We feel Dr Markovitch (1) was over critical of Hilton et al (2).
Although we agree that there was a paucity of evidence to allow them to
rebut Dr Wakefield’s suggestion that MMR could in some children cause
autism, we believe that they still could have been clearer in reporting
the full situation. The suggestion that the MMR vaccine should be given as
its separate components came, not from a scientific paper, but as an
a...
We feel Dr Markovitch (1) was over critical of Hilton et al (2).
Although we agree that there was a paucity of evidence to allow them to
rebut Dr Wakefield’s suggestion that MMR could in some children cause
autism, we believe that they still could have been clearer in reporting
the full situation. The suggestion that the MMR vaccine should be given as
its separate components came, not from a scientific paper, but as an
announcement by a single researcher at a press conference. Within a month
of the publication of the Lancet paper, a number of authors of the paper
re-emphasised the importance of the combined MMR vaccine and that they had
not proven a link between it and autism (3). It is these facts that should
have been more strongly communicated, thus allowing people to attach the
appropriate level of credence to Dr Wakefield’s views. If editors of
journals had made more of this, healthcare professionals might have been
better equipped for their discussions with parents.
We agree with Dr Markovitch that “…..they [editors] should offer
honest accounts of best practice couched in language that generalist
health care professional readers and the non-scientists writing for the
public media can understand.” However, they should include all the
relevant details including a balance that is truly reflective of the
scientific evidence. The individual health professional is often unable to
review the evidence themselves, through lack of time or access to the
relevant material, and relies on journals such as those critiqued by
Hilton et al to provide the information in a full but concise manner.
Although this approach may not make for earth shattering headlines, it is
responsible. We don’t suggest that editors should be censorious but it
behoves them to couch unsubstantiated hypotheses in an appropriately
cautious manner.
1. Markovitch H. Editors should not be propagandists. Arch Dis Child
2009; 94: 827-8.
2. Hilton S, Hunt K, Langan M, Hamilton V, Petticrew M. Reporting of MMR
evidence in professional publications: 1988-2007. Arch Dis Child 2009; 94:
831-3.
3. Murch S, Thompson M, Walker-Smith J. Autism, inflammatory bowel disease
and MMR vaccine. Lancet 1998; 351: 908.
It would be useful to ascertain whether or not the "new"
sphygmanometer being compared with the Omron HEM 711(1) was an aneroid
device, given the fact that those of us who lamented what we perceived to
be an ill advised rejection of the mercury device welcomed the prospect
that aneriod sphygmanometers "may replace the traditional mercury column
in the healthcare workplace"(2). In the latter study, there were no
signific...
It would be useful to ascertain whether or not the "new"
sphygmanometer being compared with the Omron HEM 711(1) was an aneroid
device, given the fact that those of us who lamented what we perceived to
be an ill advised rejection of the mercury device welcomed the prospect
that aneriod sphygmanometers "may replace the traditional mercury column
in the healthcare workplace"(2). In the latter study, there were no
significant differences(using the paired t-test) between the mercury
standard and the aneroid device(Baum & Co), but the oscillometric
device(Omron HEM-907)significantly(p=0.002) overestimated the systolic
blood pressure(SBP) and significantly(p=0.0002) underestimated the
diastolic blood pressure(DBP)(2). A later study study compared the Welch
Allyn Tycos 767-Series Mobile aneroid sphygmanometer with the mercury
device, and found no statistically significant difference for SBP but a
significantly(p < 0.0001) lower reading for DBP using the aneroid
device(3). Oscillometric devices, on the other hand, have proved to be
almost universally unreliable. In one study, an evaluation of 9 devices
showed that "accuracy appeared to deccrease at increasing blood pressure
levels" with the potential consequence that "in treated hypertensive
patients the necessary adaptation of treatment will not take place"(4).
More recently, a comparison was made between the professional
oscillometric device BpTRU, that had achieved an A grade of the British
Hypertension Society validation protocol for both SBP and DBP measurement,
and the standard mercury sphygmanometer(Baumanometer; WA Baum Co). A total
of 5070 BP measurements were made using the two devices simultaneously.
Unreliable readings(ie > 10 mm Hg difference in either SBP or DBP) were
found in 755 patients. Unreliable readings occured in 15% of systolic and
6.4% of diastolic blood pressures(5). In view of the fact that "A
decreasing arm circumference was a significant predictor of persistent
UOBP(unreliable oscillometric BP)"(5), this observation might signify that
oscillometric devices might be inherently unreliable in children
References
(1) Midgley PC., Wardhaugh B., Macfarlane C., Magowan R., Kelnar CJH
Blood pressure in children 4-8 years: comparison of Omron HEM 711 and
sphygmanometer blood pressure measurements
Arch Dis Child 2009;94:955-8
(2)Elliot WJ., Young PE., DeVivo L., Feldstein J., Black HR
A comparison of two sphygmanometers that may replace the traditional
mercury column in the healthcare workplace
Blood Pressure Monit 2007;12:23-8
(3) Ma Y., Temprosa M., Fowler S et al
Evaluating the accuracy of an aneroid sphygmanometer in a clinical trial
setting
Am J Hypertens 2009;22:263-6
(4) Braam RL., Thien T
Is the accuracy of blood pressure measuring devices underestimated at
increasing blood pressure levels?
Blood Pressure Monitoring 2005;10:183-9
(5)Stergiou GS., Lourida p., Tzamouranis D., Baibas NM
Unreliable oscillometric blood pressure measurement;prvalence,
repeatability and characteristics of the phenomenon
J Human Hypertension 2009;23:794-800
I was interested to read Govindaraj et al’s audit showing a fall in
the number of MMR vaccines given in their hospital over the last 2 years.
Unfortunately there was no data to show what happened to those children
initially referred to hospital for MMR, but referred back by the
outpatient sister.
A study from New Zealand suggests that children inappropriately
referred for MMR in hospital can be referred back a...
I was interested to read Govindaraj et al’s audit showing a fall in
the number of MMR vaccines given in their hospital over the last 2 years.
Unfortunately there was no data to show what happened to those children
initially referred to hospital for MMR, but referred back by the
outpatient sister.
A study from New Zealand suggests that children inappropriately
referred for MMR in hospital can be referred back and subsequently
immunised in primary care [1]. However this was not our experience in
Liverpool where 22 children, who had been advised by a health professional
to have MMR in the community, were still referred to hospital [2]. This
request for immunisation in hospital came from both primary care staff and
parents.
It is important to ensure that children referred for MMR in hospital,
but referred back to primary care, are subsequently immunised. Does Dr
Govindaraj have any data to reassure us that the fall in the number of MMR
vaccines given in their hospital is not due to children being left
unimmunised in the community?
1. Goodyear-Smith F, Wong F, Petousis-Harris H, Wilson E, Turner N.
Follow-up of MMR vaccination status in children referred to a pediatric
immunization clinic on account of egg allergy. Human Vaccines.2005: 1:118-
22
2. Ainsworth E, Debenham P, Carrol ED, Riordan FAI. Referrals for MMR
immunisation in hospital. Arch Dis Child 2009 (in press)
The question on how to manage the presence of the pandemic virus
A/H1N1 in schools when the specific vaccine is not yet available is still
open. Some countries have decided to postpone the opening of schools to
avoid the epidemic peak, others have preferred to wait for the mass
vaccination to contain the epidemic. WHO has recently issued a briefing
note in which measures to be taken in school activities to limit the
spr...
The question on how to manage the presence of the pandemic virus
A/H1N1 in schools when the specific vaccine is not yet available is still
open. Some countries have decided to postpone the opening of schools to
avoid the epidemic peak, others have preferred to wait for the mass
vaccination to contain the epidemic. WHO has recently issued a briefing
note in which measures to be taken in school activities to limit the
spread of virus A/H1N1 are detailed (1). In our experience, the education
of students towards good hygiene practices has given interesting results.
We are two recently graduated italian doctors who, in the period 6-21 July
2009, were accompanying - as a medical staff - an Italian group staying in
Birmingham, composed by 163 students and 24 staff members. During this
period, 7447 confirmed flu cases were notified in the UK(2), stating that
this was an epidemic period for the new A/H1N1 virus. To avoid the
contagion and its spread, some actions were taken in the small community:
1. Informing and educating all the guests, students and staff, on which
good hygienic practices could help;
2. Distributing in strategic locations (toilets, meeting places)
dispensers of antiseptic gel, to be used every time people had to shake
hands, to touch objects, to eat or drink or after coughing e sneezing;
3. Stopping sport activities in the pool;
4. Isolating those with fever over 38°C, accompanied by flu-like symptoms,
until the disappearance of symptoms.
5. Asking the intervention of NHS medical doctors authorized to prescribe
antiviral drugs in every case of suspected flu.
After adopting such measures, among the 187 Italian guests only 3 subjects
had fever over 38°C and flu compatible symptoms within 7 days from arrival
to the college, but only one was confirmed with swine-origin influenza
A/H1N1 according to the protocol (3). Back in Italy, one additional girl
had flu-like symptoms, and was subjected to laboratory tests which
confirmed the presence of swine-flu infection. The application of
preventive measures involved the consumption of 70 dispensers of
antiseptic gel (18.7 mL/person/day). While our group was free to come back
to Italy at the end of the programmed period, another group of 70 students
had to be withheld for several days in the UK because 26 of them, in
absence of hygienic prevention, fell down with flu in few days.
We were interested to read the paper by Jones at al1 on ‘Frequent
medical absences in secondary school students’. They conclude that ‘this
study should prompt education departments and their NHS partners to look
more critically at the problem … and to establish a system that provides
more comprehensive assessment and treatment.’
Within Bolton PCT such a system has been designed in order to
identify causes of...
We were interested to read the paper by Jones at al1 on ‘Frequent
medical absences in secondary school students’. They conclude that ‘this
study should prompt education departments and their NHS partners to look
more critically at the problem … and to establish a system that provides
more comprehensive assessment and treatment.’
Within Bolton PCT such a system has been designed in order to
identify causes of frequent medical absences from school and to provide
interventions aimed at supporting students to achieve an earlier and
consistent return to school. Originally in Bolton (from the year 2000)
referrals were made by the Education Social Work Department to a Senior
Clinical Medical officer to undertake medicals on children with poor
school attendance reported as due to ill health. This provided evidence to
support an identified medical problem or for the LEA to issue a fixed
penalties notice to the parent or carer. Since the issue of school
attendance subsequently became a high priority policy concern for both the
DfES and the DoH this service was re structured to develop an innovative
Advanced Nursing Practitioner (with a school nursing background) led model
for the evaluation of health issues for children and young people with
poor school attendance. The main focus of the model was to enhance joint
working between the advanced practitioner, Education Social Worker,
schools and families. Changes have included a standardised threshold for
referral (when attendance falls to 80%), agreed minimum information sets
on referrals, agreed time frames for assessments and production of
correspondence, holistic assessment, onward referrals, investigations and
reintegration programmes to aide full return to school.
Over the last academic year 251 new referrals were received form the
Education Social Work department (previously 55 a year). There were two
peaks of referral (December 51, April 40). There were 120 referrals from
primary schools and 131 for secondary schools. Referrals included 122 boys
and 129 girls. Referrals to the service from 18 individual education
social workers varied from 1 - 41 (median 14). The main causes of school
absence were asthma, recurrent URTI, headache, sore throat, menstruation
problems, chronic fatigue, skin problems, emotional and behavioural
problems and inadequate provision for special needs within school. A
variety of onward referrals were made including ENT, community
paediatrics, dietetics, Young Carers, social care, occupational care,
physiotherapy, CAMHs and two admissions to hospital. Support packages of
care have been initiated for some together with supported reintegration
plans to enable the young person to return to regular school attendance.
Pathways are being devised for young people identified with ‘school
phobia’ (jointly with CAMHs) and also a menstruation pathway for girls
presenting with complex menstrual history.
In all cases of non attendance it is essential that preventative and
early intervention should be seen as the cornerstone of multiagency
working in order to ensure pupils right to education and to protect their
health and well being. The redesigned service in Bolton has made good
progress towards achieving these aims.
Reference
1.Jones R, Hoare P, Elton R, Dunhill Z, Sharpe M. Frequent medical
absences in secondary school students: survey and case control study. Arch
Dis Child 2009;94:763-767
THE TSH THRESHOLD IN NEONATAL SCREENING FOR CONGENITAL
HYPOTHYROIDISM: A VARIABLE SOLUTION
Dear Editor:
In their paper on the TSH threshold in neonatal screening for
congenital hypothyroidism (CH), Korada et al. (1) conclude that a
threshold of 6 mIU/L for DELFIA-measured TSH in samples collected between
days 5 and 8 may be preferable to the 10 mIU/L recommended by the UK
Newborn Screening Programme C...
THE TSH THRESHOLD IN NEONATAL SCREENING FOR CONGENITAL
HYPOTHYROIDISM: A VARIABLE SOLUTION
Dear Editor:
In their paper on the TSH threshold in neonatal screening for
congenital hypothyroidism (CH), Korada et al. (1) conclude that a
threshold of 6 mIU/L for DELFIA-measured TSH in samples collected between
days 5 and 8 may be preferable to the 10 mIU/L recommended by the UK
Newborn Screening Programme Centre. Our laboratory instituted DELFIA
measurements of TSH in 5-8—day paper-borne heelprick samples in 1985.
Since 1998 we have used an accelerated AutoDELFIA(R); method – fully
endorsed by the results of external quality control services (DGKL, NEQAS,
AECNE) – that takes about 2 h and thus allows follow-up samples to be
called for, if necessary, on the same day as the first sample is analysed.
Since 2003, heelprick has been performed on day 3 in response to the
desire of paediatric endocrinologists to begin the treatment of CH
patients as early as possible, even though the typical physiological TSH
peak on day 2 reduces the efficiency of screening thresholds; Table 1
summarizes the distribution of TSH levels in the 102,789 newborns screened
during this period.
Having observed significant between-lot variation in TSH assay kits,
since November 2004 we recalculate our TSH threshold for every run in the
light of two factors: a) the dispersion of the calibration data in the
vicinity of 10 mIU/L; and b) measurements of certified control samples
with concentrations close to 10 mIU/L that are supplied by Perkin Elmer
and, within its Newborn Screening Quality Assurance Program, by the CDC.
Defining CV10 as the coefficient of variation of two replicate
fluorescence measurements of the calibration standard nearest to 10 mIU/L,
expressed as a percentage, factor (a) is assigned the value zero if CV10
< 10, and the value 0.1 x CV10 otherwise. The control samples (C1 and
C2, of certified concentrations c1 and c2, respectively) are each measured
once; in each case a parameter bi (i = 1,2) is assigned the value zero if
the measured value mi is greater than 90% of the certified value, or the
value 10 x (ci – mi)/ci otherwise; and the value of factor (b) is defined
as the greater of b1 and b2. Finally, the TSH threshold is defined as (10
– j) mIU/L, where j is the larger of factors (a) and (b). This entirely
empirical algorithm is displayed in flow-chart form in Fig. 1.
In the 1171 runs in which the above procedure has been followed, the
threshold so determined was > 9 mIU/L in 54.7%, 8 9 mIU/L in 35.3%, 7-8
mIU/L in 8.5%, and < 7 mIU/L in 1.5%. Of the 62 cases of CH that we
have detected in this time, three (all with adequate weight at birth) had
first-sample TSH levels lower than 10 mIU/L (see Table 2 for details).
Cristobal Colon and Jose Ramon Alonso-Fernandez.
Metabolopathy Laboratory,
Departament of Paediatrics,
Clinical Hospital and Universiy of Santiago de Compostela (Spain).
References
1) KORADA SM, PEARCE M, PLATT MPW, AVIS E, TURNER S, WASTEL H, CHEETHAM T.
Dificulties in selecting an appropriate Neonatal TSH screening threshold.
Arch Dis Child (Online First), 12 Aug 2009.
2) ALONSO-FERNANDEZ JR. V Reunion Nacional de la Sociedad Española de
Química Clínica. Santiago de Compostela 28 y 29 de abril de 1985.
3) POMBO M, ALONSO-FERNANDEZ JR, BRAVO M, FRAGA JM, PEÑA J. Diagnostico
Precoz del Hipotiroidismo Congénito y de la deficiencia de Hormona del
Crecimiento. An Esp Ped. 1987;27(sup.28):44-47.
4) COLON C, ALONSO-FERNANDEZ JR. Depistage de L’Hipothiroidie neonatal
avec un inmuno-essai marque a l’Europeum. Etude comparative de curbes de
calibrage. Proceedings of “Reunion Europeene sur le Depistage Neonatal en
1986. Evian (France). 28-30 de abril de 1986.
5) ALONSO-FERNANDEZ JR, COLON C, FRAGA JM. Neonatal Screening of
Hipotiroidism: A comparative study of RIA Technique and the Non Isotopic
Inmunoessay DELFIA System. In BL Therrel; Advances in Neonatal Screening
pp 163-164 (1987). Excerpta Medica.
6) COLON C, ALONSO-FERNANDEZ JR, CASTIÑEIRAS DE, ROMERO ME, FRAGA JM, PEÑA
J. Posible Causes of Bordeline TSH: a Summary of our experrience. In F
Delange, DA Ficher, D Glinder; Research in congenital Hypothyroidism, pp
316, 1989. Plenum Press.
7) COLON C.Epidemiological study of thyroid stimulating hormone (TSH)
levels in the Galician neonatal population (Estudio epidemiologico de los
niveles de hormona estimuladora del tiroides (TSH) en la poblacion
neonatal gallega). Microfiche ISBN 13: 978-84-8121-340-9. ISBN 10:84-8121-
340-3. Ed. Universidade de Santiago de Compostela. 1995.
8) ALONSO-FERNANDEZ JR, CASTIÑEIRAS DE, CASTIÑEIRAS C, VILLAR P.
Determinacion de TSH Neonatal con el método DELFIA reduciendo a dos horas
el periodo de Elucion-Incubacion, concentrando el trazador y el analito.
Immunoensayo 97. La Habana (Cuba) 14-18 de septiembre de 1997.
Post date
In 1985 (2, 3) we propound the adaptation of DELFIA test for seric
TSH measurement to the newborn screening sample (DBS). Once Perkin-Elmer
marketed the neonatal screening TSH test, we suggested a calibrate
modification, increasing from 3 to 5 points and using the interpolation
with logarithmic spline instead linear regression such as made in the
procedure for seric and neonatal screening TSH determination (4). It is
compared with the RIA test using until then (5). In 1988 we discussed the
causes of borderline results (6), one of the main reasons for recall
sample. In the PhD thesis of one of us (C. Colon) in 1995 (7), we could
verify that the gestational age, the birth weight, and the age of
analysis, influence on the TSH values. Also was found the thyroid function
alteration due to antiseptic iodine use (effect Wolff-Chaikoff).
In 1997 we presented (8) a new DELFIA test for neonatal TSH
modification; reducing until 2 hours the elution-incubation time, using
half buffer volume in the preparation of tracer solution and reducing to
100 microlitres the volume of this solution dispensed in the microtiter
plate wells containing the DBS disc. In the next year, using the
AutoDELFIA, we introduced another modification, increasing to double the
content of second antibody-tracer in the immunochemistry reaction mixture,
in this mixture the analyte concentration result is multiplied for 2 and
Europium-labelled antibody for 4.
Lek and Hughes(1) recently highlighted concerns that opportunities
for growth measurement in children attending hospital are frequently
missed. This has important implications for the current UK policy for
growth monitoring, which encourages opportunistic measurement. It also has
important implications for clinical practice –growth faltering may result
from any chronic illness or may be the only marker of abuse or neglect...
Lek and Hughes(1) recently highlighted concerns that opportunities
for growth measurement in children attending hospital are frequently
missed. This has important implications for the current UK policy for
growth monitoring, which encourages opportunistic measurement. It also has
important implications for clinical practice –growth faltering may result
from any chronic illness or may be the only marker of abuse or neglect. In
this context growth measurement in children attending hospital should not
be seen as opportunistic, but as an essential part of good clinical care.
Lek and Hughes examined measurement of growth in a hospital with both
paediatric and non-paediatric patients. We aimed to determine the
frequency of growth measurement in a dedicated children’s hospital. In
addition we examined whether growth was assessed by plotting data on a
centile chart.
We undertook a cross-sectional study of all patient episodes
(outpatient visits, admissions and inpatients) over a 24 hour period in
September 2009 at the Royal Hospital for Sick Children, Glasgow. We
excluded children attending specifically for growth problems, and those
attending the emergency department, fracture clinic and day care units. We
examined case records to determine whether height, weight and head
circumference (in children <2 years) had been recorded and plotted on a
standardised growth chart. Recent measurements during the current
admission were accepted for in-patients.
Comparisons were made between measurements below and above 2 years of
age and between in-patient and out-patient settings. Statistically
significant differences were identified using Fisher’s exact test.
Data were available for 323 children (140 in-patients, 183 out-
patients). Mean age was 6.14(range 0.02-17.79) years. 89 children were
under 2 years (53 in-patients, 36 out-patients). Table 1 summarises
measurements recorded and plotted, and comparison between groups. Weight
was recorded in 234 (72%) cases, of which 59 (25%) were plotted. Weight
was significantly more likely to be recorded in in-patients (p=0.02), but
less likely to be plotted (p=<0.01). Height was recorded in 152 (47%)
cases, of which 49(32%) were plotted. Outpatient heights were more likely
to be plotted (p=0.03). Head circumference was recorded in 5 (6%) of the
89 children under 2 years, only 3 were plotted.
In Lek and Hughes study weight and height were recorded in 51.5% and
12.5% of children respectively. Our data suggests that growth measurements
are more frequently recorded in this children’s hospital, however
opportunities are still missed. Measurement of head circumference was
particularly poor. We also found that growth measurements were rarely
assessed by plotting on a growth chart. Plotting is a key method of
identifying growth trends.
Some specialities used computer calculated standard deviation scores
for growth monitoring. This may be useful as a screening tool but only
identifies children outwith the normal range and not those with abnormal
trends. In-patient height recording is likely to have been improved by
local use of the PYMS score(2)for nutritional screening; however this tool
is not designed to monitor growth.
We agree with Lek and Hughes that growth measurement in hospital
needs to be improved. In busy hospitals measurement and plotting of growth
parameters may be time-consuming, but simple changes such as mandatory
placement of growth charts in notes, decimal age calculators and staff
training could help. Computer software could potentially be used to plot
growth parameters, flag up ‘danger’ signs and provide a central database
for monitoring. Any such software would need to be easily accessed by all
professionals.
Growth measurements need to be made, recorded, assessed and acted
upon to form an effective part of good paediatric care.
References
1. Opportunistic growth measurements are not frequently done in
hospital. Lek N, Hughes IA. Archives of Disease in Childhood 2009;94:702-
704
2. Implementing a novel paediatric nutritional screening tool
(Paediatric Yorkhill Malnutrition Score)-challenges and impact in
paediatric nursing practice. Macleod et al. Journal of paediatric
gastroenterology and nutrition 2009; 49(4). ESPGHAN abstract AHP-08.
In the “Images in Paediatrics” section of ADC, Sept 2009 (1), I read
with interest, and some alarm, Sheth et al.’s assertion that CT scan
findings were of “significant value” in establishing the diagnosis of
Hirschsprung’s associated enterocolitis.
As the authors themselves point out, diagnosis of enterocolitis in a
child with a history of endorectal pull-through operation for
Hirschsprung’s disease should be m...
In the “Images in Paediatrics” section of ADC, Sept 2009 (1), I read
with interest, and some alarm, Sheth et al.’s assertion that CT scan
findings were of “significant value” in establishing the diagnosis of
Hirschsprung’s associated enterocolitis.
As the authors themselves point out, diagnosis of enterocolitis in a
child with a history of endorectal pull-through operation for
Hirschsprung’s disease should be made on clinical grounds, with a plain
abdominal X-ray being the investigation of choice, if required. Although
it appears from the clinical history that the authors give that the CT
scan was performed on their patient in order to rule out intussusception -
a very reasonable intervention in the circumstances– the conclusion that
the authors draw in proclaiming CT scan findings to be of significant
value in establishing the diagnosis of enterocolitis surely cannot be
justified. In the case they describe, the CT scan was useful in ruling out
diagnosis of intussusception, not in confirming the diagnosis of
enterocolitis. The message from the article may be misinterpreted by
practitioners who are less clinically astute than the authors as a
recommendation to use CT scan, with all its inherent risks and side-
effects, as a diagnostic tool of “significant value” in children with
known Hirschsprung’s disease presenting in this way.
As a general paediatrician coming across such patients in the acute
setting in my practice, I would be loathe to subject my patients to the
radiation, not to mention the likelihood of sedation or anaesthesia, of a
CT scan which does not influence my diagnosis or management. In my non-
prefessional capacity, as the parent of a 13-month old infant with
Hirschsprung’s disease who has been admitted on several occasions with
suspected Hirschsprung’s associated enterocolitis, I would be even more
loathe to consent to such an investigation for the indications the authors
seem to suggest.
References
1. Sheth et al Images in Paediatrics “CT images of Hirschsprung’s
associated enterocolitis: a rare finding. ADC 2009; 94: 816
I read with interest the article ‘making choices: why parents present
to the emergency department for non-urgent care’ published in ADC journal
in the October 2009 edition.
Amongst the reasons mentioned for coming to PED, a total of 26 parents
(18%) responded that they were either unhappy or wanted a second opinion
for their child’s condition. It is this group of patients who increase the
workload of staff and waiting time...
I read with interest the article ‘making choices: why parents present
to the emergency department for non-urgent care’ published in ADC journal
in the October 2009 edition.
Amongst the reasons mentioned for coming to PED, a total of 26 parents
(18%) responded that they were either unhappy or wanted a second opinion
for their child’s condition. It is this group of patients who increase the
workload of staff and waiting times in A&E. I agree that very child had
the right to health, but sometimes the parents’ perspective of ‘childhood
illness’ can be quite demanding to deal with. So many of us would have
come across parents who wait with their ‘unwell’ kids in A&E for nearly 3
½ hours and finally decide to leave only when the doctor’s wait is going
to take an extra 10-15mins. I empathise with such parents because strong
emotions can completely cloud your judgement and make you behave in a
totally inappropriate manner.
In the UK, the NHS has a good system of primary care, but it would be
helpful to communities to have a GP who has some paediatric experience.
All the seemingly well children who present to A&E could be dealt with by
their GP surgery or the GP walk in centre (Out of Hours service) if they
are equipped with adequate skills in clinical Paediatrics. Paediatric work
experience should become mandatory for all GP trainees as this would
restore the confidence of parents in their own doctor.
Dear Editor,
We thank doctors Beri and Hussain for their comments. They disagree with
the suggestion of withholding a lumbar puncture in a specific subset of
infants with fever and bulging fontanelle. One of the points they raised
is that cases with aseptic meningitis will be missed. However, the purpose
of performing a lumbar puncture in infants with fever and bulging
fontanelle is not to diagnose aseptic meningitis but...
Dear Editor,
We thank doctors Beri and Hussain for their comments. They disagree with
the suggestion of withholding a lumbar puncture in a specific subset of
infants with fever and bulging fontanelle. One of the points they raised
is that cases with aseptic meningitis will be missed. However, the purpose
of performing a lumbar puncture in infants with fever and bulging
fontanelle is not to diagnose aseptic meningitis but to exclude bacterial
meningitis. Diagnosing aseptic meningitis does not influence the treatment
or the course of disease and carries a good prognosis in most cases.
Another point raised is that bacterial meningitis can cause high mortality
and morbidity, especially in cases of delay in treatment. It is, of
course, the primary purpose of every physician not to miss these cases. In
our cohort, which is the largest cohort of febrile infants with bulging
fontanelles published in the literature, only one case of bacterial
meningitis was found, and this infant had clinical and laboratory
characteristics that were substantially different from those of the other
infants. None of the well appearing infants had bacterial meningitis. We
cautiously suggest that in a well appearing infant, without signs,
laboratory tests or imaging studies that suggest a bacterial etiology, it
is reasonable to observe the infant and withhold a lumbar puncture.
Prospective studies should be carried out in the future to confirm this
approach.
We feel Dr Markovitch (1) was over critical of Hilton et al (2). Although we agree that there was a paucity of evidence to allow them to rebut Dr Wakefield’s suggestion that MMR could in some children cause autism, we believe that they still could have been clearer in reporting the full situation. The suggestion that the MMR vaccine should be given as its separate components came, not from a scientific paper, but as an a...
It would be useful to ascertain whether or not the "new" sphygmanometer being compared with the Omron HEM 711(1) was an aneroid device, given the fact that those of us who lamented what we perceived to be an ill advised rejection of the mercury device welcomed the prospect that aneriod sphygmanometers "may replace the traditional mercury column in the healthcare workplace"(2). In the latter study, there were no signific...
I was interested to read Govindaraj et al’s audit showing a fall in the number of MMR vaccines given in their hospital over the last 2 years. Unfortunately there was no data to show what happened to those children initially referred to hospital for MMR, but referred back by the outpatient sister.
A study from New Zealand suggests that children inappropriately referred for MMR in hospital can be referred back a...
The question on how to manage the presence of the pandemic virus A/H1N1 in schools when the specific vaccine is not yet available is still open. Some countries have decided to postpone the opening of schools to avoid the epidemic peak, others have preferred to wait for the mass vaccination to contain the epidemic. WHO has recently issued a briefing note in which measures to be taken in school activities to limit the spr...
We were interested to read the paper by Jones at al1 on ‘Frequent medical absences in secondary school students’. They conclude that ‘this study should prompt education departments and their NHS partners to look more critically at the problem … and to establish a system that provides more comprehensive assessment and treatment.’
Within Bolton PCT such a system has been designed in order to identify causes of...
THE TSH THRESHOLD IN NEONATAL SCREENING FOR CONGENITAL HYPOTHYROIDISM: A VARIABLE SOLUTION
Dear Editor:
In their paper on the TSH threshold in neonatal screening for congenital hypothyroidism (CH), Korada et al. (1) conclude that a threshold of 6 mIU/L for DELFIA-measured TSH in samples collected between days 5 and 8 may be preferable to the 10 mIU/L recommended by the UK Newborn Screening Programme C...
Lek and Hughes(1) recently highlighted concerns that opportunities for growth measurement in children attending hospital are frequently missed. This has important implications for the current UK policy for growth monitoring, which encourages opportunistic measurement. It also has important implications for clinical practice –growth faltering may result from any chronic illness or may be the only marker of abuse or neglect...
In the “Images in Paediatrics” section of ADC, Sept 2009 (1), I read with interest, and some alarm, Sheth et al.’s assertion that CT scan findings were of “significant value” in establishing the diagnosis of Hirschsprung’s associated enterocolitis.
As the authors themselves point out, diagnosis of enterocolitis in a child with a history of endorectal pull-through operation for Hirschsprung’s disease should be m...
I read with interest the article ‘making choices: why parents present to the emergency department for non-urgent care’ published in ADC journal in the October 2009 edition. Amongst the reasons mentioned for coming to PED, a total of 26 parents (18%) responded that they were either unhappy or wanted a second opinion for their child’s condition. It is this group of patients who increase the workload of staff and waiting time...
Dear Editor, We thank doctors Beri and Hussain for their comments. They disagree with the suggestion of withholding a lumbar puncture in a specific subset of infants with fever and bulging fontanelle. One of the points they raised is that cases with aseptic meningitis will be missed. However, the purpose of performing a lumbar puncture in infants with fever and bulging fontanelle is not to diagnose aseptic meningitis but...
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