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Recent eLetters

Displaying 1-10 letters out of 1406 published

  1. 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:

    None declared

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  2. 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:

    None declared

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

    Dear Editor

    In their excellent review on the hypoglycaemia in childhood the authors suggest that for the management of the hyperinsulinaemic hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who do not respond to diazoxide may respond to the octreotide but the efficacy of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11 are associated with severe HH that is unresponsive to medical treatment with diazoxide and octreotide. The treatment option for patients with medically unresponsive forms of diffuse HH is a subtotal pancreatectomy, but some patients who have undergone surgery continue to have recurrent hypoglycemia, whereas diabetes mellitus and exocrine pancreatic insufficiency develop in others (1).

    The authors of the review make no mention of the possible use of the mammalian target of rapamycin (mTOR) inhibitor sirolimus recently reported to be effective and safe for the severe, diffuse form of HH that had been unresponsive to maximal doses of diazoxide and octreotide (2-5). No major adverse reactions were observed during the 1-year follow-up period in the first 4 cases described (2). This finding is reinforced by the latest cases report of others infant (3,4) and older children (5).

    The suggested method of action of sirolimus includes the reduction of beta-cell proliferation, inhibition of insulin production, and induced peripheral insulin resistance (4). The sirolimus-sensitive mTORC1 pathway is present in the exocrine pancreas and the relatively sirolimus-resistant IGF1R/mTORC2/Akt pathway is overexpressed in the beta-cells, thereby suggesting that sirolimus is effective in treating diffuse HH by reducing the transdifferentiation of exocrine elements to insulin-producing cells (5).

    Even if further studies are needed, primarily to identify long-term sequelae and side effects, sirolimus appears to be a promising therapeutic option to treat children with severe HH unresponsive to diazoxide and octreotide.

    Federico Marchetti, Vanna Graziani

    Department of Paediatrics, S. Maria delle Croci Hospital, Ravenna, Italy. 48121 Ravenna, Italy e-mail: fedemarche@tin.it

    References

    1. Ghosh A, Banerjee I, Morris AAM. Recognition, assessment and management of hypoglycaemia in childhood Arch Dis Child Published Online First: 30 December 2015 doi:10.1136/archdischild-2015-308337

    2. Senniappan S, Brown RE, Hussain K. Sirolimus in severe hyperinsulinemic hypoglycemia. N Engl J Med 2014;370(25):2448-9.

    3. Abraham MB, Shetty VB, Price G, et al. Efficacy and safety of sirolimus in a neonate with persistent hypoglycaemia following near-total pancreatectomy for hyperinsulinaemic hypoglycaemia. J Pediatr Endocrinol Metab 2015;28(11-12):1391-8

    4. Meder U, Bokodi G, Balogh L, et al. Severe hyperinsulinemic hypoglycemia in a neonate: response to sirolimus therapy. Pediatrics. 2015;136(5):e1369-72

    5. Minute M, Patti G, Tornese G, Faleschini E, Zuiani C, Ventura A. Sirolimus therapy in congenital hyperinsulinism: a successful experience beyond infancy. Pediatrics. 2015;136(5):e1373-6

    Conflict of Interest:

    None declared

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  5. Re: Faecal calprotectin as an effective diagnostic aid for necrotising enterocolitis

    Many thanks for the recent letter regarding a rapid assay technique for testing fecal calprotectin1. This would indeed be useful in the clinical setting if it allows the transmission of accurate and rapid fecal calprotectin levels to treating clinicians. As discussed in the original archimedes report, the difficulties surrounding the need for an adequate cut-off remain the main barrier to the use of fecal calprotectin as a diagnostic adjunct in necrotising enterocolitis2.

    JFB Houston

    1. Bin-Nun A, Booms C, Sabag N, Mevorach R, Algur N, Hammerman C. Rapid fecal calprotectin (FC) analysis: point of care testing for diagnosing early necrotizing enterocolitis. Am J Perinatol. 2015;32:337-42. 2. Houston JFB, Morgan JE. Question 2: Can faecal calprotectin be used as an effective diagnostic aid for necrotising enterocolitis in neonates? Arch Dis Child. 2015;100:1003-6

    Conflict of Interest:

    None declared

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  6. Re: Where do the differences in childhood mortality rates between England & Wales and Sweden originate?

    We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree entirely that it is important to know where to target policy, and their data moves us on considerably in determining priorities. This is precisely the sort of approach needed on the Countdown technical committee and we look forward to further collaboration.

    Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane, Hilary Cass, Russell Viner

    Conflict of Interest:

    None declared

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  7. Re: Pickled Red Herrings

    Colvin correctly notes that we are interested in solution-focused research, and expresses some anxiety about our recommendations for improving child survival. There are two issues to consider in addressing his concerns: determining causality, and the burden of proof required to take action.

    First, Bradford Hill's criteria for considering causality are helpful in demonstrating why the association between poverty and social inequalities, and many child health outcomes including mortality, is convincing[3]. The correlation between poverty and mortality is strong and consistent, and there is a clear gradient; poor children are more likely to die, and the greater the gap between rich and poor, the greater the risk[4]. Most of the other criteria are either self-evident (temporality) or are more relevant and appropriate to simpler questions of causality, (specificity, experiment). However Colvin also questions the plausibility and coherence of the associations, focusing on low birth weight, preterm birth, and teenage pregnancy as intermediary factors. The links between poverty, social inequalities, and adverse child health outcomes are more of a causal web than simple chain, so examination from multiple perspectives is helpful and indeed the associations are plausible, supported by epidemiological association, and other studies including intervention [5, 6].

    There is specific data for England and Wales, based on individual parents' social status, demonstrating a clear social gradient in preterm birth rates of 6.8 per cent for babies with at least one parent in a managerial or professional occupation, compared with 7.8 per cent of babies with parents in routine or manual occupations[7]. Socio-economic adversity during pregnancy is also associated with an increased risk of having a low birth weight baby [6, 8]. Plausibility is supported by other associations and evidence too. For example, families from lower socio-economic backgrounds are likely to be more stressed[9] and acute and chronic antenatal maternal stress and poor maternal mental health are linked with preterm births and low birth weight [10, 11] Depression may also lead to negative maternal behaviours, and poor prenatal care, substance abuse, poor nutrition during pregnancy and smoking are associated with both socio-economic disadvantage, and with lower birth weight [12-15]. Young women from social disadvantaged backgrounds and low educational attainment are more likely to have a teenage pregnancy; teenage pregnancy rates are higher in more disadvantaged areas, approximately twice as high for women living in the most deprived areas compared with least deprived. Teenage pregnancy is associated with an increased risk of preterm birth compared with women in their 20 and 30s; in 2013, the overall rate of preterm births was 7.4 per cent, but among women under 20 years the rate was 8.0 per cent [16-19]. Infant mortality rates among babies born preterm to mothers under 20 years are higher (22.4 per thousand preterm births among mothers under 20 years) than among older mothers (15.1 per thousand among mothers aged 35-39)[7, 16-18, 20]. Colvin's suggestion that differences in teenage pregnancy rates are an alternative explanation ignores the strong association between teenage pregnancy rates and deprivation on both an individual and an area level, and the ample evidence that social disadvantage contributes to poor outcome at birth and in childhood.

    The second issue relates to the burden of proof required before taking action. Epidemiology and health systems research are important tools in the search for explanations and solutions, and there are different methods and standards according to the questions asked[21]. Applying an epidemiological standard to a health systems or social policy question is neither always sufficient nor appropriate.The logical consequence of Colvin's argument is that a randomised controlled trial would be necessary before taking action to reduce social inequalities. There has never, to our knowledge, been any evidence published suggesting detrimental health effects of reducing poverty, narrowing the gap between rich and poor, or introducing policies promoting social protection. By contrast, there is plenty of evidence demonstrating good. It would seem remiss to wait for a purported but misguided epidemiological standard of evidence. The burden of proof suggests that our recommendations are likely to be safe and do more good than harm.

    Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane, Hilary Cass, Russell Viner

    1. EURO-PERISTAT Project with SCPE and EUROCAT, European Perinatal Health Report. The health and care of pregnant women and babies in Europe in 2010,. 2013.

    2. Viner, R., et al., Deaths in young people aged 0-24 years in the UK compared with the EU15+ countries, 1970-2008: analysis of the WHO Mortality Database. . Lancet. , 2014 384(9946): p. 880-92.

    3. Bradford Hill, A., The environment and disease: association or causation? Proceedings of the Royal Society of Medicine, 1965. 58(5): p. 295-300.

    4. Marmot, M., WHO European review of social determinants of health and the health divide. . The Lancet. , 2012. 380: p. 1011-1029.

    5. Cattaneo, A., et al., Child Health in the European Union

    2012, European Commission: Luxembourg.

    6. Ohlsson, A. and Shah P, Determinants and prevention of low birth weight: a synopsis of the evidence. 2008, Institute of Health Economics Alberta, Canada

    7. Office for National Statistics. Gestation-specific infant mortality in England and Wales, 2013. 2015; Available from: http://www.ons.gov.uk/ons/publications/re-reference- tables.html?edition=tcm%3A77-39593 http://www.ons.gov.uk/ons/dcp171778_419800.pdf.

    8. Dibben, C., M. Sigala, and A. Macfarlane, Area deprivation, individual factors and low birth weight in England: is there evidence of an "area effect"? J Epidemiol Community Health, 2006. 60(12): p. 1053-9.

    9. Duncan, G.J., J. Brooks-Gunn, and P.K. Klebanov, Economic deprivation and early childhood development. Child Dev, 1994. 65(2 Spec No): p. 296-318.

    10. Talge, N.M., et al., Antenatal maternal stress and long-term effects on child neurodevelopment: how and why? J Child Psychol Psychiatry, 2007. 48(3-4): p. 245-61.

    11. Hoffman, S. and M.C. Hatch, Stress, social support and pregnancy outcome: a reassessment based on recent research. Paediatr Perinat Epidemiol, 1996. 10(4): p. 380-405.

    12. Bradley, R.H. and R.F. Corwyn, Socioeconomic status and child development. Annu Rev Psychol, 2002. 53: p. 371-99.

    13. Brooks-Gunn, J., et al., Enhancing the cognitive outcomes of low birth weight, premature infants: for whom is the intervention most effective? Pediatrics, 1992. 89(6 Pt 2): p. 1209-15.

    14. Korenman, S.M., JE. Sjaastas J., Long term poverty and child development in the United States: results from the NLSY. Institute for research on Poverty Discussion paper, . 1994, Institute for research on Poverty.

    15. Marmot, M., Marmot M. Fair Society, Healthy Lives: the Marmot Review. Strategic review of health inequalities in England post 2010. 2010.

    16. Office for National Statistics. Teenage pregnancies at lowest level since records began. 2013 [cited 2015 April]; Available from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and- wales/2011/sty-conception-estimates-2011.html.

    17. Office for National Statistics. Teenage pregnancies at record low: how does your local area compare? 2014 [cited 2015 April]; Available from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england- and-wales/2012/sty-conception-rates.html.

    18. Office for National Statistics. Conception statistics, England and Wales, 2013. . 2015; Available from: http://www.ons.gov.uk/ons/rel/regional-trends/area-based- analysis/conceptions-deprivation-analysis-toolkit/conceptions-deprivation- measures--2009-11.html.

    19. Right Care, Atlas of Variation: Children. 2012.

    20. Office for National Statistics, Teenage conceptions are highest in the most deprived areas. 2014.

    21. Ghaffar, A., et al., Changing mindsets in health policy and systems research. Lancet, 2013. 381(9865): p. 436-7.

    Conflict of Interest:

    None declared

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  8. Re: Tachypnoea in a well baby: don't forget the head

    Dear Editor

    We are so sorry not to have included cerebral arterio-venous fistula in the aetiology of unexplained tachypnoea because it is of course a rare but classic cause. Typically the symptoms begin almost immediately after birth if there is a large fistula and the pulmonary artery pressure remains elevated. The fistula allows a large systemic artery to systemic venous shunt with right atrial and right ventricular volume overload and increased pulmonary blood flow. There is almost always a systolic or continuous murmur over the occiput or anterior fontanel allowing a clinical diagnosis to be made in the majority; but absence of any murmur in the case described by your correspondent is unusual.

    Michael Rigby Ian Balfour-Lynn

    Royal Brompton Hospital London

    Conflict of Interest:

    None declared

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  9. Re: A useful tool for parents

    We would like to thank Dr Levene for her letter, and the Editors for the opportunity to respond. The authors are familiar with the Infant Sleeplab App; we are both associated with the Durham University Parent- Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as the Founder and Director). The Infant Sleep Info Source Website (ISIS, www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her colleague Dr Charlotte Russell, developed with ESRC funding, and launched in March 2012 in collaboration with UNICEF UK Baby Friendly Initiative, NCT, and La Leche League GB. Following the launch the Breastfeeding Network, Lactation Consultants GB, and Association of Breastfeeding Mothers approached us to support and endorse the ISIS website. The aim of the website is to make research-based evidence on normal infant sleep available to parents and health professionals, and help bridge the research-to-practice gap.

    Due to the popularity of the website, and data indicating that many users accessed it via their smartphones, we proposed creating an Infant Sleep app, based on the website information, in 2013. With support from the Wolfson Institute for Health & Wellbeing the development of the app was funded by Durham University who launched the app in 2014 with the name 'Infant Sleeplab'. It is available for free for both Apple and Android platforms and can be downloaded from the relevant app stores. We incorporated a bed-sharing decision tool that we developed and evaluated in collaboration with NHS Lancashire and Blackpool (Russell et al., 2015), and of course are pleased to hear Dr Levene found this helpful in making her own parenting decisions. More information about the app can be found here: www.isisonline.org.uk/app.

    Conflict of Interest:

    None declared

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  10. Re:The Skeletal Survey in suspected abuse- how necessary is it?

    We thank Dr Cohn and his colleagues for their interest in our article and agree - as stated within our paper - that there is considerable variability in the reported fracture yield of skeletal surveys. This variability is not only dependent on methods of data display (as Dr Cohn et al illustrate), but also on epidemiological and demographic differences between reported study populations and on the process by which clinicians identify and refer children for skeletal survey.

    On the latter issue of patient selection, a recent systematic review showed that there was insufficient evidence to draw any conclusions as to the benefits or otherwise of screening children for physical abuse where there is no prior suspicion [1]. Furthermore, although Sittig et al have developed a checklist for use in the Emergency Department to aid identification of abused children [2], as far as we are aware, there is as yet no validated algorithm to determine which children should progress to skeletal survey and which should not.

    Such an algorithm might be expected to improve the fracture yield of skeletal surveys and the evidence to support its development should come from a multi-centre (preferably UK) study, which will require both time and funding. Meanwhile, we conclude as we previously concluded,

    "History and examination are key to screening for abuse. A decision on the precise investigations must be influenced by clinical need and judgement and by the specific circumstances in each individual case. In children under the age of 2 years who are seen for suspected physical abuse, until better evidence is available, RCR/RCPCH guidelines should be adhered to and initial and full skeletal surveys performed."

    References:

    1. Hoytema van Konijnenburg EMM et al Insufficient evidence for the use of physical examination to detect maltreatment in children without prior suspicion: A systematic review http://www.systematicreviewsjournal.com/content/2/1/109

    2. Sittig JS et al Child Abuse Inventory at Emergency Rooms: Chain-ER Rationale and Design http://www.biomedcentral.com/1471-2431/11/91

    Conflict of Interest:

    None declared

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