We read with interest the recent paper, “Growth and lung function in
Asian patients with cystic fibrosis”.[1] The authors report a marked
reduction in lung function in Asian children with cystic fibrosis when
compared to non-Asian children with cystic fibrosis. This was more
pronounced in girls than in boys. However, the reference values for
normal lung function that they use for this comparison...
We read with interest the recent paper, “Growth and lung function in
Asian patients with cystic fibrosis”.[1] The authors report a marked
reduction in lung function in Asian children with cystic fibrosis when
compared to non-Asian children with cystic fibrosis. This was more
pronounced in girls than in boys. However, the reference values for
normal lung function that they use for this comparison are based on data
obtained from healthy Caucasian children. These values may lack validity
in Asian children. Even though the authors acknowledge that studies have
been done that demonstrate differences between healthy adult Asian and non
-Asian adults they dismiss these as, ‘poorly matched’. There is
convincing evidence[2] of a reduction in lung function in health Asian-
Indians compared to healthy Caucasians with a more marked reduction in
Asian-Indian women. Ethnicity is an important determinant of lung
function and direct comparison of pulmonary function between Asian and non
-Asian children are inappropriate. We would suggest that the reported
differences may not be due to differences in cystic fibrosis, rather due
to underlying ethnic differences.
References
1. Callaghan BD, Hoo AF, Dinwiddie R, et al. Growth and lung function
in Asian patients with cystic fibrosis. Arch Dis Child 2005;90(10):1029-
1032.
2. Fulambarker A, Copur AS, Javeri A, et al. Reference Values for
Pulmonary Function in Asian Indians Living in the United States. Chest
2004;126(4):1225-1233.
The report by Dixon et al. on the dosing of adenosine is important.[1] That the use of higher starting doses (100 - 200ug/kg) should
significantly increase the chance of adenosine terminating the
supraventricular tachycardia or demonstrating its mechanism on the first
dose was clearly demonstrated in their retrospective review.
It is worth repeating that the maximum dose for children of 500ug...
The report by Dixon et al. on the dosing of adenosine is important.[1] That the use of higher starting doses (100 - 200ug/kg) should
significantly increase the chance of adenosine terminating the
supraventricular tachycardia or demonstrating its mechanism on the first
dose was clearly demonstrated in their retrospective review.
It is worth repeating that the maximum dose for children of 500ug/kg
and neonates of 300ug/kg is for a singly administered dose. An issue that
we see far too frequently is the summing of each dose of adenosine to
arrive at a cumulative dose that "precludes further administration". When
starting at 50ug/kg and incrementing in 50ug/kg per dose a common
sequence is 50, 100, 150 and 200ug/kg at which point there will be some
who add these doses and conclude they have given 500ug/kg i.e. the upper
dose limit. The refrain is then that "adenosine did not work". From Dixon
et al's study it is not surprising.
Another issue is when adenosine does not terminate the tachycardia in
appropriate doses but the ECG has not been recorded during its
administration. In some patients, the tachycardia may only stop for a beat
and then re-initiate but this is not always clear on a monitor screen.
Knowledge that adenosine has worked - even if only for one beat - suggests
that a supraventricular re-entry tachycardia using the AV node is present.
In addition, blocking the AV node with drugs such as digoxin or
betablockers is likely to be effective due to their longer duration of
action. A brief slowing of the ventricular rate during atrial flutter or
atrial tachycardia clarifies the tachycardia mechanism – but again this is
best seen on the rhythm strip performed during adenosine administration.
The transient slowing and accelerating of the rate in sinus tachycardia is
also best appreciated on a printed rhythm strip.
Very rarely, the child has a ventricular tachycardia and adenosine
does not terminate the tachycardia but does alter the relationship of the
P-waves to the QRS complexes. This too cannot be appreciated on a monitor
screen. An example of the subtle changes is shown in Fig. 1. While these
changes would not be expected to be recognised by every general
paediatrician, the strip can always be reviewed at a cardiac centre - but
only if it has been recorded! In the example shown, the 8-year-old child
had a DC cardioversion after adenosine in appropriate doses did not
terminate the tachycardia. The diagnosis however, was altered from
supraventricular tachycardia with aberration to ventricular tachycardia
after review of the rhythm strip and the child then had a successsful
radiofrequency ablation for a left ventricular tachycardia.
Figure 1. After the starred beat in this relatively narrow QRS tachycardia it
is apparent that the regular deflection in the ST segment (circled in
beats 4 – 6 for clarity) disappears. It then becomes clear that this
deflection represents atrial activity (retrograde atrial activation from
ventricle to atrium). It also becomes clear that after the starred beat,
there is independent atrial activity (some of the P-waves are highlighted
by arrows). That the tachycardia continues independently of atrial
activity, confirms that it is a ventricular tachycardia.
References
1. Dixon J, Foster K, Wyllie J, Wren C. Guidelines and adenosine
dosing in supraventricular tachycardia. Arch Dis Child 2005; 90: 1190-1191.
Hall and Renfrew rightly describe the literature with relation to ankyloglossia as containing "little high quality objective evidence," they also describe the difficulties in study methodology in this setting with particular reference to concealing the diagnosis from parents in control studies. With regards to intervention, they note that “…frenulotomy in the newborn is a low risk minor procedure, performed...
Hall and Renfrew rightly describe the literature with relation to ankyloglossia as containing "little high quality objective evidence," they also describe the difficulties in study methodology in this setting with particular reference to concealing the diagnosis from parents in control studies. With regards to intervention, they note that “…frenulotomy in the newborn is a low risk minor procedure, performed without anaesthetic” and that “…significant venous bleeding could occur if technique is not meticulous but we found no reports of serious adverse events.”
Ankyloglossia intervention in the out-patient setting has been performed for over 20 years in Edinburgh without anaesthetic. We recently reviewed 28 months of patients (February 2002 - June 2004) who underwent the procedure to assess the complication and success rates. We fully acknowledge that our study was neither controlled nor had objective measures of outcome; nevertheless, it is the only study we know of to specifically investigate the safety of out-patient intervention in this country. Patients were identified from out-patient correspondence to general practitioners if they were initially referred for consideration of ankyloglossia as a cause of feeding difficulties. If appropriate the tongue tie was divided in the clinic by one of two consultant paediatric surgeons using the following method:
The baby is firmly swaddled in a blanket and held (by an experienced nurse) across the examination couch with his head towards the surgeon. The baby’s head is steadied by the nurse who can also assist in pulling down the chin with her thumb to encourage the mouth to open. The surgeon’s left index finger elevates the tongue placing the frenulum under tension. The transparent part of the frenulum is divided with iris scissors. Care must be taken to avoid cutting into the thicker posterior part of the frenulum which carries the blood supply. Bleeding should be minimal or nonexistent. The baby is fed by the mother in another room and checked again by the surgeon before leaving the clinic.
The mothers of the study patients were telephoned to complete a brief telephone questionnaire relating to possible complications and some subjective indicators of success after a minimum 14 day period. 44 (of a possible 51 study patients) were successfully contacted.
The mean age of infants on the day of tongue tie division was 49 days (SD 41days, Mean 38, Mode 38) with the youngest infant being 3 days old and the oldest 202 days old. The study group consisted of 25 males (57%) and 19 females (43%). The type of feeding before the procedure was documented and included all types of feeding attempted by the mother until the date of tongue tie division. 40 mothers were at least partly breastfeeding, 4 infants were exclusively formula fed. Of the 40 breastfed infants, 35 (88%) had problems latching on. 33 (83%) of the mothers had sore nipples and 15 (38%) had mastitis. 35 (80%) of the 44 mothers noted an improvement in the ease of feeding after the procedure with 28 (64%) also noting an improvement in the time taken for a feed. 3 of the 4 formula fed infants were improved in both these areas.
With regards the complication rate (Fig. 1) any pain or bleeding after leaving the clinic was considered significant as well as any episodes of infection, any need to seek medical advice and any repeat procedure required to release the tongue tie. The mean time of leaving clinic after the procedure was 29 minutes (SD 21 minutes) with the shortest wait 0 minutes and the longest wait 120 minutes in an infant whose mother was awaiting delivery of a breast pump from stores. Excluding this infant, the longest wait was 60 minutes.
One infant had bleeding after leaving the clinic. The bleeding was minimal and self limiting. The baby did not require any further medical attention and had left the clinic 15 minutes after the procedure. One infant was reported as being in pain after the procedure and was given a single dose of paracetamol with good effect. There were no incidents of infection and no requirement for further medical advice after the procedure. 2 patients required a repeat procedure which was performed in the same way on a separate day. Both repeat procedures were successful.
Fig. 1 - Complications After Leaving Clinic
Complications After Leaving Clinic
Yes
Yes (%)
No
No (%)
Total
Bleeding
1
2
43
98
44
Pain
1
2
43
98
44
Infection
0
0
44
100
44
Further Medical Advice Needed
0
0
44
100
44
Repeat Procedure Needed
2
5
42
95
44
Total
4
9
40
91
44
This study demonstrates that frenotomy in out-patients is both effective in releasing tongue tie and safe in terms of potential complications (9% overall complication rate). We suggest that the consideration of ankyloglossia is important in the differential diagnosis of an infant with difficulties feeding or a mother having pain breastfeeding. If diagnosed in either of these situations, the ankyloglossia can be easily treated in the outpatient clinic setting with a low complication rate. We would recommend the mother be encouraged to remain in clinic for a minimum of 30 minutes after the procedure in which time a test feed be performed. Routine out-patient follow-up is not required.
Richard Hansen Princess Royal Maternity Hospital Glasgow
Gordon A. MacKinlay and William G. Manson The Royal Hospital for Sick Children Edinburgh
In the useful report by P Abraham on the risk of cancer, the
incidence of hemihypertrophy (or "hemihyperplasia"), is stated as 1 in
86,000 live births, which would equate to approximately 1 child per 2
Health Districts. This would appear to be vastly lower than one's clinical
experience.
Is this an error, or is the stated incidence only of severe cases? If
so, would the risk of cancer be low...
In the useful report by P Abraham on the risk of cancer, the
incidence of hemihypertrophy (or "hemihyperplasia"), is stated as 1 in
86,000 live births, which would equate to approximately 1 child per 2
Health Districts. This would appear to be vastly lower than one's clinical
experience.
Is this an error, or is the stated incidence only of severe cases? If
so, would the risk of cancer be lower in milder cases?
What is not altogether clear from the case management of non-
epileptic events[1] is whether active steps were routinely taken to
ascertain the possibility of the co-existence of either the long QT
syndrome (LQTS) or the Brugada syndrome, either of which may be underlying
causes of non epileptic events which manifest themselves as so-called
convulsive syncope.[2,3] For both entities, a family history o...
What is not altogether clear from the case management of non-
epileptic events[1] is whether active steps were routinely taken to
ascertain the possibility of the co-existence of either the long QT
syndrome (LQTS) or the Brugada syndrome, either of which may be underlying
causes of non epileptic events which manifest themselves as so-called
convulsive syncope.[2,3] For both entities, a family history of close
relatives dying suddenly from uexplained cardiac causes before the age of
30 should raise the index of suspicion.[4,5] In LQTS there may,
additionally, be associated deafness in the index case and/or a history of
stress-related syncope.[4] Screening procedures for both should include
history taking and a 12 lead ECG although neither is infallible.
References
1. Beach R and Reading.
The importance of acknowledging clinical uncertainty in the diagnosis of
epilepsy and non-epileptic events
Arch Dis Child 2005:90:1219-22.
2. Ratshin RA et al.
QT-Interval prolongation, paroxysmal ventricular arrhythmias, and
convulsive syncope
Annals of Internal Medicine 1971:75:919-24.
3. Paydak H et al.
Brugada Syndrome An unusual cause of convulsive syncope
Archives of Internal Medicine 2002:162:1416-19.
4. Moss AJ. Long QT Syndrome
Journal of the American Medical Association2003:289:2041-44.
5. Antzelevitch C., Brugada P., Brugada J et al.
Brugada syndrome: a decade of progress
Circulation Research 2002:91:1114-8.
I am sorry to say that the BNF for Children (http://www.bnfc.org), published
in October 2005, is also incorrect in its recommendation of starting dosage for use of adenosine in newborns and infants. The BNFC incorrectly recommends starting at 50-100 micrograms/kg and increasing the dose by 50 microgram/kg until a maximum of 300 microgram/kg.
I am sorry to say that the BNF for Children (http://www.bnfc.org), published
in October 2005, is also incorrect in its recommendation of starting dosage for use of adenosine in newborns and infants. The BNFC incorrectly recommends starting at 50-100 micrograms/kg and increasing the dose by 50 microgram/kg until a maximum of 300 microgram/kg.
However, I am pleased to report that the Neonatal Formulary (4th edition published 2003 - http://www.neonatalformulary.com) correctly recommends starting with a dose of 150 microgram/kg and suggests that a larger dose of 300 microgram/kg is sometimes needed.
We would like to comment on the paper by Reed et al in which they
describe the consequences of introducing the NICE guidance on head injury
into their paediatric emergency department.[1] In particular we are
surprised at their conclusions.
This data shows that following the introduction of the NICE guidance
the number of CT scans performed doubled, but that this additional
scanning did not re...
We would like to comment on the paper by Reed et al in which they
describe the consequences of introducing the NICE guidance on head injury
into their paediatric emergency department.[1] In particular we are
surprised at their conclusions.
This data shows that following the introduction of the NICE guidance
the number of CT scans performed doubled, but that this additional
scanning did not reveal any additional intra-cranial abnormality.
Furthermore the data also suggests that, contrary to NICE guidance,
vomiting is not a useful indicator for CT scanning. It is also apparent
that this guidance did not reduce admissions, and yet admission avoidance
has previously been cited as a reason for adopting the NICE guidelines.
The authors also fail to acknowledge the very considerable radiation
dose associated with CT head scanning. In particular they have chosen to
express radiation exposure in terms of dose per total number of head
injuries rather than in the dose per child scanned. This latter figure is
what matters to the child who has a CT scan, and is equivalent to 100
chest X-rays worth of radiation.[2]
In summary this paper demonstrates that the NICE guidance on head
injury in children is flawed, and that it’s implementation unnecessarily
exposes some children to very high doses of radiation. Such concerns were
expressed when this guidance was first released.[3] Furthermore it has
been shown recently that head injuries in children can be safely managed
using a combination of skull X-rays and limited CT scanning.[4]
We would therefore suggest that Reed et al are mistaken in concluding
that in paediatric head injury skull X-rays should be abandoned and CT
scanning used more extensively. It is also apparent that NICE needs to
review it’s guidance on this subject as a matter of urgency.
References
1. Reed MJ, Browning JG, Wilkinson AG, Beattie T. Can we abolish
skull X-rays for head injury? Arch Dis Child; 90:859-864.
2. Health Protection Agency / National Radiation Protection
Board - patient dose information.
3. Leaman AM. The NICE guidelines for the management of head
injury.Emerg Med J 2004; 21: 400.
4. Macgregor DM, McKie L.CT or not CT - that is the question. Emerg
Med J 2005; 22: 541-543.
Dr Williams’ article “Teaching paediatrics for the developing world”
made interesting reading especially because he comes from a different
world! I am impressed by the insight the author has about various aspects
of health care in developing countries. He must have spent a lot of time
in these countries. I appreciate the fact that he encourages doctors from
the developed world to spend some part of the...
Dr Williams’ article “Teaching paediatrics for the developing world”
made interesting reading especially because he comes from a different
world! I am impressed by the insight the author has about various aspects
of health care in developing countries. He must have spent a lot of time
in these countries. I appreciate the fact that he encourages doctors from
the developed world to spend some part of their career in the developing
world. It is likely to be a mutually beneficial experience.
I would like to share my experience in a private, completely free,
rural charity hospital in Tamilnadu, India, during the period 1981 to
1999. After completing my masters in paediatrics in 1981, I joined a
rural, charity women and children’s hospital, as senior medical officer,
in charge of the hospital. The infant mortality was quite high in the
eighties and most poor folk tended to have large families.
One of the aims of the hospital was to provide such excellent care to
the poor children in the rural areas that the families adopted family
planning measures voluntarily so that their meagre resources could be used
for the few children they had. The biggest challenges that we faced were:
1. Constant turnover of staff: We had difficulty getting doctors and
nurses to stay on for a meaningful length of time. Unfortunately, most
doctors and nurses prefer to work in urban areas.
2. Distrust of parents and care givers, especially when it came to
giving vaccines to their children and adopting family planning methods,
temporary or permanent.
Our population was going up in leaps and bounds and it was quite
important that our patients opted for family planning measures. As
mentioned by the author, it is quite true that most rural patients prefer
traditional healers to doctors trained in “western” medicine.
It took nearly a decade to get a dedicated group of staff who were
interested in staying on in the hospital. Gradually, patients’ mind set
changed too and they started coming forward to accept treatment in the
hospital. Once we gained their trust, it was quite easy. All our earlier
frustrations were forgotten! The progress we made was slow, but definite.
We also had regular field visits by doctors and nurses, almost
everyday, to the villages nearby, providing immunisation and simple
remedies at their doorstep. Along with whatever treatment we offered, we
encouraged our patients to follow the traditional practices that were not
harmful and sometimes, even beneficial.
We trained the traditional healers in the villages in safe conduct of
delivery using sterile, or at least, new razor blades, for severing the
cord, instead of an old sickle which served many purposes! Gradually, the
traditional healers started bringing patients to the hospital. They also
brought women who were willing, for puerperal tubectomy.
We were quite fortunate that the hospital management was very
supportive in providing whatever we requested for patient care. Gradually,
from a predominantly out-patient facility, our hospital grew to become a
well equipped institution, with in-patient facilities, capable of handling
most of the medical problems of neonates, infants and children and
childbearing women. We had one of the best clinical laboratories in town.
The management also provided computer and internet facilities to the
hospital. They subscribed to more than a dozen paediatric and obstetric
journals including WHO publications, Archives of Disease in Childhood,
Paediatrics in Review and Paediatric Clinics of North America, to name a
few.
The medical staff was encouraged to attend the CME programmes in the
city regularly. There were also classes for the nurses and support staff
on common medical problems. We also had health education aides by way of
flash cards and slides from WHO, for our field visits and for use in the
hospital.
We were supported by many subspecialists in the city, who offered
their services free of charge to our patients whenever we requested. They
provided us help with surgeries, expensive investigations like CT scans,
echocardiograms, ultrasound, etc., free of charge, for the poor children
who needed them.
I believe that we cannot rely solely on the government to provide,
among other things, medical care to all the needy people in a country like
ours. Hospitals like the ones I worked in, make a difference to the
villages where they are located. Such non-governmental organisations are
needed in every district, state, zone, if we are to achieve health for
all.
Finally, it is possible that “the main objective of some doctors
travelling from developing to developed countries is emigration with an
(often vast) improvement in salary, living standards, and perhaps
educational opportunities for their children”. However, there are scores
of dedicated doctors from my country, who have been trained in
subspecialities in U.K., Australia, U.S.A., etc., who are serving without
high salaries, very high living standards or even recognition, in many
government, charity and mission hospitals. Their only reward is the
satisfaction they get from doing the best for their patients.
Acknowledgements: I thank my parents, family, friends, colleagues and
mentors in my profession who have given me their constant support and made
me believe that anyone could make a difference in people’s lives.
References
Williams, C. Teaching paediatrics for the developing world. Arch Dis Child 1998;78:484-487.
In response to the comments of Paisal (1), regarding our study on the
influence of Gaviscon Infant® on gastro-oesophageal reflux in infants
studied by the new physiologically appropriate modality of combined
intraluminal oesophageal pH/impedance (2), we would like to make the
following points.
Commenting on the study design he points to two studies which found
benefit of Gaviscon. What he...
In response to the comments of Paisal (1), regarding our study on the
influence of Gaviscon Infant® on gastro-oesophageal reflux in infants
studied by the new physiologically appropriate modality of combined
intraluminal oesophageal pH/impedance (2), we would like to make the
following points.
Commenting on the study design he points to two studies which found
benefit of Gaviscon. What he fails to point out, and perhaps realise, is
that one of these studies was carried out using what could be regarded
now, since the advent of clinical application of impedance, as the sub-
standard physiological denominator i.e. pH alone (3), and the other study is
in adults and uses completely different forms of Gaviscon from the one we
employed, and the actions of these preparations and their gastric emptying
properties are likely to be very different (4) – hence any inference drawn
from this study to make conclusions regarding gastro-oesophageal Gaviscon
Infant® exposure should be subject to significant critical scrutiny, and
then dismissed as irrelevant to our study, which was carried out in a
different age group and employing a different preparation. Given that
studies using the correct modern measurement tool i.e. combined
intraluminal impedance and pH exist for other preparations such as
thickening agents showing that methodology of comparison of different
randomised feeding events in a 24 hour period is robust in identifying
post-prandial reflux differences, we feel it is very likely that in our
study the conclusions drawn would not be influenced by hypothetical slow
gastric emptying of Gaviscon. (5)
Hence the criticism that because no wash out period was present in our
study it was this that prevented any observable objective reflux
differences between Gaviscon and placebo, is not upheld.
However, it is worth emphasising that whilst in the abstract we point
to a difference in the height of reflux migration as the only
statistically significant difference, it is small - hence conclusions
regarding the mode of action of the definite observed improvement in
clinical symptoms by parents in this cohort of infants due to this
preparation cannot be drawn on the basis of this study.
The inference that this preparation does not work in infant reflux
should not be drawn from this study, merely that the mode of action is not
shown with this accurate and appropriate physiological tool. In the
discussion section we make reference to this and suggest reasons for this.
For instance it may be that Gaviscon Infant® has an action by coating the
distal oesophagus thereby preventing mucosal injury from refluxed
substances such as acid, pepsin, or bile acids. The actual reflux
continues, as evidenced by this study (presuming adequate power for
statistical significance), but the injury resultant from it may be
diminished. This is an important question raised by this study, and the
main conclusion that it now seems that the mode of action for the observed
clinical efficacy of Gaviscon Infant® , which is an observed and
measurable phenomenon, is not by preventing reflux per se, must be
emphasised. The obvious sequela of this, as detailed in the discussion
section, should therefore be that further studies are necessary to
determine how this widely-used and effective product has an effect
clinically in infants and children.
Further studies are needed and could also be conducted over longer
periods of time, such as 24 hours placebo v 24 hours treatment with wash
out periods between, which would help to answer some of the points raised
regarding the design of our study by Paisal 1 and the group of Cresi et al
(6), but it my be that this design would be harder to justify ethically.
Clearly, as we know that this product is effective clinically in infant
reflux as first line therapy, we require a greater understanding of its
mode of action, necessitating further enquiry with well conducted
interventional studies examining in different ways the clinically
observable beneficial effect of Gaviscon Infant® on the reflux-
oesophagitis axis in infants.
References
1. Paisal V. Absence of wash-out period between Gaviscon and placebo
may be responsible for anomalous findings. Arch Dis Child. 2005;90:5;460.
2. Del Buono R, Wenzl TG, Ball G, Keady S, Thomson M. Effect of
Gaviscon Infant on gastro-oesophageal reflux in infants assessed by
combined intraluminal impedance/pH. Arch Dis Child. 2005; 90: 460-463.
3. Buts JP, Barudi C, Otte JB. Double-blind controlled study on the
efficacy of sodium alginate (Gaviscon) in reducing gastroesophageal reflux
assessed by 24 h continuous pH monitoring in infants and children. Eur J
Pediatr. 1987;146:156-158.
4. Washington N, Greaves JL, Iftikhar SY. A comparison of gastro-
oesophageal reflux in volunteers assessed by ambulatory pH and gamma
monitoring after treatment with either Liquid Gaviscon or Algicon
Suspension. Aliment Pharmacol Ther. 1992;6:579-588.
5. Wenzl TG, Trachterna M, Silny J, Heimann G, Skopnik H. Effect of
thickened feeding on gastro-esophageal reflux in infants - a placebo-
controlled study using intraluminal impedance (Abstract). J Pediatr
Gastroenterol Nutr. 2000;30:S206.
6. Cresi F, Savino F, Marinaccio C, Silvestro L. Gaviscon on gastro-
oesophageal reflux in infants: A poorly effective treatment? Arch Dis
Child. 2005;90:5;460.
We read with great interest the article by Dixon, Foster, Wyllie and
Wren, on the dosing of adenosine in supraventricular tachycardia (SVT). We
have recently reviewed cases of SVT presenting to the Children’s Heart
unit of Wales with a special focus on the effective dose of Adenosine and
have made disturbingly similar observations. Our findings were recently
presented in a research society meeting....
We read with great interest the article by Dixon, Foster, Wyllie and
Wren, on the dosing of adenosine in supraventricular tachycardia (SVT). We
have recently reviewed cases of SVT presenting to the Children’s Heart
unit of Wales with a special focus on the effective dose of Adenosine and
have made disturbingly similar observations. Our findings were recently
presented in a research society meeting.
Over a period of 10 years a total of 137 infants and children
presented to our unit with a diagnosis of SVT. Of these Adenosine was used
in 37 cases on 70 occasions. Through out South Wales the Advanced
Paediatric Life Support (APLS) guidelines for adenosine are followed which
suggest incremental doses of 50 micrograms/Kg, 100 micrograms/Kg and 250
micrograms/Kg for the acute management of SVT.
The recommended starting dose of 50 micrograms/Kg was effective only
on 4 occasions, that is in less than 6% of the cases. The second dose was
effective on another 33 (47%) occasions, while the third dose of 250
micrograms successfully terminated the arrhythmia in another 24 (34%)
cases. Adenosine was ineffective on 9 (13%) occasions. Other agents were
required in these cases. The mean effective dose of Adenosine thus works
out to be 156 micrograms/Kg.
Our findings support Dixon et al’s conclusions that the current
recommended Adenosine doses for acute management of SVT are ineffective in
the vast majority of cases. This highlights the urgent need for review of
the dose protocol of Adenosine in SVT.
Reference
1. J Dixon, K Foster, J Wyllie, and C Wren
Guidelines and adenosine dosing in supraventricular tachycardia
Arch Dis Child 2005; 90: 1190-1191
Dear Editor,
We read with interest the recent paper, “Growth and lung function in Asian patients with cystic fibrosis”.[1] The authors report a marked reduction in lung function in Asian children with cystic fibrosis when compared to non-Asian children with cystic fibrosis. This was more pronounced in girls than in boys. However, the reference values for normal lung function that they use for this comparison...
Dear Editor,
The report by Dixon et al. on the dosing of adenosine is important.[1] That the use of higher starting doses (100 - 200ug/kg) should significantly increase the chance of adenosine terminating the supraventricular tachycardia or demonstrating its mechanism on the first dose was clearly demonstrated in their retrospective review.
It is worth repeating that the maximum dose for children of 500ug...
Dear Editor,
Hall and Renfrew rightly describe the literature with relation to ankyloglossia as containing "little high quality objective evidence," they also describe the difficulties in study methodology in this setting with particular reference to concealing the diagnosis from parents in control studies. With regards to intervention, they note that “…frenulotomy in the newborn is a low risk minor procedure, performed...
Dear Editor,
In the useful report by P Abraham on the risk of cancer, the incidence of hemihypertrophy (or "hemihyperplasia"), is stated as 1 in 86,000 live births, which would equate to approximately 1 child per 2 Health Districts. This would appear to be vastly lower than one's clinical experience.
Is this an error, or is the stated incidence only of severe cases? If so, would the risk of cancer be low...
Dear Editor,
What is not altogether clear from the case management of non- epileptic events[1] is whether active steps were routinely taken to ascertain the possibility of the co-existence of either the long QT syndrome (LQTS) or the Brugada syndrome, either of which may be underlying causes of non epileptic events which manifest themselves as so-called convulsive syncope.[2,3] For both entities, a family history o...
Dear Editor,
I am sorry to say that the BNF for Children (http://www.bnfc.org), published in October 2005, is also incorrect in its recommendation of starting dosage for use of adenosine in newborns and infants. The BNFC incorrectly recommends starting at 50-100 micrograms/kg and increasing the dose by 50 microgram/kg until a maximum of 300 microgram/kg.
However...
Dear Editor,
We would like to comment on the paper by Reed et al in which they describe the consequences of introducing the NICE guidance on head injury into their paediatric emergency department.[1] In particular we are surprised at their conclusions.
This data shows that following the introduction of the NICE guidance the number of CT scans performed doubled, but that this additional scanning did not re...
Dear Editor,
Dr Williams’ article “Teaching paediatrics for the developing world” made interesting reading especially because he comes from a different world! I am impressed by the insight the author has about various aspects of health care in developing countries. He must have spent a lot of time in these countries. I appreciate the fact that he encourages doctors from the developed world to spend some part of the...
Dear Editor
In response to the comments of Paisal (1), regarding our study on the influence of Gaviscon Infant® on gastro-oesophageal reflux in infants studied by the new physiologically appropriate modality of combined intraluminal oesophageal pH/impedance (2), we would like to make the following points.
Commenting on the study design he points to two studies which found benefit of Gaviscon. What he...
Dear Editor
We read with great interest the article by Dixon, Foster, Wyllie and Wren, on the dosing of adenosine in supraventricular tachycardia (SVT). We have recently reviewed cases of SVT presenting to the Children’s Heart unit of Wales with a special focus on the effective dose of Adenosine and have made disturbingly similar observations. Our findings were recently presented in a research society meeting....
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