We read with interest the paper by Krishnan et al.1 and agree that "pulsus paradoxus" (PP) of the oximetry plethysmogram (pleth) may be useful in assessing severity of acute asthma exacerbations in children. The visual assessment they propose is one of a number of approaches which have been used, with variable success in predicting clinical outcomes2,3,4.
Rather than pulse amplitude variation associated with respiration, figure 2 in the paper1 shows predominately baseline undulation, at a rate of about 1/5 to 1/6 of pulse rate; no time base nor simultaneous respiratory waveform is included. Can the authors thus be sure that the variation is due to respiration, and if it is, could the baseline variations in fact be associated with respiratory-related changes in peripheral blood volume? As the visual pleth display is dependent on processing by the pulse oximeter, it would be helpful to know more about the oximeter used.
We have monitored respiration using Respiratory Inductance Plethysmography (RIP) bands simultaneously with oximetry pleth in children with acute wheezing illness using a SOMNOscreen plus recorder (SOMNOmedics GmbH, Germany) with Nonin oximeter module (Nonin Medical Inc., USA). We developed software in MATLAB (The MathWorks Inc., USA) for quantifying pleth pulse amplitude to assess pulsus paradoxus analogous variation. Consistent with Krishnan et al., we found that chil...
We read with interest the paper by Krishnan et al.1 and agree that "pulsus paradoxus" (PP) of the oximetry plethysmogram (pleth) may be useful in assessing severity of acute asthma exacerbations in children. The visual assessment they propose is one of a number of approaches which have been used, with variable success in predicting clinical outcomes2,3,4.
Rather than pulse amplitude variation associated with respiration, figure 2 in the paper1 shows predominately baseline undulation, at a rate of about 1/5 to 1/6 of pulse rate; no time base nor simultaneous respiratory waveform is included. Can the authors thus be sure that the variation is due to respiration, and if it is, could the baseline variations in fact be associated with respiratory-related changes in peripheral blood volume? As the visual pleth display is dependent on processing by the pulse oximeter, it would be helpful to know more about the oximeter used.
We have monitored respiration using Respiratory Inductance Plethysmography (RIP) bands simultaneously with oximetry pleth in children with acute wheezing illness using a SOMNOscreen plus recorder (SOMNOmedics GmbH, Germany) with Nonin oximeter module (Nonin Medical Inc., USA). We developed software in MATLAB (The MathWorks Inc., USA) for quantifying pleth pulse amplitude to assess pulsus paradoxus analogous variation. Consistent with Krishnan et al., we found that children with visually apparent respiratory modulation of the pleth signal were more likely to require intravenous therapy and high dependency care, and also had longer hospital stay5. We also observed that respiratory modulation of pleth was most evident during regular respiration periods, which could suggest an association with sleep state.
Respiratory modulation of the pleth signal is promising in assessment of acute wheezing illness in children, but its measurement is influenced by physiological and technical factors; these need further exploration before being adopted as a clinical tool.
1. Krishnan SG, Wong HC, Ganapathy S, Ong GY. Oximetry-detected pulsus paradoxus predicts for severity in paediatric asthma. Arch Dis Child. 2020 Jun;105(6):533-538. doi: 10.1136/archdischild-2019-318043.
2. Arnold DH, Jenkins CA, Hartert TV. Noninvasive assessment of asthma severity using pulse oximeter plethysmograph estimate of pulsus paradoxus physiology. BMC Pulm Med. 2010; 29:10:17. doi: 10.1186/1471-2466-10-17.
3. Arnold DH, Wang L, Hartert TV. Pulse Oximeter Plethysmograph Estimate of Pulsus Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to Treatment. Acad Emerg Med. 2016; 23:315-322. doi: 10.1111/acem.12886.
4. Uong A, Brandwein A, Crilly C, York T, Avarello J, Gangadharan S. Pleth Variability Index to Assess Course of Illness in Children with Asthma. J Emerg Med. 2018; 55:179-184. doi: 10.1016/j.jemermed.2018.04.058.
5. Wertheim D, Anton O, Olden C and Seddon P. Respiratory modulation of the pulse oximeter plethysmogram amplitude as a marker of severity in acutely wheezy young children. European Respiratory Journal 2020; 56: Suppl. 64, 1206. DOI: 10.1183/13993003.congress-2020.1206
Prediction rules to identify young febrile infants with serious bacterial infections (SBI) have been developed by investigators globally. Comparisons of these rules should be conducted by independent parties to avoid conflicts of interest. Two newer prediction rules use procalcitonin (PCT) as an important variable: one rule,[1] created by the authors of the Velasco[2] paper, and the PECARN Febrile Infant Rule[3] created by the authors of this letter. There are important methodological issues which must be considered when evaluating Velasco’s validation of the PECARN study. 1) The Velasco study was a retrospective analysis of a registry at one hospital in Spain, while the PECARN study was prospectively conducted at 20 centers in the United States and analyzed by an independent data center (mitigating investigator bias). 2) The rate of SBI in the Velasco study was 20.5%, much higher than the 9.3% reported by the PECARN study[3] and other investigators.[4] This suggests a different patient population or SBI epidemiology than ours, and/or enrollment bias. 3) Although the PECARN rule (using the urinalysis, absolute neutrophil count [ANC] and PCT) was derived on febrile infants 0-60 days-old, we recommend implementation only on 29-60 day-old infants, as suggested in our article.[3] In the supplement to our article, the PECARN rule using rounded cutoffs (ANC of 4000 cells/mm3 and PCT of 0.5 ng/mL) for simplicity, safety and to decrease the risk of overfitting, performed with simi...
Prediction rules to identify young febrile infants with serious bacterial infections (SBI) have been developed by investigators globally. Comparisons of these rules should be conducted by independent parties to avoid conflicts of interest. Two newer prediction rules use procalcitonin (PCT) as an important variable: one rule,[1] created by the authors of the Velasco[2] paper, and the PECARN Febrile Infant Rule[3] created by the authors of this letter. There are important methodological issues which must be considered when evaluating Velasco’s validation of the PECARN study. 1) The Velasco study was a retrospective analysis of a registry at one hospital in Spain, while the PECARN study was prospectively conducted at 20 centers in the United States and analyzed by an independent data center (mitigating investigator bias). 2) The rate of SBI in the Velasco study was 20.5%, much higher than the 9.3% reported by the PECARN study[3] and other investigators.[4] This suggests a different patient population or SBI epidemiology than ours, and/or enrollment bias. 3) Although the PECARN rule (using the urinalysis, absolute neutrophil count [ANC] and PCT) was derived on febrile infants 0-60 days-old, we recommend implementation only on 29-60 day-old infants, as suggested in our article.[3] In the supplement to our article, the PECARN rule using rounded cutoffs (ANC of 4000 cells/mm3 and PCT of 0.5 ng/mL) for simplicity, safety and to decrease the risk of overfitting, performed with similarly high test accuracy. We have validated the PECARN rule using these rounded cutoffs on another 1363 infants with nearly identical test accuracy as the original study.[5] Using these thresholds, we have now analyzed nearly 3200 febrile infants < 60 days-old and have not missed one case of bacterial meningitis. 4) If implemented as we suggest, 4 of the 5 “missed cases” of SBI reported by Velasco would not be missed.
1. Gomez B, Mintegi S, Bressan S, et al. Validation of the "Step-by-Step" approach in the management of young febrile infants. Pediatrics 2016;138:e20154381.
2. Velasco R, Gomez B, Benito J, Mintegi S. Accuracy of PECARN rule for predicting serious bacterial infection in infants with fever without a source. Arch Dis Child 2020;0;1-6.
3. Kuppermann N, Dayan PS, Levine DA, et al. A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA Pediatr 2019;173:342–51.
4. Blaschke AJ, Korgenski EK, Wilkes J, et al. Rhinovirus in febrile infants and risk of bacterial infection. Pediatrics. 2018;141:e20172384.
5. Kuppermann N, Dayan PS, VanBuren JM, et al. Validation of a prediction rule for febrile infants less than or equal to 60 days in a multicenter network. Acad Emerg Med 2020;27:S43.
Scott-Jupp et al. recent paper (Effects of consultant residence out-of-hours on acute paediatric admissions1) appeared relevant to myself as a junior doctor at the end of my training. I am interested to know whether there was learning from the resident consultant around discharge behaviour to better understand the differences?
There were approximately 40% of admissions that stayed less than 12 hours and this group were more likely to be discharged when a consultant was resident. There was no significant difference in discharge rates in children who stayed more than 12 hours1.
Should the less ill children be attending acute services anyway? Would a service consisting of resident consultants feed into propping up the acute pathway for less ill children?
A prospective observational study found up to 42.2% of ED presentations over a 14 day period were judged to have been totally avoidable if the family had had better health education2. Studies have previously looked at the appropriateness of paediatric OPD new referrals and suggest that at least 39% of them could be managed by primary care3.
I wonder whether the expansion of paediatric consultant posts due to increased ED attendance have unwittingly made secondary care reluctant to challenge the status quo of paediatric care delivery despite clear evidence that hospital is not always appropriate? If paediatric ED attendance starts to go down, would the current system become redundant? Other models...
Scott-Jupp et al. recent paper (Effects of consultant residence out-of-hours on acute paediatric admissions1) appeared relevant to myself as a junior doctor at the end of my training. I am interested to know whether there was learning from the resident consultant around discharge behaviour to better understand the differences?
There were approximately 40% of admissions that stayed less than 12 hours and this group were more likely to be discharged when a consultant was resident. There was no significant difference in discharge rates in children who stayed more than 12 hours1.
Should the less ill children be attending acute services anyway? Would a service consisting of resident consultants feed into propping up the acute pathway for less ill children?
A prospective observational study found up to 42.2% of ED presentations over a 14 day period were judged to have been totally avoidable if the family had had better health education2. Studies have previously looked at the appropriateness of paediatric OPD new referrals and suggest that at least 39% of them could be managed by primary care3.
I wonder whether the expansion of paediatric consultant posts due to increased ED attendance have unwittingly made secondary care reluctant to challenge the status quo of paediatric care delivery despite clear evidence that hospital is not always appropriate? If paediatric ED attendance starts to go down, would the current system become redundant? Other models of care such as GP hubs may be a more appropriate area in which to invest. They have already demonstrated high patient satisfaction3.
The coronavirus pandemic has challenged the way we work in many ways. In light of this, the paediatric profession has the opportunity to change our care delivery processes in a way that maximises the benefit for the child. I hope that secondary care can work more creatively with primary care, for example by running more joint clinics with GPs and developing links with community nursing/mental health teams. This will shift focus back to child centred paediatric care.
References
1. Scott-Jupp R, Carter E, Brown N. Effects of consultant residence out-of-hours on acute paediatric admissions. Arch Dis Child. Jul 2020;105(7):661-663. doi:10.1136/archdischild-2019-317553
2. Viner RM, Blackburn F, White F, et al. The impact of out-of-hospital models of care on paediatric emergency department presentations. Arch Dis Child. Feb 2018;103(2):128-136. doi:10.1136/archdischild-2017-313307
3. Montgomery-Taylor S, Watson M, Klaber R. Child Health General Practice Hubs: a service evaluation. Arch Dis Child. Apr 2016;101(4):333-7. doi:10.1136/archdischild-2015-308910
To the editor
We appreciated the Images in paediatrics ‘Necrosis of infantile haemangioma with propranolol therapy’ by Grech and colleagues1. Nevertheless, we take exception to the Authors’ statement that necrosis is due to propranolol induced-involution for several reasons: first of all, the infant was not receiving a full-dose medication (1.5 mg/kg/day) when propranolol should be given at minimum 2 mg/kg/day. Furthermore, the milestone study by Léauté-Labrèz et al showed that a daily regimen of 3 mg/kg is safe and effective in reducing haemangiomas in a cohort of 456 infants2. We do believe that considering the low dose and the proliferative phase the infant was in3, necrosis was most likely due to natural evolution of the haemangioma than drug-induced involution. The authors do not give precise measurements of the scalp lesion before and during treatment, so it is not clear how much the lesion diminished in size. In view of previous considerations, it is difficult to rule out that the lesion might just have followed its natural course. As a matter of fact, both prematurity and female gender are well known risk factors associated with ulceration4.As the authors properly underline, propranolol therapy is the treatment of choice for infantile haemangioma (IH) and adverse effects as hypoglycemia, hypotension and bradycardia are widely known. Ulceration is the most common complication of IH and so that it could be even considered an indication to continue rather than...
To the editor
We appreciated the Images in paediatrics ‘Necrosis of infantile haemangioma with propranolol therapy’ by Grech and colleagues1. Nevertheless, we take exception to the Authors’ statement that necrosis is due to propranolol induced-involution for several reasons: first of all, the infant was not receiving a full-dose medication (1.5 mg/kg/day) when propranolol should be given at minimum 2 mg/kg/day. Furthermore, the milestone study by Léauté-Labrèz et al showed that a daily regimen of 3 mg/kg is safe and effective in reducing haemangiomas in a cohort of 456 infants2. We do believe that considering the low dose and the proliferative phase the infant was in3, necrosis was most likely due to natural evolution of the haemangioma than drug-induced involution. The authors do not give precise measurements of the scalp lesion before and during treatment, so it is not clear how much the lesion diminished in size. In view of previous considerations, it is difficult to rule out that the lesion might just have followed its natural course. As a matter of fact, both prematurity and female gender are well known risk factors associated with ulceration4.As the authors properly underline, propranolol therapy is the treatment of choice for infantile haemangioma (IH) and adverse effects as hypoglycemia, hypotension and bradycardia are widely known. Ulceration is the most common complication of IH and so that it could be even considered an indication to continue rather than to stop treatment.
Best regards,
Francesca Peri, MD
Irene Berti, MD
Egidio Barbi, MD, Professor
1- Grech JA, Calleja T, Soler P, et al. Necrosis of infantile haemangioma with propranolol therapy. Archives of Disease in Childhood 2020;105:608.
2- Léauté-Labrèze C et al. A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma. N Engl J Med. 2015; 372:735-746.
3- Storch CH, Hoeger PH. Propranolol for infantile haemangiomas: insights into the molecular mechanisms of action. Br J Dermatol. 2010;163(2):269-274. doi:10.1111/j.1365-2133.2010.09848.
4- Chang CS, Kang GC. Efficacious Healing of Ulcerated Infantile Hemangiomas Using Topical Timolol. Plast Reconstr Surg Glob Open. 2016;4(2):e621. Published 2016 Feb 16.
The question of the safety of ibuprofen in lower respiratory tract infection(LRTI)(1) should be part of a bigger question. That question is the issue of the safety of ibuprofen in a child who is at risk of dehydration. A febrile child with LRTI is at risk of dehydration because of increased insensible fluid loss via the skin. Furthermore, in the presence of LRTI-related tachypnoea, there will be increased insensible fluid loss via the upper respiratory tract . These fluid losses are compounded when the child is too ill to maintain a good oral fluid intake.
In volume depleted states, such as the scenario depicted above, vasodilatory prostaglandins maintain adequate renal blood flow(RBF) and adequate glomerular filtration rate(GFR)(2). Nonsteroidal anti inflammatory drugs(NSAIDs) undermine those compensatory mechanisms by inhibiting prostaglandin synthesis(2). The consequence is the onset of NSAID-related acute kidney injury(AKI), as postulated by Misurac et al(3). These investigators postulated that NSAID-related inhibition of prostaglandin synthesis was the underlying cause of AKI in 21 of their 27 cases of NSAID-related AKI. In the remaining 6 children with AKI, acute interstitial nephritis(also attributable to NSAIDs) was the underlying cause.. Fifteen of the 20 children for whom dosing data were available took NSAID doses in the recommended range. Ibuprofen was the culprit NSAID in 67% of cases. Misurac et al also identified 54 other cases...
The question of the safety of ibuprofen in lower respiratory tract infection(LRTI)(1) should be part of a bigger question. That question is the issue of the safety of ibuprofen in a child who is at risk of dehydration. A febrile child with LRTI is at risk of dehydration because of increased insensible fluid loss via the skin. Furthermore, in the presence of LRTI-related tachypnoea, there will be increased insensible fluid loss via the upper respiratory tract . These fluid losses are compounded when the child is too ill to maintain a good oral fluid intake.
In volume depleted states, such as the scenario depicted above, vasodilatory prostaglandins maintain adequate renal blood flow(RBF) and adequate glomerular filtration rate(GFR)(2). Nonsteroidal anti inflammatory drugs(NSAIDs) undermine those compensatory mechanisms by inhibiting prostaglandin synthesis(2). The consequence is the onset of NSAID-related acute kidney injury(AKI), as postulated by Misurac et al(3). These investigators postulated that NSAID-related inhibition of prostaglandin synthesis was the underlying cause of AKI in 21 of their 27 cases of NSAID-related AKI. In the remaining 6 children with AKI, acute interstitial nephritis(also attributable to NSAIDs) was the underlying cause.. Fifteen of the 20 children for whom dosing data were available took NSAID doses in the recommended range. Ibuprofen was the culprit NSAID in 67% of cases. Misurac et al also identified 54 other cases of NSAID-related AKI in the medical literature during the period 1993 to 2009. Sixty percent of 50 cases for whom dosing data were available took the recommended does of NSAID. Fifty-three percent of the 54 cases were documented as having experienced reduced fluid intake before admission. Ibuprofen was the culprit NSAID in 20 of the 54 cases.
Comment
In the presence of LRTI-related dehydration ibuprofen has the potential to precipitate AKI as a result of NSAID-related inhibition of prostaglandin synthesis.
I have no funding and no conflict of interest
References
(1) Skehin K., Thompson A., Moriarty P
Is use of ibuprofen safe in children with signs and symptoms of lower respiratory tract infection?
Arch Dis Child 2019 Epub ahead of print
(2) Kim G-H
Renal effects of prostaglandins and cyclooxygenase-2 inhibitors
Electrolyte & Bood Disorders 2008;6:35-41
(3)Misurac JM., Knoderer CA., Leiser D et al
Nonsteroidal anti-inflammatory drugs are an important cause of acute kidney injury in children
J Pediatr 2013;162:1153-1159
Infant vitamin D supplementation prevents not just rickets but also hypocalcaemic seizures and cardiomyopathy (CMP). The BPSU survey (1) captures rickets incidence which, we feel compelled to highlight, represents only the tip of the iceberg of widespread vitamin D deficiency (VDD) in the population.
In the UK, child surveillance checks are led by general practitioners (GPs). Most GPs do not receive postgraduate paediatric training and have inadequate undergraduate paediatric exposure, as acknowledged by the RCPCH president: “by any stretch of the imagination, GP training in the UK in paediatrics is woefully inadequate” (2). Recognising rickets requires paediatric experience as exemplified by recent cases of VDD induced CMP- one child’s death was preceded by multiple unfruitful visits to GPs and casualty (3). As the BPSU survey reached out only to paediatricians and not GPs, the extent of underreporting and under diagnosis is likely huge, limiting comparison with countries where paediatricians oversee primary care. The conclusion that rickets incidence in the UK is lower than expected downplays the extent of the underlying public health crisis, particularly when a significant number of cases were excluded [table 2 of (1)]. The true disease burden is unravelled when family members of affected children are investigated (3).
Similar to previous studies, rickets incidence here is 90 to 166 fold higher in Asian and Black children compared to wh...
Infant vitamin D supplementation prevents not just rickets but also hypocalcaemic seizures and cardiomyopathy (CMP). The BPSU survey (1) captures rickets incidence which, we feel compelled to highlight, represents only the tip of the iceberg of widespread vitamin D deficiency (VDD) in the population.
In the UK, child surveillance checks are led by general practitioners (GPs). Most GPs do not receive postgraduate paediatric training and have inadequate undergraduate paediatric exposure, as acknowledged by the RCPCH president: “by any stretch of the imagination, GP training in the UK in paediatrics is woefully inadequate” (2). Recognising rickets requires paediatric experience as exemplified by recent cases of VDD induced CMP- one child’s death was preceded by multiple unfruitful visits to GPs and casualty (3). As the BPSU survey reached out only to paediatricians and not GPs, the extent of underreporting and under diagnosis is likely huge, limiting comparison with countries where paediatricians oversee primary care. The conclusion that rickets incidence in the UK is lower than expected downplays the extent of the underlying public health crisis, particularly when a significant number of cases were excluded [table 2 of (1)]. The true disease burden is unravelled when family members of affected children are investigated (3).
Similar to previous studies, rickets incidence here is 90 to 166 fold higher in Asian and Black children compared to white. As the proportion of ethnic minority in the UK continues to rise (14% in 2011 census) those at highest risk of VDD are failed most by inadequate prevention strategies (4).
Shockingly, 77% of reported cases were not on the Department of Health recommended vitamin D supplements demonstrating lack of policy implementation. Whilst we agree with the author’s recommendations on supplementation, vitamin D fortification of flour as a more cost-effective long term strategy should be seriously considered (5).
References:
1. Julies P, Lynn RM, Pall K, Leoni M, Calder A, Mughal Z, et al. Nutritional rickets under 16 years : UK surveillance results. Arch Dis Child. 2020;
2. Modi N, Simon C. Child health care: Adequate training for all UK GPs is long overdue. Br J Gen Pract. 2016;66(646):228–9.
3. Uday S, Fratzl-Zelman N, Roschger P, Klaushofer K, Chikermane A, Saraff V, et al. Cardiac, bone and growth plate manifestations in hypocalcemic infants: revealing the hidden body of the vitamin D deficiency iceberg. BMC Pediatr. 2018 Dec;18(1):183.
4. Uday S, Högler W. Prevention of rickets and osteomalacia in the UK: political action overdue. Arch Dis Child. 2018;103(9):901–6.
5. Aguiar M, Andronis L, Pallan M, Högler W, Frew E. The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales. Eur J Clin Nutr. 2019; DOI:10.1038/s41430-019-0486-x
We enjoyed reading the study by Jaquet-Pilloud et al. 1 examining the role of nebulised 3% hypertonic saline (HS) and bronchiolitis. We thank the authors for this excellent pragmatic non-blinded, randomised controlled trial. Their conclusions support the UK evidence from the SABRE study 2 and their systematic review3 which provides evidence of the futility of adding hypertonic saline to the management of bronchiolitis when compared to standard care alone with length of stay (LOS) or ready for discharge as the primary outcome. The article was well written and easy to follow. The study examined 121 infants with bronchiolitis recruited over three years from one tertiary centre in Switzerland. We felt it illustrated the very important problem of underpowered studies concluding no differences between two treatment regimens. The authors used the Korppi et al 3 study to assume that the mean LOS for infants admitted to hospital with bronchiolitis was 5 days [120 hours] with a standard deviation of 1.2 days [28.8 hours]. Reduction in hospital stay by 1 day was considered clinically significant and based on this a minimum sample size of 120 (with 60 in each group) was arrived. However the data from this paper by Jaquet-Pilloud et al show that the mean LOS was 47 hours (± 8.5) for nebulised hypertonic saline group and 50.4 hours (±11) for standard care group. The LOS at the authors’ hospital was less than half of the assumption used for their power calculation....
We enjoyed reading the study by Jaquet-Pilloud et al. 1 examining the role of nebulised 3% hypertonic saline (HS) and bronchiolitis. We thank the authors for this excellent pragmatic non-blinded, randomised controlled trial. Their conclusions support the UK evidence from the SABRE study 2 and their systematic review3 which provides evidence of the futility of adding hypertonic saline to the management of bronchiolitis when compared to standard care alone with length of stay (LOS) or ready for discharge as the primary outcome. The article was well written and easy to follow. The study examined 121 infants with bronchiolitis recruited over three years from one tertiary centre in Switzerland. We felt it illustrated the very important problem of underpowered studies concluding no differences between two treatment regimens. The authors used the Korppi et al 3 study to assume that the mean LOS for infants admitted to hospital with bronchiolitis was 5 days [120 hours] with a standard deviation of 1.2 days [28.8 hours]. Reduction in hospital stay by 1 day was considered clinically significant and based on this a minimum sample size of 120 (with 60 in each group) was arrived. However the data from this paper by Jaquet-Pilloud et al show that the mean LOS was 47 hours (± 8.5) for nebulised hypertonic saline group and 50.4 hours (±11) for standard care group. The LOS at the authors’ hospital was less than half of the assumption used for their power calculation. Our calculation suggests that based on authors LOS, the minimum sample should be at least 240 subjects. This calculation was similar to the numbers recruited in the SABRE study which used the UK hospital episode statistics that suggested that the average (mean (SD)) time to discharge was 72 (32) hours to power their study and with three years of recruitment and a total of 317 infants in this study with 158 infants randomised to HS and 159 to standard care. There was no difference between the two arms in time to being declared fit for discharge. They showed the median (not mean in this paper) time to being declared fit for discharge was 76 hours from admission in each group, and the time to actual discharge was 89 hours in each group. Essentially Jaquet-Pilloud et al needed twice as many subjects to be sure that there was no type 2 error and to be confident about the accuracy of their conclusions.
Yours sincerely
Dr Muthukumar Sakthivel, Dr Dure Yasrab, Dr Kevin Enright and Professor Colin Powell
Pediatric Emergency Department Sidra Medicine, Doha, Qatar
Dr Whitaker, in a letter in response to our Archimedes review of whether waveform capnography reliably approximates paCO2 in neonates, highlights two important questions which capnography seeks to address: Firstly, whether or not the endotracheal tube (ETT) is patent and correctly positioned in the trachea and secondly, whether the current ventilation strategy provides optimal CO2 clearance for the patient. The two questions are, of course, interlinked.
To date, in our field of neonatal medicine, the ETCO2 provides a valuable adjunct to clinical examination in determining ETT position and patency both at the point of intubation and during ongoing mechanical ventilation. However, for reasons explained in the paper, the numerical approximations to alveolar pCO2 provided by the currently available techniques of wave form capnography in neonates are not accurate enough to guide ventilatory changes. Thus, to guide ventilator changes, many neonatal intensive care units currently use transcutaneous capnometry.
In addition to the physiological properties, the waveform capnography sensors add extra weight and dead space to an infant’s ventilator circuit. This adds further complexity, like their still not fully assessed effect on volume-guarantee ventilation and potential for auto-triggering of ventilators. As volume guarantee is now considered the gold standard for ventilating preterm infants with respiratory distress syndrome, the value of waveform capnography, in addi...
Dr Whitaker, in a letter in response to our Archimedes review of whether waveform capnography reliably approximates paCO2 in neonates, highlights two important questions which capnography seeks to address: Firstly, whether or not the endotracheal tube (ETT) is patent and correctly positioned in the trachea and secondly, whether the current ventilation strategy provides optimal CO2 clearance for the patient. The two questions are, of course, interlinked.
To date, in our field of neonatal medicine, the ETCO2 provides a valuable adjunct to clinical examination in determining ETT position and patency both at the point of intubation and during ongoing mechanical ventilation. However, for reasons explained in the paper, the numerical approximations to alveolar pCO2 provided by the currently available techniques of wave form capnography in neonates are not accurate enough to guide ventilatory changes. Thus, to guide ventilator changes, many neonatal intensive care units currently use transcutaneous capnometry.
In addition to the physiological properties, the waveform capnography sensors add extra weight and dead space to an infant’s ventilator circuit. This adds further complexity, like their still not fully assessed effect on volume-guarantee ventilation and potential for auto-triggering of ventilators. As volume guarantee is now considered the gold standard for ventilating preterm infants with respiratory distress syndrome, the value of waveform capnography, in addition to standard expiratory tidal volume monitoring on volume-guarantee ventilated infants and transcutaneous capnometry, is a topic worthy of further research and discussion.
Dear Editor
We read with interest Dr Scrivens et al’s commentary [1]. The mother’s question - ‘should capnography be used for breathing tube monitoring?’ – captures the subject addressed in our ‘PICNIC survey’ [2]. Conversely, the authors examine a completely different question - ‘is capnography an optimum respiratory monitor in ventilated neonates?’
A respiratory monitor detects whether the end-tidal CO2 value usefully measures pulmonary ventilation or PaCO2. Although not our focus here, we are surprised the review omitted Kugelman’s study which reported waveform capnography monitoring in neonatal ICU (NICU) improved ventilation accuracy and neurological outcomes [3].
An airway monitor assesses ‘whether lung ventilation is taking place via a tracheal tube that is in the airway and is patent’. High rates of neonatal failed intubation, oesophageal intubation, accidental extubation and reports of associated patient harm all suggest the value of a reliable airway monitor in NICU. Waveform capnography rapidly detects correct intubation with few false positives and immediately detects displacement or disconnection, the evidence for which we have previously set out [4-6].
Some neonatologists argue that continuous waveform capnography cannot be used in neonates. It is used routinely in neonatal anaesthesia. Others use it routinely during transfer of small neonates (eg 400g) (personal communication Dr James Tooley, Consultant, Bristol) sometimes only for it...
Dear Editor
We read with interest Dr Scrivens et al’s commentary [1]. The mother’s question - ‘should capnography be used for breathing tube monitoring?’ – captures the subject addressed in our ‘PICNIC survey’ [2]. Conversely, the authors examine a completely different question - ‘is capnography an optimum respiratory monitor in ventilated neonates?’
A respiratory monitor detects whether the end-tidal CO2 value usefully measures pulmonary ventilation or PaCO2. Although not our focus here, we are surprised the review omitted Kugelman’s study which reported waveform capnography monitoring in neonatal ICU (NICU) improved ventilation accuracy and neurological outcomes [3].
An airway monitor assesses ‘whether lung ventilation is taking place via a tracheal tube that is in the airway and is patent’. High rates of neonatal failed intubation, oesophageal intubation, accidental extubation and reports of associated patient harm all suggest the value of a reliable airway monitor in NICU. Waveform capnography rapidly detects correct intubation with few false positives and immediately detects displacement or disconnection, the evidence for which we have previously set out [4-6].
Some neonatologists argue that continuous waveform capnography cannot be used in neonates. It is used routinely in neonatal anaesthesia. Others use it routinely during transfer of small neonates (eg 400g) (personal communication Dr James Tooley, Consultant, Bristol) sometimes only for it to be removed on arrival at NICU! In veterinary practice it may be used in animals weighing 50g (personal communication, Dr Jonathan Cracknell, Wildlife Anaesthesia Services, Longleat, Wiltshire).
Proving the value of safety measures by randomised controlled trials (RCTs) is often impractical because of the rarity of the adverse outcomes the intervention is intended to prevent (here hypoxaemic brain injury or death). There are no RCTs that show outcome benefit of oximetry in anaesthesia or critical care, but its use is universal. Proving capnography improves outcomes via RCT may be challenging – though studying the impact on prompt recognition of incorrect intubation, disconnections and accidental extubation is feasible.
In 2011 waveform capnography was available in half of adult ICUs and these often used it infrequently [7]. There was significant resistance to the NAP4 recommendation for universal implementation, including senior intensivists stating its use was impossible and unnecessary - because ventilator parameters would readily identify problems. That some adult ICUs were using it widely and others not at all mirrors current NICU practice: this variation in practice merits urgent investigation and explanation. Four years after NAP4, 98% of adult ICUs had waveform capnography, using it routinely at intubation and for monitoring all ventilated patients [8]. Capnography in ICU is practical and it is now accepted in UK adult ICUs as a standard of care.
Neonates, in common with all humans, exhale carbon dioxide with every breath. Detection of this has the potential to be the most rapid and reliable monitor of airway integrity in neonates reliant on an artificial airway. In determining whether waveform capnography is the right tool in their setting it is important that the neonatal community start to ask the right question.
TM Cook
KE Foy
FE Kelly
References
1. Scrivens A, Zivanovic S, Roehr CC. Is waveform capnography reliable in neonates? Arch Dis Child July 2019 Vol 104 No 7 http://dx.doi.org/10.1136/archdischild-2018-316577
2. Foy K, Mew E, Cook T, et al United Kingdom paediatric and neonatal intensive care airway management: the PICNIC survey, Anaesthesia 2018; 73: 1337-44
3. Kugelman A, Golan A, Riskin A et al. Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study. Journal of Pediatrics 2016; 168: 56-61
4. Cook TM, Foy K, Kelly F. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. (Response to Mactier et al.) http://www.respond2articles.com/ANA/forums/thread/2670.aspx
5. Cook TM, Foy K, Kelly F. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. (Response to Wyllie et al.) http://www.respond2articles.com/ANA/forums/thread/2677.aspx
6. Cook TM, Foy K, Kelly F. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia 2019; 74; 118-120
7. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2 Intensive Care and Emergency Department. British Journal of Anaesthesia 2011; 106: 632-42
8. Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. British Journal of Anaesthesia 2016; 117: 182-190
Dear authors,
I read with great interest your article on multiple café-au-lait macules and movement disorder (1). I want to point out that probably an error happened during formatting of table 1. The term RASopathies is used to refer to a group of diseases caused by a mutation in a gene coding for a key component of the RAS-pathway and resulting in hyperactivation of the pathway. This group commonly includes Noonan syndrome, Neurofibromatosis type 1, Legius syndrome, LEOPARD syndrome (now referred to as Noonan syndrome with multiple lentigines), Costello syndrome, CFC syndrome, hereditary gingival fibromatosis, capillary malformation-arteriovenous malformation and Loh syndrome (2). It is confusing to find RASopathies next to Noonan, Legius and LEOPARD syndrome in the same column of table 1. In the same column Legius syndrome is listed as well as NF-like syndrome. Legius syndrome is listed followed by (PTPN11) and NF-like syndrome is followed by the gene (SPRED1). PTPN11 should be listed after Noonan syndrome because it is the most frequent cause of Noonan syndrome and it is not related to Legius syndrome. Legius syndrome is the same as NF1-like syndrome and only one of the two should be listed followed by (SPRED1). In our first publication (3) we named the condition neurofibromatosis 1-like syndrome but later is was renamed Legius syndrome (4).
Congenital mismatch repair deficiency (CMMRD) is another autosomal recessive condition with café-au-lait macules and...
Dear authors,
I read with great interest your article on multiple café-au-lait macules and movement disorder (1). I want to point out that probably an error happened during formatting of table 1. The term RASopathies is used to refer to a group of diseases caused by a mutation in a gene coding for a key component of the RAS-pathway and resulting in hyperactivation of the pathway. This group commonly includes Noonan syndrome, Neurofibromatosis type 1, Legius syndrome, LEOPARD syndrome (now referred to as Noonan syndrome with multiple lentigines), Costello syndrome, CFC syndrome, hereditary gingival fibromatosis, capillary malformation-arteriovenous malformation and Loh syndrome (2). It is confusing to find RASopathies next to Noonan, Legius and LEOPARD syndrome in the same column of table 1. In the same column Legius syndrome is listed as well as NF-like syndrome. Legius syndrome is listed followed by (PTPN11) and NF-like syndrome is followed by the gene (SPRED1). PTPN11 should be listed after Noonan syndrome because it is the most frequent cause of Noonan syndrome and it is not related to Legius syndrome. Legius syndrome is the same as NF1-like syndrome and only one of the two should be listed followed by (SPRED1). In our first publication (3) we named the condition neurofibromatosis 1-like syndrome but later is was renamed Legius syndrome (4).
Congenital mismatch repair deficiency (CMMRD) is another autosomal recessive condition with café-au-lait macules and similar to ataxia telangiectasia it is important to recognize because it is associated with malignancies (5). I suggest to add CMMRD to table 1.
References
1 Madaan P, Mukherjee S, Reddy C, et al. Multiple café-au-lait macules and movement disorder: think beyond neurofibromatosis. Arch Dis Child 2019;0:1. doi:10.1136/archdischild-2019-317497
2 Aoki Y, Niihori T, Inoue S, Matsubara Y. Recent advances in RASopathies. J Hum Genet 2016 ;61:33-9.
3 Brems H, Chmara M, Sahbatou M,et al. Germline loss-of-function mutations in SPRED1 cause a neurofibromatosis 1-like phenotype. Nat Genet 2007; 39:1120-26.
4 Stevenson D, Viskochil D Pigmentary findings in neurofibromatosis type 1-like syndrome (Legius syndrome): potential diagnostic dilemmas. JAMA 2009;19:2150-1.
5 Suerink M, Ripperger T, Messiaen L et al. Constitutional mismatch repair deficiency as a differential diagnosis of neurofibromatosis type 1: consensus guidelines for testing a child without malignancy. J Med Genet 2019;56:53-62.
We read with interest the paper by Krishnan et al.1 and agree that "pulsus paradoxus" (PP) of the oximetry plethysmogram (pleth) may be useful in assessing severity of acute asthma exacerbations in children. The visual assessment they propose is one of a number of approaches which have been used, with variable success in predicting clinical outcomes2,3,4.
Rather than pulse amplitude variation associated with respiration, figure 2 in the paper1 shows predominately baseline undulation, at a rate of about 1/5 to 1/6 of pulse rate; no time base nor simultaneous respiratory waveform is included. Can the authors thus be sure that the variation is due to respiration, and if it is, could the baseline variations in fact be associated with respiratory-related changes in peripheral blood volume? As the visual pleth display is dependent on processing by the pulse oximeter, it would be helpful to know more about the oximeter used.
We have monitored respiration using Respiratory Inductance Plethysmography (RIP) bands simultaneously with oximetry pleth in children with acute wheezing illness using a SOMNOscreen plus recorder (SOMNOmedics GmbH, Germany) with Nonin oximeter module (Nonin Medical Inc., USA). We developed software in MATLAB (The MathWorks Inc., USA) for quantifying pleth pulse amplitude to assess pulsus paradoxus analogous variation. Consistent with Krishnan et al., we found that chil...
Show MorePrediction rules to identify young febrile infants with serious bacterial infections (SBI) have been developed by investigators globally. Comparisons of these rules should be conducted by independent parties to avoid conflicts of interest. Two newer prediction rules use procalcitonin (PCT) as an important variable: one rule,[1] created by the authors of the Velasco[2] paper, and the PECARN Febrile Infant Rule[3] created by the authors of this letter. There are important methodological issues which must be considered when evaluating Velasco’s validation of the PECARN study. 1) The Velasco study was a retrospective analysis of a registry at one hospital in Spain, while the PECARN study was prospectively conducted at 20 centers in the United States and analyzed by an independent data center (mitigating investigator bias). 2) The rate of SBI in the Velasco study was 20.5%, much higher than the 9.3% reported by the PECARN study[3] and other investigators.[4] This suggests a different patient population or SBI epidemiology than ours, and/or enrollment bias. 3) Although the PECARN rule (using the urinalysis, absolute neutrophil count [ANC] and PCT) was derived on febrile infants 0-60 days-old, we recommend implementation only on 29-60 day-old infants, as suggested in our article.[3] In the supplement to our article, the PECARN rule using rounded cutoffs (ANC of 4000 cells/mm3 and PCT of 0.5 ng/mL) for simplicity, safety and to decrease the risk of overfitting, performed with simi...
Show MoreScott-Jupp et al. recent paper (Effects of consultant residence out-of-hours on acute paediatric admissions1) appeared relevant to myself as a junior doctor at the end of my training. I am interested to know whether there was learning from the resident consultant around discharge behaviour to better understand the differences?
There were approximately 40% of admissions that stayed less than 12 hours and this group were more likely to be discharged when a consultant was resident. There was no significant difference in discharge rates in children who stayed more than 12 hours1.
Should the less ill children be attending acute services anyway? Would a service consisting of resident consultants feed into propping up the acute pathway for less ill children?
A prospective observational study found up to 42.2% of ED presentations over a 14 day period were judged to have been totally avoidable if the family had had better health education2. Studies have previously looked at the appropriateness of paediatric OPD new referrals and suggest that at least 39% of them could be managed by primary care3.
I wonder whether the expansion of paediatric consultant posts due to increased ED attendance have unwittingly made secondary care reluctant to challenge the status quo of paediatric care delivery despite clear evidence that hospital is not always appropriate? If paediatric ED attendance starts to go down, would the current system become redundant? Other models...
Show MoreTo the editor
Show MoreWe appreciated the Images in paediatrics ‘Necrosis of infantile haemangioma with propranolol therapy’ by Grech and colleagues1. Nevertheless, we take exception to the Authors’ statement that necrosis is due to propranolol induced-involution for several reasons: first of all, the infant was not receiving a full-dose medication (1.5 mg/kg/day) when propranolol should be given at minimum 2 mg/kg/day. Furthermore, the milestone study by Léauté-Labrèz et al showed that a daily regimen of 3 mg/kg is safe and effective in reducing haemangiomas in a cohort of 456 infants2. We do believe that considering the low dose and the proliferative phase the infant was in3, necrosis was most likely due to natural evolution of the haemangioma than drug-induced involution. The authors do not give precise measurements of the scalp lesion before and during treatment, so it is not clear how much the lesion diminished in size. In view of previous considerations, it is difficult to rule out that the lesion might just have followed its natural course. As a matter of fact, both prematurity and female gender are well known risk factors associated with ulceration4.As the authors properly underline, propranolol therapy is the treatment of choice for infantile haemangioma (IH) and adverse effects as hypoglycemia, hypotension and bradycardia are widely known. Ulceration is the most common complication of IH and so that it could be even considered an indication to continue rather than...
The question of the safety of ibuprofen in lower respiratory tract infection(LRTI)(1) should be part of a bigger question. That question is the issue of the safety of ibuprofen in a child who is at risk of dehydration. A febrile child with LRTI is at risk of dehydration because of increased insensible fluid loss via the skin. Furthermore, in the presence of LRTI-related tachypnoea, there will be increased insensible fluid loss via the upper respiratory tract . These fluid losses are compounded when the child is too ill to maintain a good oral fluid intake.
Show MoreIn volume depleted states, such as the scenario depicted above, vasodilatory prostaglandins maintain adequate renal blood flow(RBF) and adequate glomerular filtration rate(GFR)(2). Nonsteroidal anti inflammatory drugs(NSAIDs) undermine those compensatory mechanisms by inhibiting prostaglandin synthesis(2). The consequence is the onset of NSAID-related acute kidney injury(AKI), as postulated by Misurac et al(3). These investigators postulated that NSAID-related inhibition of prostaglandin synthesis was the underlying cause of AKI in 21 of their 27 cases of NSAID-related AKI. In the remaining 6 children with AKI, acute interstitial nephritis(also attributable to NSAIDs) was the underlying cause.. Fifteen of the 20 children for whom dosing data were available took NSAID doses in the recommended range. Ibuprofen was the culprit NSAID in 67% of cases. Misurac et al also identified 54 other cases...
Dear Editor
Infant vitamin D supplementation prevents not just rickets but also hypocalcaemic seizures and cardiomyopathy (CMP). The BPSU survey (1) captures rickets incidence which, we feel compelled to highlight, represents only the tip of the iceberg of widespread vitamin D deficiency (VDD) in the population.
In the UK, child surveillance checks are led by general practitioners (GPs). Most GPs do not receive postgraduate paediatric training and have inadequate undergraduate paediatric exposure, as acknowledged by the RCPCH president: “by any stretch of the imagination, GP training in the UK in paediatrics is woefully inadequate” (2). Recognising rickets requires paediatric experience as exemplified by recent cases of VDD induced CMP- one child’s death was preceded by multiple unfruitful visits to GPs and casualty (3). As the BPSU survey reached out only to paediatricians and not GPs, the extent of underreporting and under diagnosis is likely huge, limiting comparison with countries where paediatricians oversee primary care. The conclusion that rickets incidence in the UK is lower than expected downplays the extent of the underlying public health crisis, particularly when a significant number of cases were excluded [table 2 of (1)]. The true disease burden is unravelled when family members of affected children are investigated (3).
Similar to previous studies, rickets incidence here is 90 to 166 fold higher in Asian and Black children compared to wh...
Show MoreDear Editor
We enjoyed reading the study by Jaquet-Pilloud et al. 1 examining the role of nebulised 3% hypertonic saline (HS) and bronchiolitis. We thank the authors for this excellent pragmatic non-blinded, randomised controlled trial. Their conclusions support the UK evidence from the SABRE study 2 and their systematic review3 which provides evidence of the futility of adding hypertonic saline to the management of bronchiolitis when compared to standard care alone with length of stay (LOS) or ready for discharge as the primary outcome. The article was well written and easy to follow. The study examined 121 infants with bronchiolitis recruited over three years from one tertiary centre in Switzerland. We felt it illustrated the very important problem of underpowered studies concluding no differences between two treatment regimens. The authors used the Korppi et al 3 study to assume that the mean LOS for infants admitted to hospital with bronchiolitis was 5 days [120 hours] with a standard deviation of 1.2 days [28.8 hours]. Reduction in hospital stay by 1 day was considered clinically significant and based on this a minimum sample size of 120 (with 60 in each group) was arrived. However the data from this paper by Jaquet-Pilloud et al show that the mean LOS was 47 hours (± 8.5) for nebulised hypertonic saline group and 50.4 hours (±11) for standard care group. The LOS at the authors’ hospital was less than half of the assumption used for their power calculation....
Show MoreDr Whitaker, in a letter in response to our Archimedes review of whether waveform capnography reliably approximates paCO2 in neonates, highlights two important questions which capnography seeks to address: Firstly, whether or not the endotracheal tube (ETT) is patent and correctly positioned in the trachea and secondly, whether the current ventilation strategy provides optimal CO2 clearance for the patient. The two questions are, of course, interlinked.
Show MoreTo date, in our field of neonatal medicine, the ETCO2 provides a valuable adjunct to clinical examination in determining ETT position and patency both at the point of intubation and during ongoing mechanical ventilation. However, for reasons explained in the paper, the numerical approximations to alveolar pCO2 provided by the currently available techniques of wave form capnography in neonates are not accurate enough to guide ventilatory changes. Thus, to guide ventilator changes, many neonatal intensive care units currently use transcutaneous capnometry.
In addition to the physiological properties, the waveform capnography sensors add extra weight and dead space to an infant’s ventilator circuit. This adds further complexity, like their still not fully assessed effect on volume-guarantee ventilation and potential for auto-triggering of ventilators. As volume guarantee is now considered the gold standard for ventilating preterm infants with respiratory distress syndrome, the value of waveform capnography, in addi...
Dear Editor
Show MoreWe read with interest Dr Scrivens et al’s commentary [1]. The mother’s question - ‘should capnography be used for breathing tube monitoring?’ – captures the subject addressed in our ‘PICNIC survey’ [2]. Conversely, the authors examine a completely different question - ‘is capnography an optimum respiratory monitor in ventilated neonates?’
A respiratory monitor detects whether the end-tidal CO2 value usefully measures pulmonary ventilation or PaCO2. Although not our focus here, we are surprised the review omitted Kugelman’s study which reported waveform capnography monitoring in neonatal ICU (NICU) improved ventilation accuracy and neurological outcomes [3].
An airway monitor assesses ‘whether lung ventilation is taking place via a tracheal tube that is in the airway and is patent’. High rates of neonatal failed intubation, oesophageal intubation, accidental extubation and reports of associated patient harm all suggest the value of a reliable airway monitor in NICU. Waveform capnography rapidly detects correct intubation with few false positives and immediately detects displacement or disconnection, the evidence for which we have previously set out [4-6].
Some neonatologists argue that continuous waveform capnography cannot be used in neonates. It is used routinely in neonatal anaesthesia. Others use it routinely during transfer of small neonates (eg 400g) (personal communication Dr James Tooley, Consultant, Bristol) sometimes only for it...
Dear authors,
Show MoreI read with great interest your article on multiple café-au-lait macules and movement disorder (1). I want to point out that probably an error happened during formatting of table 1. The term RASopathies is used to refer to a group of diseases caused by a mutation in a gene coding for a key component of the RAS-pathway and resulting in hyperactivation of the pathway. This group commonly includes Noonan syndrome, Neurofibromatosis type 1, Legius syndrome, LEOPARD syndrome (now referred to as Noonan syndrome with multiple lentigines), Costello syndrome, CFC syndrome, hereditary gingival fibromatosis, capillary malformation-arteriovenous malformation and Loh syndrome (2). It is confusing to find RASopathies next to Noonan, Legius and LEOPARD syndrome in the same column of table 1. In the same column Legius syndrome is listed as well as NF-like syndrome. Legius syndrome is listed followed by (PTPN11) and NF-like syndrome is followed by the gene (SPRED1). PTPN11 should be listed after Noonan syndrome because it is the most frequent cause of Noonan syndrome and it is not related to Legius syndrome. Legius syndrome is the same as NF1-like syndrome and only one of the two should be listed followed by (SPRED1). In our first publication (3) we named the condition neurofibromatosis 1-like syndrome but later is was renamed Legius syndrome (4).
Congenital mismatch repair deficiency (CMMRD) is another autosomal recessive condition with café-au-lait macules and...
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