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Recent eLetters

Displaying 1-8 letters out of 1356 published

  1. 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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  2. 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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  3. 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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  4. 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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  5. How to make a microbiologist go pale

    There are a few ways in which we can induce funny turns in our microbiology colleagues. One of the easiest is to say, within their earshot: "We'll stop the antibiotics if the cultures are negative". Blood cultures are a terrible gold standard. If they're positive, for a plausible organism, then they're useful - they allow you to refine antimicrobial therapy, and make decisions about duration etc. But negative cultures? My practice was strongly influenced by McWilliam and Riordan's review of CRP. http://ep.bmj.com/content/95/2/55.full In short, if you have two CRPs, more than 18 hours apart, and both 10 or lower, you can be pretty sure that you're not dealing with serious bacterial sepsis. The exception to this is the child who looked genuinely dreadful when they came in. We use the following hierarchy: - the clinical status of the child - paired CRP - cultures at 48 hours The sepsis 6 principles (http://survivesepsis.org/the-sepsis-six/) will undoubtedly improve our management of the child with true sepsis - but they will also promote over treatment, unless we're really good at stopping antibiotics too.

    Conflict of Interest:

    I'm an editor at ADC, with responsibility for the Education and Practice edition

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  6. 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 [1]. Following the report by Jamieson et al. [2], 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.

    REFERENCES

    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:

    None declared

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  7. 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.

    Conflict of Interest:

    None declared

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  8. 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.[1] Obsessive compulsive disorder (OCD), social phobia and generalised anxiety disorder are most commonly reported, though separation anxiety may also co- occur.[1] 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.[2] 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.[3] 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.

    References:

    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

    Conflict of Interest:

    None declared

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