1586 e-Letters

  • is withdrawal of care ever appropriate language?

    There was an enquiry as
    I immediately saw the relevance of the service provided. Only one phrase seemed to me to be discordant. "...whether a cardiac pacemaker could
    be turned off during withdrawal of care, profoundly disturbing from the perspective of the clinicians.' this language , withdrawal of care is inaccurate and unfortunate. We may withdraw interventions, but not care. If the child dies as a consequence of the withdrawal I hope we care for the child during the process of dying, and look after the body with respect after the death. I hope we look after parents and siblings during the process of discussing treatment options and withdrawing. I speculate that a strong reassurance that we will continue to provide care for the child and family may be helpful in discussing withdrawing intervention.

  • High-flow oxygen therapy in moderate to severe bronchiolitis: a randomised controlled trial.

    Most of the results in table 3 express the difference as high flow minus low flow except for two in the section "VWS (hours) at 6 and 12 hours "that use low flow minus high flow.
    In the abstract the primary outcome is expressed as low flow minus high flow while in Table 3 it is expressed as high flow minus low flow.
    This is an underpowered study and rather than say "we find no measurably clinically relevant benefit in the use of HF compared with LF in hypoxic children......" would it be more accurate to say "we conclude there is insufficient evidence to show a difference in HF versus LF....", ie. this is called a Type 2 error.

  • Can you check ASOT in article?

    "Nineteen per cent of reported cases had an elevated ASOT (200 IU/mL or above) and the mean titre was 600 IU/mL. "

    Is 600 the mean of all ASOT measured, or just the 19% of children with elevated results?

  • Paediatric nurse support and supervision is critical

    I am sure many readers will support Chapman et al’s call to action around the need for greater confidence with, and involvement in, the treatment of very low weight eating-disordered states by paediatricians on paediatric wards. Since the article’s publication, many eating disorders resources have been made available, free of charge, which should help with this upskilling project.

    However, if increasing paediatrician skill and confidence is to translate into greater acceptance of the presence of this group of young people on paediatric wards, the whole hospital paediatric workforce will need to feel more comfortable with treating very low weight eating-restriction. I am thinking here of the nurses and healthcare assistants who spend so much more time with this group of inpatients. And I am also thinking of the ward dietician.

    As Chapman et al note, paediatricians have a vital role with psycho-education, in regularly reviewing the child or young person’s physical state, and in making treatment decisions based on this. However, they do not spend sustained periods of time each day at the bedside. They do not have to tolerate - for such long periods - the powerful emotional ‘projections’ that accompany each mealtime or each ng insertion ie the spoken-aloud emotional statements, as well as the belly ‘vibes’ (feelings) that one person can generate in another. It is this aspect of the daily care of children and young people in dangerous states of eating-disordered...

    Show More
  • We have a responsibility to discuss and record the detrimental health effects of air pollution

    Varghese and colleagues draw attention to and argue for better capture of the link between air pollution and fatal or near-fatal asthma at a patient level [1]

    Evidence on the detrimental effects of air pollution on health have led to the World Health Organisation proposing stringent targets in guidelines for improving air quality [2,3], which in the UK we fall far short of [4].
    There is a clear mismatch: if air pollution is a major risk for 5 million excess deaths per year globally and 30-40 thousand excess deaths in the UK [5], why is that risk rarely discussed in clinical consultations or documented in clinical records? We frequently ask about smoking and pets in the household when taking a clinical history, but not about outdoor air pollution exposure in terms of where children live or how they walk to school in relation to local busy roads.

    In 2020 the result of an inquest linked the death of a 9 year old girl, to air pollution based on careful examination of timing of admissions and spikes in air pollution over the preceding years. The coroner rightly criticised many professional groups. This included those responsible for medical education for failing to focus on air pollution and clinicians for failing to warn this girl’s family about the health risks of air pollution [6].

    So despite the considerable scientific evidence, air pollution is seldom recorded clinically. It has a code that is rarely used (Exposure to air pollution ICD10 Co...

    Show More
  • The importance of objective assessment of prenatal exposure to alcohol through measurement of biomarkers in meconium

    The importance of objective assessment of prenatal exposure to alcohol through measurement of biomarkers in meconium

    Oscar Garcia-Algar1,2,3*, Luigi Tarani4, Francesco Paolo Busardò5, Simona Pichini3,5, Emilia Marchei5

    1. Neonatology Unit, Hospital Clinic-Maternitat, ICGON, BCNatal, Barcelona Centre for Maternal Foetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Barcelona, Spain
    2. Department de Cirurgia i Especialitats Mèdico-Quirúrgiques, Universitat de Barcelona, Barcelona, Spain
    3. European Foetal Alcohol Spectrum Disorders Alliance (EUFASD), Stockholm, Sweden
    4. Department of Pediatrics, Sapienza University of Rome, Rome, Italy
    5. National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy

    Dear Editor,
    We read with attention the paper by Henderson et al. concerning comparison of confidential postnatal maternal interview and measurement of alcohol biomarkers in meconium (1). We would like to draw attention on their conclusion: “Fatty acid ethyl esters (FAEEs) and Ethylglucuronide (EtG) measured in meconium have low sensitivity and specificity for self-reported alcohol consumption after 20 weeks’ gestation in an unselected Scottish population and measurement of these alcohol biomarkers in meconium cannot currently be recommended for the identification of newborns at risk of Fetal Alcohol Spectrum Disorders (FASD).”
    It has been more than 20 years since meconium analy...

    Show More
  • Is a clinical distinction between these conditions sustainable?

    Many thanks for an important study. It raises the question if a distinction between Reactive Attachment Disorder and autism based on the presumed aetiology can be sustained. The genetic aetiology of autism spectrum conditions was established on the impressive difference in concordance rates between MZ and DZ twins but there are epigenetic mechanisms which could explain this difference. MZ twins have exactly equal biochemical exposures before conception (preconception environment) whereas DZ twins do not. A number of environmental exposures in prior generations are associated with autism (Magdelena 2020, Golding 2021). A huge study of the MSSNG database finds a genetic cause involving different 134 genes in only 14% of autistic individuals (Trost 2023). What then is being acquired or inherited? If the answer is early childhood stress, the rise in autism need not be spurious.

  • Will there be sufficient person-power for this growing population?

    Great work Nicki. I have long argued the need for more paediatric respirologists to service this expanding population. There is a shortage of pediatric pulmonologists [sic] in the USA and most in practice are graying. Now we have data to support this argument. Of greater concern is the (lack of) availability of home nursing support, placing tremendous stress on family. In part due to the “mass resignation” arising during and after the pandemic, there is critical shortage of trained personnel to care for such children in their homes. We have been forced to start weaning patients from mechanical ventilatory support – chiefly those with chronic lung disease of prematurity – while they are still hospitalized before initial NICU discharge. Indeed, we may have our first decannulation of one such child in the next few months! Thank you for undertaking this study and reporting the trend we all foresaw.

  • Is self assessment the way forward in general paediatric clinics?

    Pubertal staging is rarely needed in a general paediatric clinic and I wonder if there is a way to avoid the difficult issues in examining older children and young people.
    I think the issues around chaperones are complex, as a male doctor, male patients often do not want a female nurse as a chaperone and on the whole peri-pubertal girls do not want to be examined at all by a male doctor.
    My strategy, when needed, is therefore to ask older children and young people to let me know what they think their pubertal stage is - testicular size can be self-assessed using a standard orchidometer, all other changes can be described with reference to standard drawings from a growth chart.
    I realise this is not evidence based practice but wonder if there is the possibility of a trial to compare paediatrician-assessed as opposed to self-assessed staging in non-specialist clinics?

  • Predictors of cerebral oedema in DKA management

    Dear authors, the article made for some interesting reading especially as the current DKA ICP recommended by BSPED has now been in force for almost 2 years. It provides some perspective on whether the difference in liberalized vs conservative management is clinically significant or otherwise. Our question relates to whether the authors found any data in the studies regarding change in osmolarity / rate of rise of sodium which are early predictors for risk of cerebral oedema.