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Recent eLetters

Displaying 1-10 letters out of 1434 published

  1. Conclusions not justified by findings

    It is encouraging to see a clinical service making an effort to examine the patterns of growth found in their condition. However the conclusions drawn from their data seem greatly overstated. They describe a pattern of 'progressive growth failure' in nearly a quarter of children with ataxia telangiectasia (AT), yet there is an average decline across all children of less than half a centile space over 3 years. These children are as a group very short, with a majority being below the 2nd centile, but far fewer are thin, making a nutritional origin for this short stature unlikely. Even those children who are thin are not necessarily malnourished. Our experience in a specialist feeding clinic is that children with neurodisability and chronic disorders often have low lean mass due to low muscle mass, which may actually coexist with normal or even high fat levels (1). It is clear from the figure that three of the 12 children who received PEG feeding showed marked weight and some height gain, but others showed no weight acceleration or even a decline, with an overall median annualised gain of less than a third of a centile space. PEG feeding is an invasive, expensive, life changing treatment and to be justified there must be the substantial objective evidence of benefit. It thus seems unreasonable to infer from these findings that more children with AT should be PEG fed at an earlier stage. This should be reserved for individual children where there are clearcut problems with swallowing, or objective evidence of low fat reserves measured using skinfolds or other methods. 1.Wright CM, Smith K, Morrison j. Withdrawing feeds from children on long term enteral feeding: factors associated with success and failure. Arch-Dis-Child 2011 96(5):433-9.

    Conflict of Interest:

    I work in a clinic that specialises in helping children withdraw form or avoid tube feeding

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  2. Integrated services for infants, children and young people

    This article helps us think about how we would like to provide services to infants, children and young people (ICYP) in response to changing needs, financial constraints and a push for multi-agency integrated working. We propose that paediatric services should have integrated mental health expertise in primary care, community and hospital based services. This would allow for prevention and early intervention, development of staff confidence and expertise when confronted with mental health difficulties as part of the paediatric presentations, as well as timely assessments, formulation and treatment of mental health disorders. Such integrated working would facilitate the early detection of mental health difficulties which may be the primary difficulty and improve the quality of paediatric treatment and attendant outcomes. This relates not only to ICYP with chronic illness and complex disability, but also to those who present at general paediatric clinics. Much time is spent by paediatric colleagues without the relevant training and expertise in addressing psychological difficulties which are regularly part of the clinical presentation and separate services prevent development of skills in managing these where appropriate, as well as causing delay to ICYP who need to be referred elsewhere. An integrated health response facilitates working across social services, education and other agencies which is seen as the most helpful response to supporting children's well-being as well as in the domain of child protection and disability. Anyone considering the commissioning, continuation or development of paediatric services should be thinking of ICYP holistically and remembering that "there is no health without mental health".

    Conflict of Interest:

    None declared

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  3. The lost children

    Wright and Wales highlight the issues of childhood obesity but there is a lack of clear guidance on who should deal with it. The suggestion to " opportunistically discuss a childs weight" is easier said than done. Whose responsibility is it ? There is little immediate consequence if it is not done. Obesity is rarely the presenting complaint to a doctor. So tackling obesity, in addition to the primary complaint is two consultations. With time pressures in healthcare this is challenging. The obesity diagnosis, for a child , and sometimes the parents is breaking bad news, it is traumatic and difficult, and often avoided for that reason. The family doctor hopes the Paediatrician will do it and vice versa. The Paediatrician rarely sees the long term consequences of obesity - hypertension, Type 2 diabetes, cardiovascular disease and arthritis and does not own these problems. By the time we see these patients it is often too late. The obese child is often from an obese family which requires the doctor to address the parents obesity as well, something that Paediatricians cannot do.

    They recommend walking ( may require a supervisor, some children dislike it and not easy in winter) cycling ( see walking) and use of sports centres ( requires transport and organization) "Encouraging" a child to play less video games is like asking an addict to use less drugs. Prescribe the following: unplug the television, turn off the wifi and put the kids out the door to the garden or street. If these fail refer to the enforcer for radical phonectomy!. This can result in hours of activity. The authors don't emphasize the difficulties of getting obese children active. In calorie burning sports the obese child is often the goalie ( with little calorie burning) or the substitute , or cannot compete e.g. running - where weight is a major disadvantage. The child often leaves the team after a time having had no matches and a feeling of inferiority. The indignity of always being last in the race will put any child off running. Coaches who focus on the elite and have a win at all cost mentality give little time , or worse , to the weaker children.

    Could I suggest that any sporting organization, club or school that receives government or municipal funding, is obliged to play every child on the team in every match for at least half an hour. They should allow every child to play on at least one team regardless of ability. Failure to comply should result in reduction of funds.

    There are too many lost kids. They are lost between the specialties and they are lost between the schools and clubs. Time to find them again.

    Brian McNicholl FRCEM FRCS FRCPI FFSEM MCh Consultant Emergency Medicine and amateur sports coach University College Hospital Galway Ireland

    Conflict of Interest:

    None declared

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  4. Re:Bruising in children with bleeding disorders - Limitations

    Dear Editors

    We thank Drs Chakraborty and Morris for their interest in our study. We acknowledge that the children without bleeding disorders were only recruited in south Wales whilst those with bleeding disorders were recruited in centres around the UK. Given the data available we are not able to comment on whether children are likely to bruise differently dependent on where they live.

    We agree that it would have been useful to validate training of carers of children with bleeding disorders, although the 100% concordance between carer and trainer in the children without bleeding disorders is a result that suggests that the data are valid.

    Children with bleeding disorders are inevitably more likely to be male than female. Previous work by ourselves and others has shown that there is no detectable difference between bruising pattern in male and females in this age group (1-4). Importantly, this is the case for the control children in this study (5).

    Yours sincerely

    Peter W Collins, Melinda Hamilton, Frank D Dunstan, Sabine Maguire, Diane E Nuttall, Ri Liesner, Angela E Thomas, John Hanley, Elizabeth Chalmers, Victor Blanchette and Alison M Kemp

    References

    1. R F Carpenter. The prevalence and distribution of bruising in babies Arch Dis Child 1999;80:363-366

    2. Labb? J, Caouette G.Recent skin injuries in normal children. Pediatrics. 2001 108:271-6.

    3. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. 1999 153:399-403.

    4. S Maguire, M K Mann, J Sibert, A Kemp, Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review Arch Dis Child 2005;90:182-186

    5. Kemp AH, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S. Patterns of bruising in pre-school children - a longitudinal study. Archives of Disease in Childhood 2015;100:426-431.

    Conflict of Interest:

    None declared

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  5. What we may have missed

    Two alternative explanations are given by Professor Taylor for the global problem with ADHD diagnosis, but he overlooks one interesting possibility- perhaps the reported prevalences are about right. That is, perhaps the rates really do vary considerably between populations and are rising in the USA and in other countries.

    Professor Taylor recognises some obvious facts. Firstly, there is a large unmet need. Secondly the reported rates are very high in some places and are changing quite rapidly. Thirdly, places where medical treatment is well established have higher prevalence.

    It can be pointed out that a large unmet need might be due to a rising prevalence and that wealthy places with higher prevalence are likely to have more established treatments. In short, we are offered no good reason to disbelieve the data.

    The unspoken reason why the prevalence data is questioned is that it doesn't fit with our aetiological model. ADHD is supposedly genetic. Professor Taylor, however, points out that the diagnosis for an individual is not made based on aetiology and can't be disproved by aetiology. It is made on well established behavioural diagnostic criteria.

    Are we not left with the serious possibility that our aetiological model is wrong. Genetics are involved with every condition. Might not twin studies identify epigenetic as well as genomic processes? Epigenetics is a science which is moving the ground beneath our feet. If we should not dither in rigid constructions when the roof is falling in.

    Conflict of Interest:

    None declared

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  6. Acute, unplanned paediatric admissions and earlier consultant review

    The team from Evelina are to be commended for questioning the current direction of travel of acute hospital practice, seeking to find "policy- based evidence" supporting the drive for increasingly consultant-delivered healthcare and their detailed report should help inform wider discussions, not just in paediatrics but across the entire spectrum of acute hospital medicine.

    Apart from two specific instances (very short-stay admissions and acute gastroenteritis (AGE) - conditions which of themselves are not mutually exclusive), earlier consultant review does not appear to significantly impact on hospital length of stays.

    Whilst the authors describe AGE as "one of the commonest reasons for an acute paediatric admission" and report that, following the introduction of earlier consultant review, children presenting with (AGE) were discharged sooner in 2014-'15 when compared to 2012-'14, they failed to highlight the dramatic effect Rotavirus (Rotarix?) vaccination, introduced into the United Kingdom's Immunisation Programme in July 2013 (roughly midpoint in the study), has subsequently had on disease prevalence, which goes some way towards negating this reported benefit from earlier AGE discharge.

    In 2012-'14, AGE made up 6.5% (291 admissions) of Evelina London Children's Hospital (ELCH)'s unplanned admissions, whereas in 2014-'15 only 3.5% (70 admissions) of admissions were due to AGE, a fall of almost 50% (Table 2), an effect that must surely be attributed to vaccination and reflects national trends where acute, unplanned admissions from rotavirus have fallen dramatically [1].

    Pre-2013, there were 13,000 hospital admissions for rotavirus in England and Wales but since then rotavirus admissions have fallen significantly with laboratory reported rotavirus infections in England 2013/14 falling 67% when compared to the previous 10-season averages from 2003-'13. Epidemiological reports have confirmed that this decline in cases has continued and been sustained, suggesting that rotavirus vaccination has been extremely successful in reducing the burden of disease rotavirus placed on our acute paediatric units [2].

    There can be no doubt that vaccination success has produced a dramatic and sustained decrease in paediatric presentations/admissions with acute gastroenteritis which, considered in the context of this study's findings and conclusions, must further question the need for increasingly earlier consultant review, the position endorsed by politicians and royal colleges alike [3].

    [1] Does increased duration of consultant presence affect length of hospital stay for unplanned admissions in acute paediatrics?: an observational before-and-after analysis using administrative healthcare data. Cromb, D et al. Arch Dis Child Published Online First:10.1136/archdischild-2016-311318

    [2] PHE Monthly National Norovirus and Rotavirus Report Summary of surveillance of norovirus and rotavirus 12 June 2015. Page 8. www.gov.uk/government/uploads/system/uploads/attachment_data/file/434768/GEZIreportTableNew12062015.pdf

    [3] RCPCH "Facing the Future: Standards for Acute General Paediatric Services - 2015" www.rcpch.ac.uk/sites/default/files/page/Facing%20the%20Future%20Standards%20web.pdf

    Conflict of Interest:

    None declared

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  7. Re: Apple juice for rehydration.

    I am grateful to Prof Weizman for his response to my Archivist article. Like him, I was concerned that the saccharide content and high osmolality of apple juice might make diarrhoea worse, not better. However, the authors of this article did not find this. It is possible that their surveillance for this adverse effect was inadequate but this cannot be deduced from the article. Archivist can only convey what authors report: readers must make up their own minds whether or not to act on any paper's findings.

    Dr Robert Scott-Jupp

    Associate Editor, Lucina and Archivist

    Conflict of Interest:

    None declared

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  8. The challenges of communication to address Moral Distress

    We thank Dr Kraemer for his constructive response and commend his initiative to facilitate weekly staff meetings within neonatal intensive care units. We concur that communication is an essential component of addressing not only moral distress but improving workplace culture.

    As Dr Kraemer notes, finding the best forum for such discussions continues to be challenging. In our various institutions we continue to struggle to address a range of questions about when and how to communicate in ways that will be genuinely helpful. Some questions are about the nature of the discussion, such as: Do such meetings only really cater for those who are most vocal, or who have the ability to articulate their concerns? (And if so, what approaches will help those who struggle to be heard?) How do we bring the honesty and transparency of 'tea room' discussions to these more formal clinical meetings?

    Some questions are practical: How can such meetings meet the needs of both day and night time healthcare professionals? When the facilitator is the clinical lead, who will support and care for him/her as he/she seeks to support and highlight all other voices in the matter?

    Other questions are about attitudes and values: How do we turn the attitude that such discussions "don't change anything", into positive responses that both advance medicine and serve the patients and their families? At times our efforts to build trust, communicate openly and to walk a line of integrity still seem to fall short of what is needed or expected to maintain morale and a safe workplace environment.

    It is our hope that our current longitudinal study into moral distress will highlight the key time points where further interventions and debriefing meetings will be most effective in addressing healthcare professionals' valid concerns while providing a unified team that is equipped to care for the best interests of the patient and the family, no matter how challenging that may be.

    Conflict of Interest:

    None declared

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  9. Re:Hypercalcaemia and neonatal sepsis

    The purpose of our study was to document the prevalence of hypercalcaemia in children and its possible associations and we agree with the correspondent that it would be helpful to confirm these associations, such as the one highlighted for sepsis, thorough more detailed and rigorous studies.

    Conflict of Interest:

    None declared

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  10. Apple juice for rehydration.

    I read with great interest the Archivist regarding Apple juice for rehydration. It summarizes a recent study from Toronto, Canada set out to see whether dilute apple juice was as good as standard electrolyte maintenance solution for rehydration (Freedman S, et al. JAMA 2016;doi:10.1001/jama.2016.5352). They conclude that the use of half- strength apple juice may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration. The Archivist recommends to use this mode of rehydration in developed countries.

    In my opinion the authors failed to fully delineate the dangers of using fruit juice as rehydration fluid, even when diluted. Fruit juices, such as apple juice, contain usually fructose, glucose, sucrose and sometimes sorbitol, and their osmolality might reach occasionally a level of 1,070 Osm/Kg H2O. Decreased carbohydrate absorption occurs more often after ingestion of juices that contain more sorbitol, a non-absorbable sugar, and higher concentrations of fructose over glucose than after ingestion of juices which lack sorbitol and contain equal amounts of glucose and fructose. Moreover, other factors in apple juice, probably complex carbohydrates originating from the fruit skin, seem to be capable of provoking osmotic diarrhea (Hyams JS, et al. Carbohydrate malabsorption following fruit juice ingestion in young children. Pediatrics 1988;82:64- 8). Therefore, suggestions to use fruit juices as an alternative to oral rehydration solutions, even when diluted half-strength, as advised in the present study, should be accompanied by additional warnings. Recommendations to take precautions are especially relevant for very young children and infants, as efficiency of these carbohydrates absorption increases with age (Nobigrot T,et al. Carbohydrate absorption from one serving of fruit juice in young children: age and carbohydrate composition effects. J Am Coll Nutr 1997;16:152-8).

    Conflict of Interest:

    None declared

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