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The paper by Lek and Hughes highlights a serious deficiency in the
assessment of children admitted to their hospital and there is no reason
to think that their findings are atypical. However, there are two
important issues arising from their work.
First, the authors failed to define good practice. Is it realistic
to expect specialist surgeons to measure a child’s height and weight in
their outpatient consul...
The paper by Lek and Hughes highlights a serious deficiency in the
assessment of children admitted to their hospital and there is no reason
to think that their findings are atypical. However, there are two
important issues arising from their work.
First, the authors failed to define good practice. Is it realistic
to expect specialist surgeons to measure a child’s height and weight in
their outpatient consultations? And it appears that the clinical episodes
included both new patients and follow-up visits – but should
paediatricians do this at every consultation or would it be sufficient to
measure a child at the first visit and thereafter only as indicated? The
paper would have been more convincing if the authors had followed good
audit principles and decided what constitutes good practice before
collecting their data.
The second concern about this paper is the terminology used by the
authors. If a child presents with a health concern, whether identified by
parents or by health professionals, clinical evaluation should normally
include assessment of growth. That is no more “opportunistic” than
taking a proper history and conducting a physical examination. An example
of how the term “opportunistic” can be used legitimately would be catching
up on missed immunisations for a child admitted to the ward.
This paper tells us that current practice is poor and that we lack a
consensus statement on good hospital practice in assessing growth. There
is a legitimate continuing debate about monitoring the growth of all
children to detect disorders of growth and emerging obesity but this paper
throws no new light on that debate, except perhaps to warn us that if we
cannot even get paediatricians to weigh and measure appropriately, there
would be a long battle ahead to introduce a more ambitious programme of
growth monitoring in primary care settings.
It is simple to present male circumcision as the scientific and
sensible thing
to do. Indeed, the foreskin is one of those parts of the body, like wisdom
teeth and the appendix, that seem to be ripe for the plucking.
However, those who argue both for and against circumcision are likely
to
overstate their case. Guy Cox pointed out that some people have religious
and philosophical objections to circumcision. How...
It is simple to present male circumcision as the scientific and
sensible thing
to do. Indeed, the foreskin is one of those parts of the body, like wisdom
teeth and the appendix, that seem to be ripe for the plucking.
However, those who argue both for and against circumcision are likely
to
overstate their case. Guy Cox pointed out that some people have religious
and philosophical objections to circumcision. However, characterising this
opposition as “anti-Semitic or anti-Islamic” makes as much sense as
calling
someone who opposes slavery as anti-Christian, anti-Islamic and anti-
Semitic because the Bible and the Koran allow it.
The human foreskin is a natural part of a man’s penis. It is
therefore not
surprising that many people question the idea of removing it. Far from
being
as simple as an inoculation, circumcision is far from risk-free. Unless
the
operator is competent, and can control or eliminate infection and
bleeding,
the procedure is dangerous and even life-threatening.
The basic objection to infant circumcision is that the owner of the
foreskin is
the one to decide what to do with it. Medical huxterism may persuade a
grown woman that a ‘designer vagina’ is what she needs; however, the law
strictly prohibits genital cutting of underage girls. Paradoxically, the
genital
cutting of boys is accepted by custom and two powerful religions and even
the mildest criticism of male circumcision is likely to be decried as an
attack
upon faith.
Commonsense dictates that circumcisers must be up to the task.
However,
Great Britain may thank Omunnakwe Amechi for showing every quack in the
land that you don’t need medical qualifications to circumcise in Britain.
Even
better, quacks' handiwork isn't subject to oversight by the General
Medical Council.
<http://news.bbc.co.uk/2/low/uk_news/england/london/3244925.stm>
A judge in Ireland went one better. He instructed a jury not to bring
what he
called their white western values to bear on Osagie Igbinedion. As a
result, he
was found not guilty of reckless endangerment after his 4 week old son had
bled to death after Igbinedion circumcised him.
<http://www.rte.ie/news/2005/1007/igbinediono.html>
In the United States, cases have gone either way. Edwin Baxter, a
fervent
Christian was sentenced to jail for assault for circumcising his son
<http://www.cirp.org/news/thecolumbian12-16-04/> but the case
against
Jeffrey Henderson for circumcising his child was dismissed. Henderson said
that he was Hebrew and circumcised the child out of religious duty. The
judge found nothing in California’s legal code about circumcising a male
child, so he got off. <http://www.cirp.org/news/inlandvalleynews02-14-
05/>
Whether we are for or against circumcision, the procedure is not part
of a
Monty Python script. Circumcision needs to be properly regulated. And,
despite the advantages that are claimed for the procedure, the owner of
the
foreskin should ordinarily be the one to decide the fate of his foreskin.
Prais et. al. present data showing an odds ratio of 2.8 for
hopitalization for urinary infection after circumcision by a traditional
mohel as compared to a medical practitioner. The 95% confidence interval
includes 1 and the p value is 0.06. The authors, admitting that the
results do not reach statistical significance, suggest that a larger study
would strengthen the finding. They do not admit that a larger study might
e...
Prais et. al. present data showing an odds ratio of 2.8 for
hopitalization for urinary infection after circumcision by a traditional
mohel as compared to a medical practitioner. The 95% confidence interval
includes 1 and the p value is 0.06. The authors, admitting that the
results do not reach statistical significance, suggest that a larger study
would strengthen the finding. They do not admit that a larger study might
equally well weaken the finding. Furthermore, their estimate of the
frequency of ritual versus medical circumcision in the population was
based on a sample from the Rabin Medical Centre, sited in the relatively
modern and secular central region of Israel where medical circumcision
might well be more popular, as compared to the other regions of the
country which were included in their survey of hospitalizations for post-
circumcision urinary infection. This bias could invalidate the results
altogether. The conclusion that ritual circumcision places the infant at
increased risk of urinary infection, attributed to poor dressing
techniques, is not sustained by the data and is suspect due to sampling
bias.
Griffiths et al have studied conditional weight gain from birth to
the age of 3 years in babies from the Millennium Cohort Study and drawn
conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not
accounted for.
Weight must be clearly related to height. The authors report weight
(z score) at age 3 co...
Griffiths et al have studied conditional weight gain from birth to
the age of 3 years in babies from the Millennium Cohort Study and drawn
conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not
accounted for.
Weight must be clearly related to height. The authors report weight
(z score) at age 3 conditional on birthweight, however they have not
treated height in the same way, using only height (z score) at age 3. BMI
at age 3 was not used. This uses height (2) not height.
No account has been made of the genetic influence on growth. By the age of
3 years the genetic influence is evident on growth in height.2 Since no
data are presented for either maternal or paternal height this important
confounding effect has not been assessed.
The authors state that children not breastfed are both heavier and
fatter at 3 years. However the study does not include any measure of
fatness to justify this statement, the heavier babies could have had more
muscle/bone and even larger brains.
Child obesity is known to be associated with poverty and children
likely to be affected by this have been under-reported in this study.
The authors conclude that strategies to support mothers to follow
internationally recommended infant feeding practices are required. Very
few of the babies in this study were exclusively breastfed even to the age
of 4 months. This study does not assess the effects of current guidelines
(exclusive breastfeeding to the age of 6 months) on weight gain.
Yours sincerely
Dr C A Walshaw
Oakworth Surgery
Keighley
BD22 7HN
1 Griffiths L J, Smeeth L, Hawkins S S, Cole T J Dezatoux C. Effects
of infant feeding
Practice on weight gain from birth to 3 years. Arch. Dis. Child.
Doi:10.1136/adc.2008.
137554
2 Silventoinen K. Pietilainen KH, Tynelius P, Sorensen TI, Kaprio J,
Rasmussen F.
Genetic regulation of growth from birth to 18 years of age: the
Swedish young male
twins study. American Journal of Human Biology. May 2008, 20/3(292-
8), 1520-6300.
Leven and Mcdonald (1) report on the common occurrence of neonatal
hypernatremic dehydration in breastfed infants and how early weighting is
an effective means of detecting this condition. Studies of this type are
the “tip of the iceberg” of much bigger problem, that of insufficient
lactation in primiparous women. It is well recognized that primiparous
woman produce less milk than multiparous and that 16% of exclusivel...
Leven and Mcdonald (1) report on the common occurrence of neonatal
hypernatremic dehydration in breastfed infants and how early weighting is
an effective means of detecting this condition. Studies of this type are
the “tip of the iceberg” of much bigger problem, that of insufficient
lactation in primiparous women. It is well recognized that primiparous
woman produce less milk than multiparous and that 16% of exclusively
breastfed infants of primiparous women have > 10% weight loss.(2, 3)
Neonatal hypernatremic dehydration is difficult to recognize on clinical
grounds and can easily be confused for neonatal sepsis.(4) Insufficient
lactation and excessive weight loss should be an anticipated problem.
Excessive weight loss and hypernatremic dehydration is largely preventable
by the judicious use of supplement infant formula or expressed breast
milk.
A simple and effective way of preventing neonatal dehydration is to
have breastfeeding mothers use a supplemental nursing system until
successful lactation is established. This system is used with great
success by lactation consultants, yet most physicians, maternity wards and
breastfeeding mothers are unaware that this system exists. A supplemental
nursing system consists of a container which delivers supplemental milk
via a capillary tube that is taped to the mother’s nipple. The flow rate
of supplemental milk through the capillary tube can be adjusted.
Supplemental milk is delivered while the infant is nursing from the
mother’s breast, therefore the mother’s milk supply is stimulated and the
child continues to receive breast milk. The supplemental milk can be
discontinued once the milk supply has come in and successful lactation has
been established. The wider use of this system in the first few days of
life until successful lactation is established would greatly reduce the
incidence of both neonatal hypernatremic dehydration and breastfeeding
jaundice. While early detection of excessive weight loss is important,
the ultimate goal is prevention.
1. Leven LV, Macdonald PD. Reducing the incidence of neonatal
hypernatraemic dehydration. Arch Dis Child 2008;93:811.
2. Ingram J, Woolridge M, Greenwood R. Breastfeeding: it is worth
trying with the second baby. Lancet 2001;358:986-7.
3. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for
suboptimal infant breastfeeding behavior, delayed onset of lactation, and
excess neonatal weight loss. Pediatrics 2003;112:607-19.
4. Moritz ML, Manole MD, Bogen DL, Ayus JC. Breastfeeding-associated
hypernatremia: are we missing the diagnosis? Pediatrics 2005;116:e343-7.
This is a timely and important article. Pretermitting whether
parental consent can ever be valid for non-therapeutic surgeries on
minors, certainly Mr. Wheeler is correct that at the very least the
permission of both parents should be necessary for the circumcision of a
male child. Too often here in the U.S. the matter ends up in court. I
have been involved in one way or another in seven such cases in t...
This is a timely and important article. Pretermitting whether
parental consent can ever be valid for non-therapeutic surgeries on
minors, certainly Mr. Wheeler is correct that at the very least the
permission of both parents should be necessary for the circumcision of a
male child. Too often here in the U.S. the matter ends up in court. I
have been involved in one way or another in seven such cases in the last
ten years. Quite often the matter is one of spite, although occasionally
religion is involved. One such important case is presently wending its
way through the Oregon courts. The child is invariably placed in the
middle, where he does not belong. The real solution is statutory.
Parliament (and in the U.S., Congress or the state legislatures) should
pass legislation requiring the consent of both parents (unless the
parental rights of one parent have been entirely forfeited) for the non-
therapeutic circumcision of male minors, whether the circumcision be
secular or religious. (In cases of divorce where one parent has custody
but the other parent might obtain custody automatically upon the death of
the custodial parent, the consent of both parents should be required).
However, regardless of the statutory or common law, basic ethics require
that the surgeon ascertain the wishes of both parents and refrain from
circumcising a boy if either parent, or the boy himself, objects.
There is a curious paradox in this debate. Male circumcision is, like immunisation, prophylactic medicine. Its benefits (protection against UTIs, HIV, balanitis, phimosis and penile and cerivcal carcinoma) are well established. The risks of circumcision are lower than those of most immunisations, and in at least some cases (where the diseases in question are now rare) its benefit is greater.
There is a curious paradox in this debate. Male circumcision is, like immunisation, prophylactic medicine. Its benefits (protection against UTIs, HIV, balanitis, phimosis and penile and cerivcal carcinoma) are well established. The risks of circumcision are lower than those of most immunisations, and in at least some cases (where the diseases in question are now rare) its benefit is greater.
Yet if a parent's religious beliefs proscribe immunisation there is huge pressure to over-ride that belief, whereas when that belief prescribes circumcision the pressure is in the opposite direction!
In the English-speaking world male circumcision was widely recognized as beneficial until relatively recent times, and paradoxically it has become less popular even as the evidence of its benefits has grown. The main driving factors against circumcision in western countries seem to be beliefs which are either religious (anti-semitic or anti-islamic) or 'quasi-religious' - that is, based on philosophical or irrational grounds rather than science.
We do need to recognize that male circumcision has a valid place in preventative medicine, and that parents should be able to make a free and informed decision for or against the procedure. And, living in the real world, we must also realise that religious issues may help to sway the decision in either direction.
Dragging so-called 'female circumcision' into the debate is a red herring. The term is used in such a vague and broad way, covering a number of totally different operations, that it has become meaningless. And what on earth sterilization has to do with the issue is quite beyond me.
Efforts to reduce the gap between research and practice: the Italian
experience
Elena Chiappini (1), Filippo Festini (1), Riccardo Longhi(2),
Franscesca Bonsignori (1), Maurizio de Martino (1)
(1)Department of Paediatrics, University of Florence, Italy
(2)Department of Paediatrics, Sant’Anna Hospital, Como, Italy
Key words: fever, antipyretics, guidelines
Corresponding author: Prof. Maurizio de Martino, Department of
Paediatrics, University of Florence, Viale Pieraccini, 24, I-50132
Florence, Italy.
E-mail: maurizio.demartino@unifi.it
Editor,
In his article, El-Radhi underlines the barriers to the clinical
application of literature evidence, including lack of awareness among
health care professionals, inertia of previous practice and parents’
misconceptions(1). Targeted physician and parental education programs are
advocated.
We would like to report the recent Italian experience.
Fever-phobia is widespread in Italy and prescription practices often do
not follow scientific evidence (2). In a recent survey, paracetamol was
the off-label drug most often used in children, being frequently
administered at higher dosages than those indicated in the product
licences (2). Worryingly, antipyretic overdoses have been reported with
increased frequency in Italy (3). The NICE guideline for the management of
the febrile child (4) is not completely applicable in other countries,
since the structure of the health care system varies among European
countries.
For these reasons, a targeted national guideline has been developed
by the Italian Society of Paediatrics (SIP) and has been divulgated among
Italian primary care and hospital paediatricians (5). The document focuses
on the management of the sign/symptom fever in children. Detailed
information regarding methods to measure the body temperature (by parents
in a domiciliary setting, and by health care professionals in ambulatory
or hospital settings) is provided. Use of antipyretics for a substantial
proportion of febrile children with minimal or no symptoms and alternated
use of antipyretics are discouraged. Paediatricians are also alerted that
several concomitant conditions may be associated with increased risk of
paracetamol and/or ibuprofen toxicity. Written advices for the parents,
recommendations for the management of fever in the newborn and child with
an underlying chronic disease and algorithms for the management of the
child with suspected antipyretic toxicity are provided.
Quality care is depending on the best evidence. The Italian guideline
for the management of the sign/symptom fever aims to reduce the gap
between research and clinical practice in our country.
References
1)El-Radhi AS. Why is the evidence not affecting the practice of fever
management? Arch Dis Child 2008;93:918-20.
2)Pandolfini C, Impicciatore P, Provasi D, Rocchi F, Campi R, Bonati M;
Italian Paediatric Off-label Collaborative Group. Off-label use of drugs
in Italy: a prospective, observational and multicentre study. Acta
Paediatr 2002;91:339-47.
3) Italian Drug Agency- Paracetamol – Reports of overdoses (AIFA
16/02/2007). Available at website : http//www.agenziafarmaco.it (accessed
30 october, 2008).
4) National Institute for Health and Clinical Excellence. NICE. Clinical
Guideline. Feverish illness in children younger that 5 years. BMJ
2007;334:1165-7.
5) de Martino M, Principi N. Italian Guideline for the management of the
sign/symptom fever in children (abs.) Minerva Pediatr 2008;60: 489-501.
We read with interest El-Radhi’s article on the management of fever
and whilst we agree that fever is a very common complaint a more recent
paper by Armon et al showed that the most common medical presenting
complaint to a UK paediatric emergency department was breathing
difficulties (31%). Febrile illness was the second most common of medical
ED attendances (20%) with similar figures demonstrated in other
contemporary...
We read with interest El-Radhi’s article on the management of fever
and whilst we agree that fever is a very common complaint a more recent
paper by Armon et al showed that the most common medical presenting
complaint to a UK paediatric emergency department was breathing
difficulties (31%). Febrile illness was the second most common of medical
ED attendances (20%) with similar figures demonstrated in other
contemporary studies1.
The optimal antipyretic strategy remains controversial with a swell
of recent papers examining this problem. The recent PITCH study 2 found
that using paracetamol and ibuprofen in combination maximised the time
children were without fever, thereby complicating the issue further.
Modern paediatricians are undoubtedly aware of the risk of febrile
convulsions and also that fever is uncomfortable and unpleasant to the
child. The author states that ‘the majority of paediatricians in
Massachusetts believe that fever could be dangerous to a child with
seizures, death and brain damage being the most common complications.’
This statement implies that these are currently held beliefs. The article
quoted was in fact published in 1985. We question it’s relevance to
current beliefs held by paediatricians working in the UK. The author
states that the media and pharmaceutical companies contribute to the myths
and parental fears by the use of emotive slogans and headlines. An
internet search revealed advertising taglines such as “helping make kids
better day or night” and “nothing reduces fever faster or for longer.”
Similarly recent newspaper headlines 3,4 do not seem emotive and the
articles accompanying these headlines are, in our opinion, balanced, up to
date and well referenced.
When presented with outdated evidence and unreferenced assertions
perhaps we begin to see how myths arise in the first place.
References
1 Armon K, Stephenson T, Gabriel V, MacFaul R, Eccleston P, Werneke U,
Smith S Audit: Determining the common medical problems presenting to the
emergency department. Arch Dis Child 2001;84:390-392
2 Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M,
Hollinghurst S, Peters TJ. Paracetamol plus ibuprofen for the treatment of
fever in children (PITCH): randomised controlled trial. BMJ 2008;337:a1302
3. Vine S. I’m sticking with the Pink Peril. The Times. Sept 19 2008,
London.
4. Anon. Are we using too much calpol? The Telegraph Feb 16 2005,
London
We thank Amaddeo et al for their comments regarding our follow-up
study of children hospitalised with community-acquired pneumonia (CAP) 1.
They are correct in stating that Castro-Rodriguez et al postulated that
diminished lung function in children following CAP may be due to a pre-
existing alteration in airway tone, however this is only one of the
possible explanations offered by the authors 2. The second explanation is...
We thank Amaddeo et al for their comments regarding our follow-up
study of children hospitalised with community-acquired pneumonia (CAP) 1.
They are correct in stating that Castro-Rodriguez et al postulated that
diminished lung function in children following CAP may be due to a pre-
existing alteration in airway tone, however this is only one of the
possible explanations offered by the authors 2. The second explanation is
that lower respiratory tract infections in children may produce
alterations in lung structure and lung function and that these alterations
may be, in part, responsible for the lower levels of lung function
observed subsequently in children. Either way, CAP has been found to be
associated with deficits in lung function, as was the case in our cohort
of children, and can therefore be considered to be an important ‘marker’
in bringing such children to the attention of a Physician.
We agree that the assessment of chronic cough by parental reporting
is subject to bias, however the questionnaire chosen has been widely used
and previously validated in studies investigating respiratory morbidity in
Australian children 3,4. Reproducibility has been shown to be good or
excellent for the specific symptom questions, with Cohen’s kappa value
greater than 0.7 for the question pertaining to persistent cough 5. The
alternative tool available at the time of study, the cough score, is a
quantitative measure of cough and had been validated using an ambulatory
cough meter in children with normal respiratory examinations, chest
radiographs and spirometry findings only 6. It would have been an
inappropriate tool to apply to our study population, who had quite
different characteristics, without a further validation exercise. It is
acknowledged that pectus excavatum and pectus carinatum are congenital
chest wall abnormalities and are not a consequence of chronic respiratory
disease and therefore the definition of ‘signs of chronic respiratory
disease in the absence of intercurrent respiratory tract infection’ has
been subsequently revised for the purpose of future investigations.
Congenital chest wall abnormalities were present in only 2 of the 13
children found to have with abnormal chest shape; both were controls with
normal lung function. The clinical assessment was conducted by the
Principle Investigator (KE) who was also responsible for recruitment and
therefore was not blinded to case or control status. Strategies to
minimise such bias were considered in study methodology. These included a
categorical approach to the classification of questionnaire outcomes to
reduce the potential for interpretation and misclassification bias, with
outcomes cross-checked with the individual components of each item. Lung
function was measured in accordance with published guidelines and lower
limits of normal were clearly defined 7,8. Abnormal respiratory
examination findings were confirmed by a Consultant Respiratory
Paediatrician (DS) for those children who attended the Tertiary Paediatric
Respiratory Clinic.
We acknowledge in our Discussion section that the deficit in lung
function observed in our cohort may not be of immediate clinical
significance, and it is not on this basis that we would suggest that a
parent consult their doctor in the future, particularly in the absence of
clinical symptoms. We suggest that those children with problems of new
persistent cough, asthma or wheeze following CAP should be reviewed by
their doctor as we have shown that a small percentage of children may have
significant underlying chronic respiratory disease. The triad of doctor
diagnosis of a asthma, persistent cough and abnormal respiratory
examination was present in 2 cases both of whom were found to have non-CF
bronchiectasis and obliterative bronchiolitis, 1 case of productive cough
with peribronchial thickening on HRCT scan, and 1 case of severe asthma
with right middle lobe scarring. Further prospective work is required to
delineate ‘at risk’ groups and to investigate an appropriate follow-up
strategy. Whilst a deficit of 7.0% may not be clinically significant in
itself, this may become more so over time especially if there are further
respiratory insults. Furthermore, we do not know if this deficit is static
or progressive. Longer term follow-up would be required to answer this
question.
References
1. Eastham KM, Hammal D, Parker L, Spencer D. A follow-up study of
children hospitalised with community-acquired pneumonia. Archives of
Disease in Childhood 2008;93:755-759
2. Castro-Rodriguez JA, Holberg CJ, Wright AL et al. Association of
Radiologically Ascertained Pneumonia before Age 3 yr with Asthmalike
Symptoms and Pulmonary Function during Childhood. American Journal of
Respiratory and Critical Care Medicine 1999;159:1891-1897.
3. Gray EJ, Peat JK, Mellis CM et al. Asthma severity and morbidity
in a population sample of Sydney school children: Part I--Prevalence and
effect of air pollutants in coastal regions. Australian & New Zealand
Journal of Medicine 1994;24(2):168-75.
4. Faniran AO, Peat JK, Woolcock AJ. Persistent cough: is it
asthma? Archives of Disease in Childhood 1998;79(5):411-4.
5. Faniran AO, Peat JK, Woolcock AJ. Measuring Persistent Cough in
Children in Epidemiological Studies; Development of a Questionnaire and
Assessment of Prevalence in Two Countries. Chest 1999;115(2):434-439.
6. Chang AB, Newman RG. Subjective scoring of cough in children:
parent-completed vs child-
completed diary cards vs an objective method. European Respiratory Journal
1998;11:462-466.
7. American Thoracic Society. Standardization of spirometry: 1987
update. American Review of Respiratory Disease 1987;136:1285-1298.
8. Official statement of the European Respiratory Society.
Standardized lung function testing. European Respiratory Journal -
Supplement. 1993;16:1-100.
The paper by Lek and Hughes highlights a serious deficiency in the assessment of children admitted to their hospital and there is no reason to think that their findings are atypical. However, there are two important issues arising from their work.
First, the authors failed to define good practice. Is it realistic to expect specialist surgeons to measure a child’s height and weight in their outpatient consul...
It is simple to present male circumcision as the scientific and sensible thing to do. Indeed, the foreskin is one of those parts of the body, like wisdom teeth and the appendix, that seem to be ripe for the plucking.
However, those who argue both for and against circumcision are likely to overstate their case. Guy Cox pointed out that some people have religious and philosophical objections to circumcision. How...
Prais et. al. present data showing an odds ratio of 2.8 for hopitalization for urinary infection after circumcision by a traditional mohel as compared to a medical practitioner. The 95% confidence interval includes 1 and the p value is 0.06. The authors, admitting that the results do not reach statistical significance, suggest that a larger study would strengthen the finding. They do not admit that a larger study might e...
Dear Editor
Griffiths et al have studied conditional weight gain from birth to the age of 3 years in babies from the Millennium Cohort Study and drawn conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not accounted for.
Weight must be clearly related to height. The authors report weight (z score) at age 3 co...
Leven and Mcdonald (1) report on the common occurrence of neonatal hypernatremic dehydration in breastfed infants and how early weighting is an effective means of detecting this condition. Studies of this type are the “tip of the iceberg” of much bigger problem, that of insufficient lactation in primiparous women. It is well recognized that primiparous woman produce less milk than multiparous and that 16% of exclusivel...
Sirs:
This is a timely and important article. Pretermitting whether parental consent can ever be valid for non-therapeutic surgeries on minors, certainly Mr. Wheeler is correct that at the very least the permission of both parents should be necessary for the circumcision of a male child. Too often here in the U.S. the matter ends up in court. I have been involved in one way or another in seven such cases in t...
There is a curious paradox in this debate. Male circumcision is, like immunisation, prophylactic medicine. Its benefits (protection against UTIs, HIV, balanitis, phimosis and penile and cerivcal carcinoma) are well established. The risks of circumcision are lower than those of most immunisations, and in at least some cases (where the diseases in question are now rare) its benefit is greater.
Yet if a parent's religiou...
Efforts to reduce the gap between research and practice: the Italian experience
Elena Chiappini (1), Filippo Festini (1), Riccardo Longhi(2), Franscesca Bonsignori (1), Maurizio de Martino (1)
(1)Department of Paediatrics, University of Florence, Italy (2)Department of Paediatrics, Sant’Anna Hospital, Como, Italy
Key words: fever, antipyretics, guidelines
Corresponding author: Prof. M...
We read with interest El-Radhi’s article on the management of fever and whilst we agree that fever is a very common complaint a more recent paper by Armon et al showed that the most common medical presenting complaint to a UK paediatric emergency department was breathing difficulties (31%). Febrile illness was the second most common of medical ED attendances (20%) with similar figures demonstrated in other contemporary...
We thank Amaddeo et al for their comments regarding our follow-up study of children hospitalised with community-acquired pneumonia (CAP) 1. They are correct in stating that Castro-Rodriguez et al postulated that diminished lung function in children following CAP may be due to a pre- existing alteration in airway tone, however this is only one of the possible explanations offered by the authors 2. The second explanation is...
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