(1) The diagnosis of child abuse is a complex process which requires an evidence-informed approach combining clinical acumen with collaborative multi-agency working. Skeletal imaging, including CT scans, provide a valuable tool for the clinician, but, as Bajaj and Offiah point out, is not without its risks. The clinician must take a lead in informing the parents and other professionals of the potential benefits of imaging, the inherent risks, and the statutory responsibilities under which we work.

    The concept of informed consent in such situations is problematic. What reasonable parent will subject their child to a potentially harmful procedure to rule out abuse which they 'know' has not happened? Conversely, what reasonable parent, having abused their child, will consent to a test which may help to prove that abuse? Parents must be informed of the small but real risks associated with skeletal imaging and that these need to be balanced against the clinical imperative to identify or exclude injury and the statutory duty to investigate cases of possible harm. Where parents do not give their consent to such imaging, the case needs to be discussed with the multi-disciplinary team, and a decision made as to whether to work with the increased uncertainty inherent in not having a skeletal survey or CT scan, or whether to seek a court order to obtain such investigations outwith parental consent.

    Such decisions need to be made in the light of the known short- and long-term harms caused by child abuse. These include a small risk of fatality from severe physical abuse, and the much more prevalent ongoing harm suffered by children living in contexts of ongoing physical or emotional abuse and neglect. The risk of fatality, while clearly significant, should not be overstated. Our current analysis of Serious Case Reviews in England from 2009-14 suggests an average of 28-33 deaths per year directly caused by child abuse (Sidebotham, unpublished data). In their article, Bajaj and Offiah state that 'Data from Child Death Reviews has identified "deliberately inflicted injury, abuse or neglect" as the single largest category of childhood deaths with modifiable factors in England.'(2) In fact, these data show that this is the category with the highest proportion of deaths considered modifiable (65% compared to 20% overall). However, of the 784 child deaths for which child death overview panels considered there to be modifiable factors present, only 28 (3.6%) were due to deliberately inflicted injury, abuse or neglect. This compares to 185 sudden unexpected and unexplained deaths (24% of all deaths with modifiable factors present); 178 deaths from perinatal or neonatal events (23%); and 145 (18%) from trauma and other external factors. Far from being the 'single largest category of childhood deaths with modifiable factors', deaths from child abuse make up a very small proportion of those child deaths which we, as a society, may be able to prevent.

    References 1. Bajaj M, Offiah AC. Imaging in suspected child abuse: necessity or radiation hazard? Arch Dis Child. 2015;100(12):1163-8. 2. Department for Education. Child death reviews: year ending 31st March 2012. London: Department for Education, 2013.

    Conflict of Interest:

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  10. Herpes Zoster possibly unreported in childhood

    This editorial is a very helpful review of the current state of the debate.

    I am concerned that zoster is under diagnosed in childhood because of lack of familiarity in both primary and secondary care. Anecdotally it is not uncommon in a paediatric unit, in otherwise well children, but does cause significant concern and use of resources. This needs to be accurately captured as it may shift the economic modelling used to decide whether to go ahead with varicella vaccination.

    Conflict of Interest:

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