A definition of iron deficiency based solely on the serum ferritin
cut-off levels stipulated by the authors(1) runs the risk of
underestimating the prevalence of this disorder because patients who have
iron deficiency in the presence of chronic inflammation may have serum
ferritin levels which fall within the normal range(2). In order to
identify such patients, the authors could have documented the levels of C
reactive...
A definition of iron deficiency based solely on the serum ferritin
cut-off levels stipulated by the authors(1) runs the risk of
underestimating the prevalence of this disorder because patients who have
iron deficiency in the presence of chronic inflammation may have serum
ferritin levels which fall within the normal range(2). In order to
identify such patients, the authors could have documented the levels of C
reactive protein(CRP) as was the case in a study which compared the
sensitivities and specificities of serum ferritin cut-off levels of <15
mcg/l and < 20 mcg/l, respectively, in primary care, where only 10.2%
of patients had raised CRP levels vs secondary care, where 44% had raised
CRP levels(3). Having identified the subgroup with co-existing chronic
inflammation the most practical diagnostic manouvre would be a trial of
iron replacement therapy monitored according to a specified therapeutic
response score(TRS) as was the case in the trial which showed that a mean
corpuscular haemoglobin(MCH) of < 25 pg and/or a haemoglobin(Hb) level
of < 11 g/dl predicted a significant response to iron replacement
therapy which was not exhibited by a mean cell volume(MCV) of < 75
fl(4). The superior predictive accuracy of MCH might be attributable to
the fact that serum transferrin receptor(sTfR) levels which are raised in
iron deficiency, show a steeper inverse correlation(r= -0.65; p=0.0001)
with MCH than with MCV, the inverse correlation with the latter being
documented as r= -0.47; p=0.009(5). The additional advantage of MCH over
MCV is that MCH "is independent of the technology used by the different
counters available in haematology laboratories. This is reflected in the
consistent equality in the results reported by the different technologies
within the UK NEQAS schemes" . By contrast "different counting systems
will yield clinically significant different estimates of the MCV. This is
reflected in the monthly reports of the UK General Haematology NEQAS
Scheme"(6). The final issue is that of identifying iron deficiency in the
presence of normal Hb and/or normal MCH. This isuue has been settled by
the documentation that a reticulocyte haemoglobin content(CHr) of <
27.5 pg, without anaemia, was associated with subsequent iron deficiency
anaemia when screened again a year later(7). The superior predictive
accuracy of CHr is borne out by the fact that the receiver operator
characteristic(ROC) curve for CHr shows a significantly greater area under
the curve than the ROC for either Hb or MCH(7). Additionally, according to
a recent report, whose confirmation by other studies is keenly anticipated
by the haematological community, in its ability to recognise iron
deficiency, CHr is not affected by the acute phase reaction(8).
References
(1)McGillivray G., Skull SA., Davie G et al
High prevalence of asymptomatic vitamin D and iron deficiency in East
African immigrant children and adolescents living in a temperate climate
Archives of Disease in Childhood 2007:92:1088093
(2) Guyatt GH., Oxman AD., Ali M et al
Laboratory diagnosis of iron deficiency anemia: an overview
Journalm of General Internal Medicine 1992:7:145-53
(3) O'Broin S., Kelleher B., Balfe A., McMahon C
Evaluation of serum transferrin receptor assay in a centralised iron
screening service
Clinical and Laboratory Haematology 2005:27:190-4
(4) Wright CM., Kelly J., Trail A., Parkinson KN., Summerfield G
The diagnosis of boredrline iron deficiency: results of a therapeutic
trial
Archives of Disease in Childhood 2004:89:1028-31
(5) Kivivouri SM., Pelkonen P., Ylijoki H., Verronen P., Siimes MA
Elevated serum transferrin receptor concentration in children with
juvenile chronic arthritis as evidence of iron deficiency
Rheumatology 2000:39:193-7
(6) Cavill I
Automated haemoglobinopathy screening(letter)Clinical and Laboratory
Haematology 2004:26:305
(7) Ullrich C., Wu A., Armsby C et al
Screening healthy infants for iron deficiency using reticulocyte
hemoglobin content
Journal of the American Medical Association 2005:294:924-930
(8) Markovic M., Majkic-Singh N., Ignjatovic S., Singh S
Reticulocyte haemoglobin content vs soluble transferrin receptor and
ferritin index in iron deficiency anaemia accompanied with inflammation
Clinical and Laboratory Haematology 2007:29:341-6
We read with interest the article by Maguire et al 1, reporting the
results of a systematic review of torn frenum and other intraoral injuries
in diagnosing abuse. We do accept that in the absence of case control
studies, the most appropriate study design to answer a diagnostic clinical
question, the authors had to settle for case series or case studies.
However, when none of the included case series were specifically desi...
We read with interest the article by Maguire et al 1, reporting the
results of a systematic review of torn frenum and other intraoral injuries
in diagnosing abuse. We do accept that in the absence of case control
studies, the most appropriate study design to answer a diagnostic clinical
question, the authors had to settle for case series or case studies.
However, when none of the included case series were specifically designed
to look for a torn frenum, any firm conclusion based on such studies is
weak. It was also surprising to note that some of the studies that were
given a rank of one for abuse (highly suggestive of abuse), were case
reports based on a single child. Also, we thought it would be useful to
point that the number of patients (in Table 4 and 5) do not add up and
tally with the total number described in the text. Finally, we do agree
that the best way forward is to conduct a well-designed comparative study
involving our dental colleagues.
Competing interests: None declared
Reference
1 Maguire et al, Diagnosing abuse: a systematic review of torn frenum
and other intra-oral injuries. Arch Dis Child.2007; 92: 1113-1117
The Archimedes offering by Khashu and Balusubramaniam [1] contains an
overstatement of the evidence from our Cochrane Review [2] (Early volume
expansion for prevention of morbidity and mortality in very preterm
infants) in suggesting in their 'Clinical Bottom Line' that "Weak evidence
suggests an increased risk of necrotising enterocolitis with use of
Gelofusine in neonates”. We had cautioned against over i...
The Archimedes offering by Khashu and Balusubramaniam [1] contains an
overstatement of the evidence from our Cochrane Review [2] (Early volume
expansion for prevention of morbidity and mortality in very preterm
infants) in suggesting in their 'Clinical Bottom Line' that "Weak evidence
suggests an increased risk of necrotising enterocolitis with use of
Gelofusine in neonates”. We had cautioned against over interpretation of
the subgroup findings in this review, and this is particularly important
for analyses between different types of volume expansion. Focusing on NEC
and sepsis , which are the points of contention, the NNNI 1996 study
reported that necrotising enterocolitis was significantly reduced (RR
0.22, 95% CI 0.06, 0.74) in infants receiving fresh frozen plasma (FFP)
compared to placebo, but sepsis significantly increased (RR 1.65, 95% CI
1.13, 2.40). In contrast, the NNNI 1996 study also reported no significant
differences in the rate of necrotising enterocolitis (RR 1.06, 95% CI
0.52, 2.15) and sepsis (RR 0.93, 95% CI 0.60, 1.44) in infants treated
with Gelofusine compared to placebo. Clearly, from these analyses compared
to placebo, there is evidence from one study of a 4% reduction in NEC and
a 9% increase in sepsis in infants treated with FFP, although the
confidence intervals are wide and the data pertain to a single study.
There is no evidence of an effect of Gelofusine compared to placebo on NEC
or sepsis. A subgroup analysis of FFP versus Gelofusine merely highlights
the findings of the FFP subgroup, making the observation of an increased
risk of NEC in the Gelofusine group by the authors of the Archimedes
article inappropriate. As in all trials, it is important to focus on the
comparator as well as the treatment of interest.
David Osborn
References:
1. Khashu M, Balusubramaniam V. In neonates requiring intravascular
volume resuscitation is the use of Gelofusine safe and efficacious? Arch.
Dis. Child. 2007;92;1037-1038.
2. Osborn DA, Evans N. Early volume expansion for prevention of
morbidity and mortality in very preterm infants. Cochrane Database of
Systematic Reviews 2004, Issue 2. Art. No.: CD002055.
In the February 2007 issue of the Archives, Mitchell(1) published a
discussion document on recommendations for prevention of sudden infant
death syndrome (SIDS), focussing particularly on the advice issued by the
Department of Health (DoH) in England on 3 occasions, in 2000, 2004 and
2005. A revised version was published in February 2007,(2) too late for
inclusion in Mitchell’s paper. In the paper he reviews some of the...
In the February 2007 issue of the Archives, Mitchell(1) published a
discussion document on recommendations for prevention of sudden infant
death syndrome (SIDS), focussing particularly on the advice issued by the
Department of Health (DoH) in England on 3 occasions, in 2000, 2004 and
2005. A revised version was published in February 2007,(2) too late for
inclusion in Mitchell’s paper. In the paper he reviews some of the recent
evidence pertaining to prevention of such deaths, and criticises the DoH
for some of its current recommendations and, more generally, for relying
largely on the Foundation for the Study of Infant Deaths (FSID) for the
scientific advice on which their advice is based. This letter is a
response to the paper on behalf of FSID. I shall take the specific points
raised by Mitchell in the order in which they appear in his paper.
The definition of cot death
Mitchell states that “...the DoH uses the FSID definition of cot
death” and “The FSID definition equates cot death with sudden unexpected
death in infants (SUDI)”. The category SUDI includes some cases in which a
complete or partial explanation for the death is found either from the
autopsy findings or by detailed examination of the circumstances of the
death: SIDS does not. This is true, but it is not clear that this has any
important bearing on the advice that is given to prevent unexpected death
in infancy generally, and Mitchell presents no evidence that it does.
Sleeping position
Both the DoH and FSID recommend supine sleeping (on the back) for all
infants, with rare exceptions for medical reasons, in accordance with the
international consensus which is based on much evidence from many
countries. This includes a recommendation to avoid side, as well as front
(prone) sleeping which has been shown to increase the risk of SIDS
although much less so than for front sleeping. Mitchell hypothesises that
the risk of side sleeping may be explained by the fact that infants placed
on their side are more likely to roll into the prone position than those
placed on their backs. However, this is unlikely to be the whole
explanation since one recent study found that SIDS infants were more
likely to be found dead on their sides, as well as having been placed in
that position.(3) There is no obvious disparity between the advice
currently issued by the DoH and that which Mitchell would favour.
Maternal smoking in pregnancy
Mitchell supports the advice that women should not smoke in
pregnancy. He argues that “...the greatest benefit is achieved by getting
light smokers to stop rather than heavy smokers to reduce the amount
smoked”, based on figures published in the CESDI report into SUDI.(4) This
conclusion depends on exactly how the odds ratios (ORs) are interpreted.
If one converts the ORs into real figures, as advocated by Gigerenzer,(5)
it is not quite so clear cut. Compared with a reference group of non-
smoking mothers (group 1), the OR (95% confidence interval) of the risk of
SUDI for babies born to mothers smoking 1-9 cigarettes daily (group 2) is
4.25 (2.93-6.18), that for babies born to mothers smoking 10-19 daily
(group 3) is 6.49 (4.23-9.96) and that for babies born to mothers smoking
20+ daily (group 4) is 8.56 (5.12-14.31). If one makes the reasonable
assumption that the incidence of SIDS in the reference group at the time
of the study was 0.5 per 1,000 live births, for every 10,000 women in
group 2 who stopped smoking the mean estimate of infant lives saved would
be 16.25, while for every 10,000 women in group 4 who reduced their
cigarette consumption to 10-19 per day the number of lives saved would be
10.35. However, for every 10,000 group 4 women who reduced their smoking
to 1-9 cigarettes per day, the estimated number of lives saved would be
21.55. If a different estimate of the SIDS incidence in the reference
group is substituted, the calculated numbers of lives saved would be
somewhat different but the ratios between the effects of different degrees
of smoking reduction would not. If the same exercise is performed using
the ORs calculated in another published study,(6) not cited by Mitchell,
the estimate of lives saved for every 10,000 women in group 2 who stopped
smoking would be 8, as compared with 20.5 for every 10,000 group 4 women
who reduced their consumption to that of those in group 3. It is obvious
that, however the figures are manipulated, the greatest number of lives
would be saved if all women abstained completely from smoking during
pregnancy. Inserting small print into the advice to the effect that light
smokers should stop and heavy ones should merely reduce their cigarette
consumption seems likely to dilute the message and would very probably be
counterproductive.
Bed sharing and room sharing
There is no dispute that bed sharing increases the risk of SIDS if
the mother is a smoker, is under the influence of alcohol or other
sedative drugs (prescription or not) or is ‘excessively tired’ (whatever
that may mean for a woman caring for a baby aged less than 6 months).
There is less agreement as to the risk if the mother does not come into
any of the above risk categories, and especially if she is a non-smoker.
As Mitchell points out, a meta-analysis by the European Concerted Action
on SIDS Study(7) has shown a small but significant increase in risk for
infants under about 12 weeks of age, and this is reinforced by the finding
of 2 more recent studies.(8 9) Several reports have demonstrated that the
risk of SIDS is approximately doubled if an infant sleeps in a separate
room as compared with sleeping in a cot in the parents’ bedroom.(7 8 10
11) The FSID and DoH advice that “The safest place for your baby to sleep
is in a cot in your room for the first six months of life” incorporates
both these sets of findings as well as being unequivocal and easy to
understand. The observation that “the advice is not explicit as to which
components are most important” reflects the fact that we do not actually
know which components are most important, but does not invalidate the
advice.
Illness and infection
Mitchell argues that, because a recent German study (of which he is a
co-author)(12) “has shown that infection is not a risk factor for SIDS in
a population where few infants sleep prone” (the reference is wrongly
cited in Mitchell’s article: his reference number 50 is an earlier study
from New Zealand). Firstly, failure to demonstrate an effect does not mean
that no effect exists (‘the curse of the null hypothesis’). Secondly,
another recent study found that parents in families who had lost a
previous child to SIDS were more likely to report non-specific symptoms
and signs of illness in subsequent infants who died than in those who did
not.(13) While doubt exists, it seems prudent to continue the advice to
bring ill babies to professional advice in view of the vulnerability of
small infants to illness of all kinds.
Breast feeding
Breast feeding has now been included in the FSID recommendations for
prevention of SIDS following the recent publication of a meta-analysis by
the US Agency for Healthcare Research and Quality,(14) which showed an OR
of 0.64 (95% CI 0.51-0.81) for ‘ever’ breast feeding compared with no
breast feeding.
Pacifier (dummy) use
Since February 2007 the DoH and FSID have advised that pacifier use
may provide significant protection against SIDS following the publication
of the two meta-analyses cited by Mitchell.(15 16) There was much overlap
between the material analysed in these two reports and the statistical
results of the two were very similar. Resistance to the use of pacifiers
has largely been based on the fear that early use might interfere with the
establishment of breast feeding, but there is no convincing evidence to
this effect despite the publication of three controlled trials(17-19)
(although one of them(19) showed a small negative effect of early
introduction of a pacifier, at a mean age of 7 days, but none when the
introduction was delayed until a mean of 28 days). Accordingly, the new
recommendation is that dummies should be offered for all sleep periods
from 1 month to 6 months of age.
Publication of the evidence base
FSID has produced a document (Factfile 2) summarising the published
scientific evidence on which their recommendations are based. This has
just been updated (2007) and is available on the FSID website at
www.fsid.org.uk.
George Haycock
Foundation for the Study of Infant Deaths, 11-19 Artillery Row, London
SW1P 1RT
Correspondence to: Professor G B Haycock, Scientific advisor, Foundation
for the Study of Infant Deaths, 11-19 Artillery Row, London SW1P 1RT
research@fsid.org.uk
References
1 Mitchell EA. Recommendations for sudden infant death
syndrome prevention: a discussion document. Arch Dis Child 2007;92(2):155-
9.
2 Department of Health. Reduce the risk of cot death: an easy
guide, 2007.
http://www.dh.gov.uk/en/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/DH_4123625.
3 Blair PS, Platt MW, Smith IJ, et al. Sudden infant death
syndrome and sleeping position in pre-term and low birth weight infants:
an opportunity for targeted intervention. Arch Dis Child 2006;91(2):101-6.
4 Fleming PJ, Bacon C, Blair PS, et al., editors. Sudden
unexpected deaths in infancy. The CESDI SUDI studies 1993-1996. London:
The Stationery Office, 2000.
5 Gigerenzer G. Reckoning with risk: learning to live with
uncertainty London: Penguin Books Ltd., 2002.
6 Poets CF, Schlaud M, Kleemann WJ, et al. Sudden infant death
and maternal cigarette smoking: results from the Lower Saxony Perinatal
Working Group. Eur J Pediatr 1995;154(4):326-9.
7 Carpenter RG, Irgens LM, Blair PS, et al. Sudden unexplained
infant death in 20 regions in Europe: case control study. Lancet
2004;363(9404):185-91.
8 Tappin D, Ecob R, Brooke H. Bedsharing, roomsharing, and sudden
infant death syndrome in Scotland: a case-control study. J Pediatr
2005;147(1):32-7.
9 McGarvey C, McDonnell M, Hamilton K, et al. An 8 year study of
risk factors for SIDS: bed-sharing versus non-bed-sharing. Arch Dis Child
2006;91(4):318-23.
10 Blair PS, Fleming PJ, Smith IJ, et al. Babies sleeping with
parents: case-control study of factors influencing the risk of the sudden
infant death syndrome. CESDI SUDI research group. BMJ 1999;319(7223):1457-
61.
11 Mitchell EA, Thompson JMD. Co-sleeping increases the risk of
SIDS, but sleeping in the parents' bedroom lowers it. In: Rognum TO,
editor. Sudden infant death syndrome: new trends in the nineties. Oslo:
Scandinavian University Press, 1995:266-9.
12 Vennemann MM, Findeisen M, Butterfass-Bahloul T, et al.
Infection, health problems, and health care utilisation, and the risk of
sudden infant death syndrome. Arch Dis Child 2005;90(5):520-2.
13 Wailoo M, Thompson JR, Waite AJ, et al. Signs and symptoms of
illness in early infancy: associations with sudden infant death. Arch Dis
Child 2003;88(11):1001-4.
14 Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and
infant health outcomes in developed countries. Evidence report/technology
assessment No. 153 (prepared by Tufts-New England Medical Center Evidence-
based Practice Center, under contract No. 290-02-0022): Agency for
Healthcare Research and Quality, 2007:1-186.
http://www.ahrq.gov/clinic/tp/brfouttp.htm.
15 Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the
risk of sudden infant death syndrome? A meta-analysis. Pediatrics
2005;116(5):e716-23.
16 Mitchell EA, Blair PS, L'Hoir MP. Should pacifiers be
recommended to prevent sudden infant death syndrome? Pediatrics
2006;117(5):1755-8.
17 Schubiger G, Schwarz U, Tonz O. UNICEF/WHO baby-friendly
hospital initiative: does the use of bottles and pacifiers in the neonatal
nursery prevent successful breastfeeding? Neonatal Study Group. Eur J
Pediatr 1997;156(11):874-7.
18 Kramer MS, Barr RG, Dagenais S, et al. Pacifier use, early
weaning, and cry/fuss behavior: a randomized controlled trial. Jama
2001;286(3):322-6.
19 Howard CR, Howard FM, Lanphear B, et al. Randomized clinical
trial of pacifier use and bottle-feeding or cupfeeding and their effect on
breastfeeding. Pediatrics 2003;111(3):511-8.
With interest we have read the review by VandenPlas and coworkers (1)
in which guidelines for the diagnosis and management of cow’s milk protein
allergy (CMPA) in infants are discussed and general recommendations with
respect to these issues are given. The authors present two diagnostic
algorithms, on which we would like to comment.
The authors developed separate diagnostic algorithms for ex...
With interest we have read the review by VandenPlas and coworkers (1)
in which guidelines for the diagnosis and management of cow’s milk protein
allergy (CMPA) in infants are discussed and general recommendations with
respect to these issues are given. The authors present two diagnostic
algorithms, on which we would like to comment.
The authors developed separate diagnostic algorithms for exclusively
breast-fed and formula-fed infants with a suspicion of CMPA. In both
algorithms a clinical assessment divides the flow chart into two branches:
suspicion of mild to moderate CMPA or suspicion of severe CMPA. Symptoms
that put the child at an immediate life-threatening risk or may interfere
with the child’s normal development, differentiate severe from mild to
moderate CMPA. Children with a suspicion of severe CMPA are referred to a
paediatric specialist and a food challenge will be performed in a hospital
setting.
Our first comment on the presented diagnostic algorithms concerns the
manner at which the diagnosis CMPA is confirmed. Nowadays the food
challenge, preferable a double blind placebo controlled challenge
(DBPCFC), is the gold standard for the diagnosis of food allergy. The food
challenge is part of a diagnostic procedure that includes three phases:
elimination of the suspected food, challenge with the suspected food, and
re-elimination. For simplicity and socio-economic reasons an open food
challenge instead of a DBPCFC is recommended by the authors. It is well
known that the diagnosis of food allergy based on an open food challenge
will result in large numbers of false positive diagnoses. To limit this
number of false positive diagnoses, the diagnostic procedure should
include the three phases mentioned above. Unfortunately, in both
diagnostic algorithms the re-elimination phase is not mentioned.
Second, in the algorithm for formula-fed infants angio-edema and
urticaria are described as mild to moderate symptoms. This implies that
children with these symptoms are not referred to a paediatric specialist
and a food challenge will be performed in a non-hospital setting, with
which we strongly disagree. Urticaria and angio-edema are both
manifestations of a systemic reaction and are the most common
manifestations of anaphylaxis (2;3). No clear data are available that
describe the risk of a severe life threatening allergic reaction in
children suspected of CMPA with initial symptoms such as urticaria and
angio-edema. For other food allergies such as nut allergy, it is known
that severity of subsequent reactions can not be predicted by history
alone (4). Furthermore, in children with initial mild symptoms such as
atopic eczema dermatitis syndrome, acute allergic reactions to cow’s milk
after a prolonged cow’s milk protein diet are described (5). In our
opinion children with initial symptoms of angio-edema and generalized
urticaria are at risk of a similar or even severe allergic reactions when
they are challenged with the suspected food. Therefore, a challenge test
should be performed in a hospital setting supervised by a medical staff
experienced in recognizing and managing severe allergic reactions.
Third, the instructions how to perform a food challenge in formula-
fed infants are incomplete. The authors propose a challenge protocol with
a stepwise increased dose scheme expressed in milliliters formula. No
instructions are given about the amount of cow’s milk protein needed in
each dose step. The amount of cow’s milk protein is different in each
infant formula. Therefore the guideline should provide information about
the amount of cow’s milk protein in milligrams needed in each challenge
step.
Furthermore, no instructions are given by the authors how to perform a
food challenge in breast-fed infants. According to the national guideline
of the baby health clinics in the Netherlands (6), we propose that a food
challenge in breast-fed infants is performed by instructing the mother to
drink a stepwise increasing amount of milk on three consecutive days (up
to 500ml daily). If symptoms of CMPA re-appear, the challenge is followed
up by a re-elimination phase of one week. If no reaction occurs, the
mother is instructed to drink 500ml milk each day for the next two weeks
and the parents are told to observe the child for late reactions.
In summary, children suspected of CMPA need to complete a diagnostic
procedure including a re-eliminiation phase to confirm the diagnosis CMPA.
Furthermore, children suspected of CMPA with initial symptoms such as
urticaria and angio-edema should be referred to a paediatric specialist
and a food challenge needs to be performed in a hospital setting.
Finally, instructions on how to perform a food challenge should include
the amount of cow’s milk protein needed in each challenge step.
Reference List
(1) Vandenplas Y, Brueton M, Dupont C et al. Guidelines for the
diagnosis and management of cow's milk protein allergy in infants. Arch
Dis Child 2007; 92(10):902-908.
(2) Lieberman P, Kemp SF, Oppenheimer J et al. The diagnosis and
management of anaphylaxis: An updated practice parameter. Journal of
Allergy and Clinical Immunology 2005; 115(3, Supplement 2):S483-S523.
(3) Bindslev-Jensen C, Ballmer-Weber BK, Bengtsson U et al.
Standardization of food challenges in patients with immediate reactions to
foods--position paper from the European Academy of Allergology and
Clinical Immunology. Allergy 2004; 59(7):690-697.
(4) Wang J, Sampson HA. Food anaphylaxis. Clin Exp Allergy 2007;
37(5):651-660.
(5) Flinterman AE, Knulst AC, Meijer Y, Bruijnzeel-Koomen CA,
Pasmans SG. Acute allergic reactions in children with AEDS after prolonged
cow's milk elimination diets. Allergy 2006; 61(3):370-374.
(6) Kneepkens CM, van Drongelen KI, Aarsen C. Landelijke standaard
voedselallergie bij zuigelingen. 5e druk. Den Haag; voedingscentrum, 2005.
Mahajan's study was commendable as it was pertinent to a large
percentage of training paediatricians within the UK. Being of Indian
ethnic origin myself (but from the African continent) I could relate to
several issues highlighted by the article.
Barriers such as communication skills and work culture should also be
viewed as goals or strengths whilst training within the NHS. These are
major "barriers" when train...
Mahajan's study was commendable as it was pertinent to a large
percentage of training paediatricians within the UK. Being of Indian
ethnic origin myself (but from the African continent) I could relate to
several issues highlighted by the article.
Barriers such as communication skills and work culture should also be
viewed as goals or strengths whilst training within the NHS. These are
major "barriers" when training within developing countries. The ever
increasing patient load and lack of resources in these settings challenge
medical personnel in achieving effective communication with the
parent/patient. The focus on communication skills in the Royal College
examinations are wholly appropriate. These desirable skills attained
whilst training in the UK have afforded us (as future paediatricians) not
only good medical practice, but also a boost of self-confidence and
improved intercolleague relationships.
Team working has also influenced our improved communication skills.
The focus on the "leader" within teams has fallen away and today all
members are viewed with equal importance, each with their individual goals
contributing towards a central goal. This UK work culture has humbled the
"doctor" within us . It has heightened our appreciation and respect of
other disciplines and personnel.
Job applications and visas do cause anxiety and are unfortunately a
reality of being a foreigner working within the UK. This is time-consuming
but absolutely necessary. It is a barrier for which we do not receive any
support in the working environment.
Cultural differences do exist and integration within the society can
be viewed as difficult to achieve. On a positive note, the UK is a
multicultural society and foreigners are encountered on a day-to-day
basis. Socialising is somewhat easier when people are aware of different
cultures and are open minded. It is a matter of personal importance - the
balance between learning new and retaining old cultural practices.
This study makes all aware of the barriers we face. I reinforce that
some of these barriers have made us, as overseas doctors, better doctors
and people in ourselves. It may in fact enhance our progress in the
training process.
In the relevant review by Osborn and Evans, (2004) subgroup
analysis: Gelatin based plasma substitute versus FFP, the authors clearly
state under secondary outcomes:
The rate of NEC was significantly higher (RR 4.92, 95% CI 1.44,
16.80) in infants who received the gelatin based plasma substitute.
In the relevant review by Osborn and Evans, (2004) subgroup
analysis: Gelatin based plasma substitute versus FFP, the authors clearly
state under secondary outcomes:
The rate of NEC was significantly higher (RR 4.92, 95% CI 1.44,
16.80) in infants who received the gelatin based plasma substitute.
We agree that analysis 5.11 demonstrates no difference in incidence
of NEC in infants treated with gelofusine when compared to placebo.We also
agree that the above subgroup analysis finding should be treated with
caution (as the authors advise) as most likely it is related to multiple
statistical analysis and these were not predefined secondary trial
outcomes.However, we feel that caution should be exercised both
ways.Neither Osborn & Evans nor anyone can totally discount any
potential link between NEC and use of gelofusine.A query has been raised
and this can only be answered by further research, pending which caution
should be exercised in its use especially in preterm neonates. The authors
(Osborn and Evans) have suggested that the finding be treated with
caution, not be disregarded.
Analysis 4.14 suggests that there was significantly less NEC in the
FFP group compared to placebo.This makes analysis 6.11 even more
interesting as it suggests that there was significantly more NEC in the
gelatin group compared to FFP. Thus even though analysis 5.11 is
reassuring that the incidence of NEC was the same when gelatin was
compared to placebo, the combined evidence presented in 4.14 and 6.11
raises doubts.
In conclusion, we agree that there is no clear evidence regarding
increased risk of NEC with gelofusine. However, a doubt regarding
potential link has been raised by analysis 6.11 and this warrants further
research.Pending such safety studies, caution should be exercised in the
use of gelofusine in preterm neonates.
The argument by Roderick et al as to whether varicella vaccine should
be introduced has particular relevance to Australia. Here, a single dose
only is offered at 18 months, with a further opportunity in the teenage
years for those without prior history of disease or vaccination. My
concern lies in the provisional evidence of waning vaccine-induced
immunity over time, as this will only result in chicken pox shifting from...
The argument by Roderick et al as to whether varicella vaccine should
be introduced has particular relevance to Australia. Here, a single dose
only is offered at 18 months, with a further opportunity in the teenage
years for those without prior history of disease or vaccination. My
concern lies in the provisional evidence of waning vaccine-induced
immunity over time, as this will only result in chicken pox shifting from
being a predominantly preschool illness to being an adult illness. Far
from protecting those at higher risk of disease (like pregnant women and
their unborn children), a childhood vaccine could create increased numbers
of such an at-risk population. This potential long term implication of
childhood vaccination needs to be addressed by answering the question
whether two doses will provide lifelong immunity - or at least, from a
paediatric point of view, through the child-bearing years.
It may be that with increased herd immunity these adults and pregnant
women wil be at less risk, but overall I would still urge caution, and I
would not be surprised if Australia sees an increase in congenital
varicella or neonatal chicken pox in twenty to thirty years time, unless
that 2nd dose is added in soon.
I have 22 years experience in a pediatric general care unit and can
say with certainty that the most important aspect of venipuncture is a
skilled technician. EMLA is Ok and distractive techniques can help, but
when it comes down to it.. venipuncture is always scary for kids. Rarely
do any distractive attempts or local anesthetics do much to diminish the
crying and struggling (fear). Whats most important is for the
p...
I have 22 years experience in a pediatric general care unit and can
say with certainty that the most important aspect of venipuncture is a
skilled technician. EMLA is Ok and distractive techniques can help, but
when it comes down to it.. venipuncture is always scary for kids. Rarely
do any distractive attempts or local anesthetics do much to diminish the
crying and struggling (fear). Whats most important is for the
phlebotomist to perform accurately and quickly. No amount of distraction
or anesthesia (which can be prohibitively time-consuming) will make a
repeat attempt scenario any better. Train the nurses and phlebotomists
intensively on vein selection and proper tourniquet application, with
appropriate "bedside technique", and you'll have much better "patient
satisfaction."
We found the article of S H Dijkstra et al (1) very interesting. We
recently conducted a study in 93 non-pregnant women, aged 20 to 50 years,
to determine the prevalence of vitamin D deficiency in women at risk of
vitamin D deficiency because of their wearing of concealing clothes (such
as a veil). This prospective study was performed between December 2004 and
January 2005 in general practitioner se...
We found the article of S H Dijkstra et al (1) very interesting. We
recently conducted a study in 93 non-pregnant women, aged 20 to 50 years,
to determine the prevalence of vitamin D deficiency in women at risk of
vitamin D deficiency because of their wearing of concealing clothes (such
as a veil). This prospective study was performed between December 2004 and
January 2005 in general practitioner setting in Lyon France. We found that
almost 99% of these young women had a mild D deficiency (25-hydroxyvitamin
D< 53 nmol/l), 83% had a severe deficiency (25-hydroxyvitamin D< 30
nmol/l) and 14% had no vitamin D at all.
These results can be compared with those of a national survey, SUVIMAX, of
1500 healthy volunteers aged 35-65 years. This survey showed the overall
prevalence of vitamin D deficiency in France was 14% (vitamin D <30
nmol/l) and 9% in the Lyon region (2). Other European studies have shown a
long delay between first symptoms and appropriate diagnosis (2 to 2.5
years in average), and that women often end up with a diagnosis of
depression or “psychological disorder” but no appropriate treatment (3).
In our sample, 73% of the women suffered chronic pain and fatigue that had
lasted for more than 6 months at the time of the study. None of them had
been diagnosed nor treated appropriately and 35% had had at least one
hospitalisation during the preceding 6 months.
In France, there are increasing numbers of women wearing concealing
clothes especially in urban regions such as the area of Lyon. This
phenomenon is quite recent, thus general practitioners are not aware that
these women represent a group at high risk of severe vitamin D deficiency.
Furthermore, the question of vitamin D deficiency does not appear to be
well recognised in our country where most food products are not
supplemented with vitamin D. We haven’t been successful so far in our
efforts to set up a program of prevention and implementation of guidelines
following our descriptive study. It seems that the medical community
apparently do not believe this is an important public health problem. If
we don’t succeed in increasing the awareness of this problem in the health
community we may well see a re-emergence of osteomalacia in adults and
probably deleterious consequences in children as Dijkstra et al
demonstrated in their study.
1-Dijkstra S H, van Beek A, Janssen J W, de Vleeschouwer L H M,
Huysman W A, van den Akker E L T. High prevalence of vitamin D deficiency
in newborn infants of high-risk mothers. Arch. Dis. Child. 2007;92:750-
753.
2-Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S,
Meunier PJ. Prevalence of vitamin D insufficiency in an adult normal
population. Osteoporos Int. 1997;7(5):439-443.
3-Nellen JF; Smulders- YM; Frissen-PH; Slaats-EH; Silberbusch-J.
Hypovitaminosis D in immigrant women: slow to be diagnosed. Br Med J.
1996;312(2):570-572.
A definition of iron deficiency based solely on the serum ferritin cut-off levels stipulated by the authors(1) runs the risk of underestimating the prevalence of this disorder because patients who have iron deficiency in the presence of chronic inflammation may have serum ferritin levels which fall within the normal range(2). In order to identify such patients, the authors could have documented the levels of C reactive...
We read with interest the article by Maguire et al 1, reporting the results of a systematic review of torn frenum and other intraoral injuries in diagnosing abuse. We do accept that in the absence of case control studies, the most appropriate study design to answer a diagnostic clinical question, the authors had to settle for case series or case studies. However, when none of the included case series were specifically desi...
Sir,
The Archimedes offering by Khashu and Balusubramaniam [1] contains an overstatement of the evidence from our Cochrane Review [2] (Early volume expansion for prevention of morbidity and mortality in very preterm infants) in suggesting in their 'Clinical Bottom Line' that "Weak evidence suggests an increased risk of necrotising enterocolitis with use of Gelofusine in neonates”. We had cautioned against over i...
In the February 2007 issue of the Archives, Mitchell(1) published a discussion document on recommendations for prevention of sudden infant death syndrome (SIDS), focussing particularly on the advice issued by the Department of Health (DoH) in England on 3 occasions, in 2000, 2004 and 2005. A revised version was published in February 2007,(2) too late for inclusion in Mitchell’s paper. In the paper he reviews some of the...
Dear editor,
With interest we have read the review by VandenPlas and coworkers (1) in which guidelines for the diagnosis and management of cow’s milk protein allergy (CMPA) in infants are discussed and general recommendations with respect to these issues are given. The authors present two diagnostic algorithms, on which we would like to comment.
The authors developed separate diagnostic algorithms for ex...
Mahajan's study was commendable as it was pertinent to a large percentage of training paediatricians within the UK. Being of Indian ethnic origin myself (but from the African continent) I could relate to several issues highlighted by the article.
Barriers such as communication skills and work culture should also be viewed as goals or strengths whilst training within the NHS. These are major "barriers" when train...
Dear Dr.Richmond,
Thankyou for your e letter.
In the relevant review by Osborn and Evans, (2004) subgroup analysis: Gelatin based plasma substitute versus FFP, the authors clearly state under secondary outcomes:
The rate of NEC was significantly higher (RR 4.92, 95% CI 1.44, 16.80) in infants who received the gelatin based plasma substitute.
We agree that analysis 5.11 demonstrate...
The argument by Roderick et al as to whether varicella vaccine should be introduced has particular relevance to Australia. Here, a single dose only is offered at 18 months, with a further opportunity in the teenage years for those without prior history of disease or vaccination. My concern lies in the provisional evidence of waning vaccine-induced immunity over time, as this will only result in chicken pox shifting from...
I have 22 years experience in a pediatric general care unit and can say with certainty that the most important aspect of venipuncture is a skilled technician. EMLA is Ok and distractive techniques can help, but when it comes down to it.. venipuncture is always scary for kids. Rarely do any distractive attempts or local anesthetics do much to diminish the crying and struggling (fear). Whats most important is for the p...
Dear Editor,
We found the article of S H Dijkstra et al (1) very interesting. We recently conducted a study in 93 non-pregnant women, aged 20 to 50 years, to determine the prevalence of vitamin D deficiency in women at risk of vitamin D deficiency because of their wearing of concealing clothes (such as a veil). This prospective study was performed between December 2004 and January 2005 in general practitioner se...
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