It was with great interest that I read the case report of an unusual
case of tetraparesis.[1] The authors present a case of transverse
myelopathy, and I agree that it is most likely that this was caused by a
vascular insult rather than inflammatory transverse myelitis, and the
presentation would be in keeping with 'Anterior spinal artery syndrome'.
This typically presents with a combination of flaccid...
It was with great interest that I read the case report of an unusual
case of tetraparesis.[1] The authors present a case of transverse
myelopathy, and I agree that it is most likely that this was caused by a
vascular insult rather than inflammatory transverse myelitis, and the
presentation would be in keeping with 'Anterior spinal artery syndrome'.
This typically presents with a combination of flaccid weakness, sphincter
disturbance and dissociated sensory loss. The anterior spinal artery
supplies the ventral part of the spinal cord and as such, the classical
presentation is with impaired pain and temperature sensation which follows
the spino-thalamic tracts, but preserved fine sensation including position
and vibration sense which is transmitted through the posterior columns
which are spared. The suggestion that sensation was intact, but lack of a
response to cold spray would be in keeping with this. It is important to
highlight that early MRI imaging may be normal, while later imaging can
show changes including swelling, signal change or atrophy.
Anterior spinal artery compromise has been described following
cardiovascular operations, in particular on the aorta.[2,3] Other children
may present without any significant preceding intervention or insult, but
often there is a history of minor trauma or hyper-extension of the
neck.[3,4] The pathophysiology in these cases has been speculative and
there has been suggestion about fibro-cartilaginous emboli causing
compromise of the anterior spinal artery.[5] A small number of children
have been identified as having arachnoiditis, compromising the vascular
supply of the spinal cord, increasing their risk of developing this
clinical problem.[4]
While the Chiari malformation and the crowding around the foramen
magnum may have been contributory to the progression of the myelopathy,
the primary mechanism of the myelopathy could well be unrelated to this. I
note the report of a fall down the stairs prior to presentation, which
would be suggestive of a preceeding 'minor trauma' that has been reported
in other children who do not have a Chiari malformation.
It is helpful to raise awareness of the specific features of this
relatively rare presentation.
Christian de Goede
Correspondence to Dr Christian de Goede, Department of Paediatric
Neurology, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK;
Christian.degoede@lthtr.nhs.uk
Competing interests: none
REFERENCES
1. Sullivan DJ, Bevan C, Sinha S. An unusual case of acute tetraparesis.
Arch Dis Child 2011;96:1047
2. Puntis JWL, Green SH. Ischemic spinal cord injury after cardiac
surgery. Arch Dis Child 1985;60:517-520
3. Blennow G, StarckL. Anterior spinal artery syndrome. Report of
seven cases in childhood. Pediat Neurosci 1987;13:32-37
4. De Goede CGEL, Jardine PE, Eunson P et al. Severe progressive late
onset myelopaty and arachnoiditis following neonatal meningitis. Eur J of
Paediatr Neurol 2006;10:31-36
5. Han JJ, Massagli TL, Jaffe KM. Fibrocartilaginous embolism - an
uncommon cause of spinal cord infarction: a case report and review of the
literature. Arch Phys Med Rehabil 2004;85:153-157
I was surprised that the report of "keloid scarring secondary to
foetal blood sampling"[1] omitted any differential diagnosis. This 2 cm
hairless tumour "present and unchanged since birth" cannot easily be
attributed to trauma. The location at the crown is in fact highly
characteristic of aplasia cutis congenita (type 1, Frieden
classification[2]), the morphology with complete alopecia and "lumpiness"
is typical, and th...
I was surprised that the report of "keloid scarring secondary to
foetal blood sampling"[1] omitted any differential diagnosis. This 2 cm
hairless tumour "present and unchanged since birth" cannot easily be
attributed to trauma. The location at the crown is in fact highly
characteristic of aplasia cutis congenita (type 1, Frieden
classification[2]), the morphology with complete alopecia and "lumpiness"
is typical, and the presence of a second lesion consistent with that
diagnosis. One should also consider hamartomatous lesions and atretic
meningocele. I would like to know the results of histology and X-ray to
exclude underlying skull defect. A dermatological opinion would have been
advisable. Failure to recognize natural disease can lead to inappropriate
litigation, and publication of this incomplete report has serious
medicolegal implications.
References
1. Birkhamshaw E, Gupta S. Images in paediatrics: An unusual
complication of foetal blood sampling Arch Dis Child 2011;96:1065
2. Frieden IJ: Aplasia cutis congenita: A clinical review and
proposal for classification. J Am Acad Dermatol 14:646-660, 1986.
the proper management of fever in children (1) is jeopardized by the
exaggerated fear of fever (the so called "fever phobia") not only among
parents but also among health professionals, leading to misalignment
between evidence and practice (2). While it could be comprehensible a
limited understanding of fever by parents, it is not acceptable that
professionals could still believe that fever is dan...
the proper management of fever in children (1) is jeopardized by the
exaggerated fear of fever (the so called "fever phobia") not only among
parents but also among health professionals, leading to misalignment
between evidence and practice (2). While it could be comprehensible a
limited understanding of fever by parents, it is not acceptable that
professionals could still believe that fever is dangerous by itself (3).
We have recently conducted a survey among 1019 paediatric health
professionals (162 hospital paediatricians, 599 primary care
paediatricians, 92 paediatric trainees, and 166 paediatric nurses) to
detect the knowledge about febrile seizures' management. Since we were
particularly interested in the quality of the information that parents
receive, we asked them to answer to five possible parents' questions
starting from a clinical scenario of a 18-month-old girl at her first
febrile seizure. One of the five questions was: "If seizures are triggered
by fever, is it advisable to give her a timely antipyretic?". Not
surprisingly 75.2% of the respondents chose the right answer which stated
"No, there is no evidence that an antipyretic, even though if given in
time, could reduce the recurrence of febrile seizures". The rate of
correct answer, however, varied significantly between categories: 82,5%
and 81,5% among hospital and primary care paediatricians respectively,
while only 65,2% among trainees and 48,2% among nurses (chi-square per
trend, p<0.05). This question, together with the one asking about the
timing of rectal diazepam at the next febrile seizure (74,8%), had a
lower rate of right answers compared to the question on the advisability
to perform an EEG at the first episode (81,2%), but a higher rate when
compared to the questions querying about incidence (64,3%) and chance of
recurrence of febrile seizures (58,1%) (chi-square per trend, p<0.05),
showing a positive trend from the more notionistic towards the more
practical inquiries.
These data confirm that the higher the expertise and skilfulness
correlates with appropriate management provision including reassurance
information to parents. There is still room for improvement in the correct
use of antipyretics in febrile seizures: reaching uniformity in management
among health professionals will possibly lead to a clear and effective
message to families.
Gianluca Tornese*, Filippo Festini**, Paolo Siani***, Giovanni
Simeone***, Federico Marchetti*
* Department of Paediatrics, Institute for Maternal and Child Health
IRCCS "Burlo Garofolo" - University of Trieste, Trieste, Italy
** Societa' Italiana di Scienze Infermieristiche Pediatriche (SISIP)
- Italian Society of Paediatric Nurse Science, Italy
*** Associazione Culturale Pediatri (ACP) - Paediatric Cultural
Association, Italy
References
(1) McIntyre J. Management of fever in children. Arch Dis Child. 2011
Oct 28.
(2) El-Radhi AS. Why is the evidence not affecting the practice of
fever management? Arch Dis Child. 2008;93:918-20.
(3) Kramer MS, Naimark L, Leduc DG. Parental fever phobia and its
correlates. Pediatrics 1985;75:1110-13.
Sir,
We welcome the recent elucidation of the significance of rare diseases in
children provided by the Archives of Disease in Childhood (Arch Dis Child
2011;96:791-792), and the increased recognition they are receiving by the
European Union, and in England by the Chief Medical Officer (CMO report
2009). A key component of increasing recognition will be the provision of
epidemiological surveillance of rare diseases....
Sir,
We welcome the recent elucidation of the significance of rare diseases in
children provided by the Archives of Disease in Childhood (Arch Dis Child
2011;96:791-792), and the increased recognition they are receiving by the
European Union, and in England by the Chief Medical Officer (CMO report
2009). A key component of increasing recognition will be the provision of
epidemiological surveillance of rare diseases.
In their editorial 'The importance of rare diseases: from the gene to
society', Professor Dodge and colleagues argue for an expansion in disease
registries. These can indeed provide important information about the
manifestations and long term complications of a condition. However
registries have significant limitations as they are often based on an
incomplete sample. Inclusion on a register usually requires the informed
consent of patients or their parents. A disease registry does not permit
measures of incidence, nor can describe the full range of clinical
presentation of a particular condition. The numbers and types of patients
that do not join are not known; there is no accurate denominator for many
sampled populations.
National surveillance systems for rare childhood disorders do exist
in many countries, linked together as part of the International Network of
Paediatric Surveillance Units (INoPSU). In the UK and Republic of Ireland
such surveillance is carried out by the British Paediatric Surveillance
Unit (BPSU), which is celebrating 25 years of work this year. Over this
time the BPSU has coordinated 80 studies resulting in over 300
publications, 222 presentations and 8 book chapters (Knowles et al Journal
of Public Health 2011.doi:10.1093/pubmed/fdr058). As well as studying the
epidemiology of rare diseases, BPSU studies have contributed to the
surveillance of infections (eg HIV) and emerging conditions (eg vCJD),
contributed to the evidence base for screening (eg MCADD) and responded to
public health emergencies (eg H1N1 vaccine study). The conditions studied
are indeed rare- as a rule only diseases with an annual incidence in the
UK and Ireland of less than 200 cases are currently permitted.
The BPSU methodology of voluntary reporting of anonymised cases by
paediatricians working within a National Health Service is efficient and
cost-effective, and has now been replicated in many countries worldwide
(see: www.inopsu.com.), as well as other specialities in the UK,
including ophthalmology (BOSU), neurology (BAPN) and child psychiatry
(CAPSS). The BPSU 'orange card' will be familiar to UK and Irish
paediatricians; an e-mail version is currently being trialled. National
coverage rates remain high (94%).
Further information about the BPSU can be found at: www.rcpch.ac.uk/bpsu.
The BPSU model has been proven as a collaborative system at the
forefront of rare disease research since 1986. Surveillance systems of
this nature provide large population-based platforms to study the
incidence, presentation, initial complications and management of rare
diseases. Good epidemiological surveillance systems and disease registries
are both needed to increase awareness and improve the care of children
with rare diseases.
Yours faithfully,
Alan Emond,
on behalf of the BPSU executive committee
We read the findings of the Feast Trial Group with interest and agree
with many comments that the results appear counter-intuitive. Given our
experience of managing children with hypovolaemic shock secondary to a
surgical cause, in Africa and beyond, we feel that it is necessary to
state that the findings of The FEAST trial should not be extrapolated to
hypovolaemic shock secondary to a surgical cau...
We read the findings of the Feast Trial Group with interest and agree
with many comments that the results appear counter-intuitive. Given our
experience of managing children with hypovolaemic shock secondary to a
surgical cause, in Africa and beyond, we feel that it is necessary to
state that the findings of The FEAST trial should not be extrapolated to
hypovolaemic shock secondary to a surgical cause (bowel obstruction,
trauma.)
The pathophysiology of hypovolaemia secondary to a surgical cause is
distinct from "impaired perfusion" secondary to severe infection. We
believe that withholding fluid bolus resuscitation from children with
hypovolaemic shock secondary to a surgical cause would result in excess
mortality.
To our concern, at a recent symposium on the management of
gastroschisis at our centre, the results of The FEAST Trial were being
used, out of context, to suggest reduced intravenous fluid resuscitation
in neonates with gastroschisis.
Yours faithfully,
Stewart Cleeve FRCS (Pead Surg),Children's Hospital, Oxford
University Hospitals, UK (stewart.cleeve@orh.nhs.uk)
Kokila Lakhoo PhD, FRCS, FCS, MRCPCH,Children's Hospital, Oxford
University Hospitals, UK (corresponding author -
kokila.lakhoo@paediatrics.ox.ac.uk)
We read with interest the publication by Ladomenou et al entitled
"Protective effect of exclusive breastfeeding against infections during
infancy" (1). The authors conclude that exclusive breastfeeding protects
infants against common infections and lessens the frequency and severity
of infectious episodes. This study, however, failed to reach a conclusion
about the potential protective role of breastfeeding on the sever...
We read with interest the publication by Ladomenou et al entitled
"Protective effect of exclusive breastfeeding against infections during
infancy" (1). The authors conclude that exclusive breastfeeding protects
infants against common infections and lessens the frequency and severity
of infectious episodes. This study, however, failed to reach a conclusion
about the potential protective role of breastfeeding on the severity of a
Urinary Tract Infection (UTI). We recently published our results (2)
concerning the role of breastfeeding on the development of renal lesions
in infants with UTI. Our conclusions, which show a protective effect of
breastfeeding in certain infants, may contribute to the study of
Ladomenou et al. We correlated the frequency of acute pyelonephritis (APN)
with the duration of breastfeeding in infants who experienced their first
episode of UTI. Findings of APN on Technetium-99m-dimercaptosuccinic acid
(DMSA) scintigraphy were documented in 45% of infants who were still on
breastfeeding during the infection, in 56% of infants who were being
breastfed in the past for different periods of time and in 70% of infants,
who had never been breastfed (p=ns). Among boys, APN was detected in 52%,
48% and 56% of infants with ongoing breastfeeding, different duration of
breastfeeding and no breastfeeding respectively (p=ns) whereas among girls
the corresponding values were 29%, 62.5% and 79% (p=0.008). Consequently,
a protective role of breastfeeding against the development of APN lesions
on DMSA scan was noted for girls with UTI. A possible explanation for our
failure to detect the same protective role in boys may be attributed to
mother's milk action on the intestinal flora in combination with the
anatomical differences in the lower urinary tract between the genders (3).
It is also well known that infant boys with first episode of UTI are
younger than girls (4) and consequently the protective role of
breastfeeding may be less obvious for them. Nevertheless, APN changes on
DMSA scan during a UTI is a multifactorial event and further prospective
studies are needed in order to clarify the role of breastfeeding.
LITERATURE
1. Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E.
Protective effect of exclusive breastfeeding against infections during
infancy: a prospective study. Arch Dis Child. 2010;95:1004-8
2. Doganis D, Delis D, Mavrikou M, Issaris G, Martirosova A, Stamoyiannou
L, Siafas K. The protective role of breastfeeding against pyelonephritis
in infants with urinary tract infection. Paediatriki. 2011;74:43-47.
3. Hanson LA. Protective effects of breastfeeding against urinary tract
infection. Acta Paediatr. 2004;93:154-6.
4. American Academy of Pediatrics. Committee on Quality Improvement.
Subcommittee on Urinary Tract Infection. Practice Parameter: the
diagnosis, treatment and evaluation of the Initial urinary tract infection
in febrile infants and young children. Pediatrics. 1999;103:843-52.
We welcome Dr Rees' October review as it highlights the need for a
radical re-think in safeguarding training if the paediatrician is to start
to contribute to the protection of children in the way she suggests.
Most maltreated children are seen by paediatric trainees and traditional
training has not equipped them or their seniors to view their role in the
way suggested. As well as recognition and response, training should...
We welcome Dr Rees' October review as it highlights the need for a
radical re-think in safeguarding training if the paediatrician is to start
to contribute to the protection of children in the way she suggests.
Most maltreated children are seen by paediatric trainees and traditional
training has not equipped them or their seniors to view their role in the
way suggested. As well as recognition and response, training should
include risk factors, burdens and consequences (1) focusing on the
interplay between the physical, psychological, emotional and social.
Teaching in this way will lead to improved paediatric assessments and more
meaningful management plans which consider both immediate and long term
outcomes.
The concept of the 'child protection medical' is a major barrier to doing
this as it implies Paediatricians are technicians who only look at the
presenting complaint. This hinders us and the multidisciplinary team from
thinking about the purpose or benefits of our consultation and
contribution to the child's overall assessment. Paediatricians are fearful
of child protection and may feel that there is not enough time to
undertake a complex consultation. This again is a misconception that lies
in the lack of wider knowledge of child maltreatment, so a full medical
history with relevant questions is not taken.
It is not just what we know that needs to change but clarity in how much
we can expect of paediatricians in their understanding of such a complex
and specialist subject. Rees article suggests the need for a new approach
which if taught from undergraduate level may lead to a generation of
doctors that may begin to understand maltreatment in the way suggested and
also identifies a role for the tertiary safeguarding paediatrician. This
is the key to practising modern safeguarding that can lead to better
outcomes for children.
References
1.Gilbert R, Spatz Widom C, Browne K, Fergusson D, Webb E, Janson S,
Burden and consequences of child maltreatment in high-income countries,
The Lancet, 2009; 373: 68 - 81.
We read with interest Marko Kerac's excellent article on wasting
amongst under 6-month old infants in developing countries (1). There is
a considerable amount of excellent research on how to identify
malnutrition. We also have comprehensive, effective, evidence on how to
manage malnutrition and reduce mortality (2). However, we and others have
audited the identification of malnutrition in children...
We read with interest Marko Kerac's excellent article on wasting
amongst under 6-month old infants in developing countries (1). There is
a considerable amount of excellent research on how to identify
malnutrition. We also have comprehensive, effective, evidence on how to
manage malnutrition and reduce mortality (2). However, we and others have
audited the identification of malnutrition in children admitted to
hospital and found that it is often unrecognized and so the appropriate
management is not instituted. Unfortunately there is a paucity of good
quality research on why many health professionals in developing countries
fail to identify malnutrition in hospitalized children and even if they do
why they are not instigating the published and widely disseminated
guidelines. Failure to recognize malnutrition can have catastrophic
consequences, as mortality rates can be reduced from as high as 50% to 5%
by simply using the WHO "10-step" guidance (2).
Our audit and literature review suggested potential barriers to the
identification of malnutrition included: that the focus of attention was
an infective illness or other co-morbidities, low staff to patient ratio,
lack of supplies, poor health care infrastructures (leading to poor
conditions on wards), inadequate or non-existent undergraduate and in-
service training and a lack of successful dynamics within the work-force.
With malnutrition contributing to 53% of child deaths (3), it is
imperative that we address the failure to identify malnutrition and the
implementation of management guidelines.
References
1. Kerac, M., Blencowe, H., Grijalva-Eternod, C., McGrath, M.,
Shoham, J., Cole, T., Seal, T. Prevalence of wasting among under 6-month-
old infants in developing countries and implications of new case
definitions using WHO growth standards: a secondary data analysis,
Archives of diseases in childhood. 2011 ;96:1008-1013 Published Online
First: 2 February 2011 doi:10.1136/adc.2010.191882
2. WHO. Guidelines for the in-patient treatment of severely
malnourished children, 2003.
3. Caulfield, L.E., de Onis, M., Bl?ssner, M., Black, R.E.
Undernutrition as an underlying cause of child deaths associated with
diarrhea, pneumonia, malaria, and measles. The American Journal of
Clinical Nutrition. 2004 July 1, 2004;80(1):193-8.
Re: Association of paediatric inflammatory bowel disease with other
immune-mediated diseases. Kappelman at al. 96: 1042-6
We read with interest the article by Michael Kappelman et al (1)
exploring the association of paediatric inflammatory bowel disease with
other immune-mediated diseases. There is however the potential for
confusion over the nomenclature used within the article. The article uses
the term rheum...
Re: Association of paediatric inflammatory bowel disease with other
immune-mediated diseases. Kappelman at al. 96: 1042-6
We read with interest the article by Michael Kappelman et al (1)
exploring the association of paediatric inflammatory bowel disease with
other immune-mediated diseases. There is however the potential for
confusion over the nomenclature used within the article. The article uses
the term rheumatoid arthritis and associates it with inflammatory bowel
disease. The study population goes up to the age of 20 years. The age when
the individuals developed their arthritis is unclear from the text. If
arthritis developed before the sixteenth birthday, it would be preferable
to use the ILAR classification of juvenile idiopathic arthritis (JIA) (2)
rather than referring to older (now superceded) terms such as juvenile
rheumatoid arthritis in children.
We note that arthralgia and arthritis are indeed important and well
recognised, but relatively uncommon, complications of inflammatory bowel
disease in children (3). Typically this association is with either the
oligoarthritis or enthesitis-related arthritis subtypes of JIA. It would
be interesting to know whether the study by Kappelman et al concurred with
this subtype association.
Within an adult population developing arthritis from the sixteenth
birthday, the correlation between inflammatory bowel disease and
arthritis was first documented in 1929 (4). It is however most likely to
be a sero-negative spondyloarthropathy which is seen in patients with
inflammatory bowel disease rather than an association with rheumatoid
arthritis.
All these types of arthritis generally affect large joints and
entheses with a risk of spinal involvement including sacro-iliitis. There
is an association with the HLA B27 antigen. They do not have a symmetrical
small joint polyarthritis generally associated with true rheumatoid
arthritis. We therefore would be interested to know the type of joint
involvement associated with the arthritis described in their study.
References
1. Kappelman, M.D. et al. Association of paediatric inflammatory
bowel disease with other immune-mediated diseases. Arch Dis Child 2011;
96:1042-6
2. Petty, R.E. et al. International League of Associations for
Rheumatology classification of juvenile idiopathic arthritis: second
revision. J Rheumatol 2004; 31: 390-2
3. Cabral, D.A. et al. Spondyloarthropathies of childhood. Paediatric
Clinics of North America 1995; 42:1051-70
4. Bargen J.A. et al. Complications and sequelae of chronic ulcerative
colitis. Ann Intern Med. 1929; 3: 335-52
The study of the mortality of 'bilateral cerebral palsy' by Gillian
Baird and colleagues from the South East Thames cohort indicates factors
that are associated with high and lower risk of death. Although they have
used the category of bilateral cerebral palsy , these fall into three
clearly recognisable clinico-pathological diagno...
The study of the mortality of 'bilateral cerebral palsy' by Gillian
Baird and colleagues from the South East Thames cohort indicates factors
that are associated with high and lower risk of death. Although they have
used the category of bilateral cerebral palsy , these fall into three
clearly recognisable clinico-pathological diagnostic groups which are much
easier to use in clinical practice.
The highest mortality is in those with bilateral cerebral cortical
damage/malformation and designated as spastic tetraplegia by the
Gothenburg group1. These children are not usually preterm and have a
combination of microcephaly, very severe cognitive impairment, epilepsy,
upper limb and bulbar functions are severely affected by spasticity as
well as lower limbs and they very rarely walk. They have high rates of
contractures of limbs and spine and generally a very high rate of
intercurrent illness particularly respiratory, bulbar and seizure related.
The second group with four limb spasticity are those with severe
periventricular leucomalacia following preterm delivery2. As expected
with a primarily white matter disease, the group have much higher
cognitive abilities than those with spastic tetraplegia, a low rate of
epilepsy and commonly develop assisted or independent walking. These are
the North American Orthopaedic surgeons' patients with 'quadriplegia' or
'whole body involvement3. It is important that the much more favourable
prognosis in this group is understood so that they are not denied
appropriate treatment.
The third group with four limb dyskinetic/athetoid/dystonic cerebral
palsy, usually following full term birth asphyxia, have predominantly
basal ganglia damage and relatively preserved intellect and a low rate of
epilepsy and as expected, a relatively low mortality4.
The fourth four-limbed involvement group or Worster-Drought syndrome
cannot be discussed because they never enter cerebral palsy
epidemiological studies5.
The factors associated with high mortality, particularly intellectual
impairment, in this study broadly point towards spastic tetraplegia. A
mortality of between 10 and 20% during childhood has been generally
accepted in this condition.
Although the original epidemiological study was done without imaging,
this is now available and the pathogenic sequences outlined above have
been largely confirmed. Thus four limb cerebral palsy becomes at least 3
separate pathogenic sequences with their own quite distinct natural
history and mortality and it is these 'diseases' that clinicians mostly
now use6.
Brian Neville
References
1. Edebol-Tysk K, Hagberg B, Hagberg G. Epidemiology of spastic
tetraplegic cerebral palsy in Sweden. II: Prevalence, birth data and
origin. Neuropediatrics 1989; 20: 46-52.
2. Wicklund LM, Uvebrant P. Periventricular leukomalacia at full-
term birth - a lesion of prenatal origin. 1990; University of
Gothenburgh.
3. Horstmann HM , Bleck EE. Orthopaedic management in cerebral
palsy. Second Ed. Mac Keith Press, 2007, p.7.
4. Kyllerman M. Reduced optimality in pre- and perinatal conditions
in dyskinetic cerebral palsy. Distribution and comparison to controls.
Neuropediatrics 1983; 14: 29-36.
5. Clarke M, Carr L, Reilly S, Neville BGR . Worster-Drought
syndrome, a mild Ectraplegic perisylvian cerebral palsy: A review of 47
cases. Brain 2000; 123: 2160-70.
6. Stanley F, Blair, E, Alberman E. Cerebral palsies: epidemiology
and causal pathways. Clinics in Developmental Medicine No. 151. 2000;
London Mac Keith Press.
Dear Sir,
It was with great interest that I read the case report of an unusual case of tetraparesis.[1] The authors present a case of transverse myelopathy, and I agree that it is most likely that this was caused by a vascular insult rather than inflammatory transverse myelitis, and the presentation would be in keeping with 'Anterior spinal artery syndrome'. This typically presents with a combination of flaccid...
I was surprised that the report of "keloid scarring secondary to foetal blood sampling"[1] omitted any differential diagnosis. This 2 cm hairless tumour "present and unchanged since birth" cannot easily be attributed to trauma. The location at the crown is in fact highly characteristic of aplasia cutis congenita (type 1, Frieden classification[2]), the morphology with complete alopecia and "lumpiness" is typical, and th...
Dear Editor,
the proper management of fever in children (1) is jeopardized by the exaggerated fear of fever (the so called "fever phobia") not only among parents but also among health professionals, leading to misalignment between evidence and practice (2). While it could be comprehensible a limited understanding of fever by parents, it is not acceptable that professionals could still believe that fever is dan...
Sir, We welcome the recent elucidation of the significance of rare diseases in children provided by the Archives of Disease in Childhood (Arch Dis Child 2011;96:791-792), and the increased recognition they are receiving by the European Union, and in England by the Chief Medical Officer (CMO report 2009). A key component of increasing recognition will be the provision of epidemiological surveillance of rare diseases....
Dear Editor,
We read the findings of the Feast Trial Group with interest and agree with many comments that the results appear counter-intuitive. Given our experience of managing children with hypovolaemic shock secondary to a surgical cause, in Africa and beyond, we feel that it is necessary to state that the findings of The FEAST trial should not be extrapolated to hypovolaemic shock secondary to a surgical cau...
We read with interest the publication by Ladomenou et al entitled "Protective effect of exclusive breastfeeding against infections during infancy" (1). The authors conclude that exclusive breastfeeding protects infants against common infections and lessens the frequency and severity of infectious episodes. This study, however, failed to reach a conclusion about the potential protective role of breastfeeding on the sever...
We welcome Dr Rees' October review as it highlights the need for a radical re-think in safeguarding training if the paediatrician is to start to contribute to the protection of children in the way she suggests. Most maltreated children are seen by paediatric trainees and traditional training has not equipped them or their seniors to view their role in the way suggested. As well as recognition and response, training should...
Dear Sir:
We read with interest Marko Kerac's excellent article on wasting amongst under 6-month old infants in developing countries (1). There is a considerable amount of excellent research on how to identify malnutrition. We also have comprehensive, effective, evidence on how to manage malnutrition and reduce mortality (2). However, we and others have audited the identification of malnutrition in children...
Re: Association of paediatric inflammatory bowel disease with other immune-mediated diseases. Kappelman at al. 96: 1042-6
We read with interest the article by Michael Kappelman et al (1) exploring the association of paediatric inflammatory bowel disease with other immune-mediated diseases. There is however the potential for confusion over the nomenclature used within the article. The article uses the term rheum...
4.11.11
The Editor Archives of Disease in Childhood
Dear Sir,
The study of the mortality of 'bilateral cerebral palsy' by Gillian Baird and colleagues from the South East Thames cohort indicates factors that are associated with high and lower risk of death. Although they have used the category of bilateral cerebral palsy , these fall into three clearly recognisable clinico-pathological diagno...
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