1579 e-Letters

  • 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.

  • Excluding all deaths

    By excluding all deaths, it is possible that a significant number of high-cost high-need patients were missed? Some deaths will follow a prolonged admission and care may have been escalated, for example to PICU, prior to death.

  • Short-term daytime urotherapy is likely to be ineffective in nocturnal enuresis treatment and it should be considered complementary to other therapeutic choices

    Dear editor, we read with interest the randomised controlled trial by Borgström et al.1 showing the lack of effectiveness of daytime urotherapy as first-line treatment of nocturnal enuresis. While the study has the remarkable point of strength of a prospective trial with a control, we take exception with some of the authors’ statements, and believe that some limits should be acknowledged.

    Reduction of enuresis frequency was evaluated after 7 and 8 weeks since the beginning of the study while previous studies showed effectiveness for longer treatments, lasting four months, with a 60% success rate2. While the authors acknowledge this difference they simply state that a longer duration would disqualify the therapy as a first-line choice anyway, increasing the risks of drop out. We believe that this is, as the author state in the discussion, simply their view, which is not based on any evidence. The length of a treatment should not necessarily rule out it as a first line option, especially when weighted against the costs of other options, specifically unpleasantness of the alarm and possible adverse effects of desmopressin. As a matter of fact, it could be speculated that 8 weeks are a too short period in a physiological perspective to develop different voiding patterns after years of an enuretic bladder function.

    Moreover, patients’ follow-up consisted only in contact by phone after 2 and 6 weeks, without clinical examination, and this could have contributed t...

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  • It's not time to ditch the pad: pads have a place

    26th January 2022

    To the Editor

    Archives of Disease in Childhood

    re Diagnosing urinary tract infection in children: time to ditch the pad?

    Harkensee C, Clennett J, Wilkinson S, et al

    Arch Dis Child 2021; 106: 935-936

    We read with interest the article by Harkensee et al, (1) suggesting that the urinary collection pad (UCP) no longer had a role in obtaining samples for diagnosis of urinary tract infections (UTI). Whilst it is well established that there is an unacceptably high rate of contamination with UCPs making them unsuitable for microbiological culture, and that the preferred (non-invasive) method for obtaining a sample for culture is by 'clean catch' +/- stimulation or Quick-Wee method, we would suggest that the UCP has a role in screening for UTI, by dipstick analysis of the aspirated pad sample for leucocyte esterase (LE) and nitrites (2). It would be useful, in a paediatric 'acute referral clinic' or Emergency Department, in infants or children, with non-specific abdominal pain, or fever without a focus, where a combination of a negative test for both LE and nitrites can be reasonably used to exclude UTI, and equally a positive LE and nitrite result would indicate a high likelihood of a UTI and the need to obtain a 'clean catch' or catheter specimen for microbiological analysis (3). The advantages of the UCP are that it allows 'point of care' dipstick analysis with inf...

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  • Outdated by reality

    Child mortality in Europe dropped considerably in the first year of the pandemic, but since mid-2021 it is increasing considerably, as the data from the euromomo registry suggest. https://www.euromomo.eu/graphs-and-maps/ I first thought that Corona "saves children´s life" (for an intolerable expense), but now the contrary is true. While by the end of 2020 almost 400 Children (0-14) less died in the participating countries, excess mortality in Europa was about 500 Children at the end of 2021. So it was to early to draw conclusions.

  • Listeria infection in young infants: a clear understanding of presenting clinical picture

    Dear Editor,

    We read with great interest recent study by Vergnano et al.1 investigating the epidemiology, age at infection, clinical characteristics, and outcome of listeria infection in the young infant. We congratulate the authors on providing a novel and interesting study that is relevant to the UK population and agree that the empirical use of amoxicillin in the paediatric infant should be reconsidered given the conclusions of their data.

    However, when considering how we might be able to incorporate your novel findings into our centres practice, we required further clarification on table 2. The table describes increased oxygen requirement/respiratory support in 2/27 infants and yet, within results, report a prevalence of increased oxygen requirement/respiratory support of 89%. Furthermore, hypotension requiring inotropes is reported to occur in 4/27 infants but has a reported prevalence of 115%. These reported data appear to be miscalculated.

    Clinical identification of invasive listeriosis through the understanding of symptoms within the infant is a key finding of this study given its poor description within the current literature2. We conducted a focused literature search and found scarce information on infant symptom prevalence; one notable exception includes the MONALISA study by Charlier et al.3 which recorded detailed clinical features (appendix p 21). Early diagnosis of invasive listeriosis has been demonstrated to have key prognostic value...

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  • Children should be vaccinated against Covid-19

    The Centers for Disease Control and Prevention (CDC) now recommends a Covid -19 vaccine for children ages 5 and older. Johns Hopkins Medicine encourages all families to have eligible children vaccinated with the Covid - 19 vaccine. Currently, Pfizer's vaccine is the only approved Covid-19 vaccine for children and its side effects are still the same in children. Children might notice pain at the injection site (upper arm), and could feel more tired than usual. Headache, achy muscles or joints, and even fever and chills are also possible and these side effects are usually temporary and generally clear up with 48 hours.

  • Further cautions regarding children being vaccinated against COVID-19

    This review1, listing all the pros and cons of covid vaccinations for children, is to be welcomed but the authors have omitted some important questions on the downside. They rightly state that a large proportion of children might already be immune and point to waning immunity after vaccinations, suggesting that primary infection at young age with boosting exposure over time might be a better strategy. But they do not cite recent evidence that people who are first vaccinated then exposed afterwards, appear to mount brisk IgG response to the spike protein since this is already in their immune memory, but may fail to mount the broader response associated with natural infection, including N-antibodies2. For those children (>75%) already immune, there is no significant benefit to vaccination with an emergency use authorised product. For otherwise healthy children who are not yet immune, they can obtain this by natural infection over the months ahead, at minimal risk to themselves or to the vaccinated adults around them.
    Under the heading ‘Long-term safety’, the authors rightly quote concerns of possible ongoing effects of myocarditis, but they make no mention of any other potential as yet unknown effects of these novel technologies. If there are effects on T-cell function, then there is risk for autoimmune diseases3 and also for potential cancer cells4 to pass unchecked. There are also no adequate animal reproductive studies and the nanoparticles have been shown b...

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