Thank you for your interesting review of the literature. The problem
is wider than just recreational use of screens and is so pervasive it is
difficult to see how limitations on screen time can be effectively
implemented. For pre-school children, many screen devices or programmes
for e.g. ipads, are marketed as educational or to help children develop,
so parents think they are doing their children a service. Equally, in...
Thank you for your interesting review of the literature. The problem
is wider than just recreational use of screens and is so pervasive it is
difficult to see how limitations on screen time can be effectively
implemented. For pre-school children, many screen devices or programmes
for e.g. ipads, are marketed as educational or to help children develop,
so parents think they are doing their children a service. Equally, in
schools, to promote skills that children are deemed to need in our
increasingly technology-dependent world, interactive white boards are
replacing blackboards and many better-resourced schools use laptops or
other individual computers for much of the delivery of education. So our
children, from a young age, are spending many hours a day in front of
screens.
The debate needs to be broadened to include educationalists as well
as toy manufacturers etc. As is often the case, new things are embraced
quickly and unforeseen consequences follow. Striking the right balance
will not be straightforward. If this article stimulates debate and further
exploration, it will be a good thing.
We want to congratulate Abel et al. with their recent publication
"The successful use of the nasopharyngeal airway in Pierre Robin sequence:
an 11 year experience".
We do want to make some comments that might be of interest for the
reader. First the authors define Robin Sequence (RS) as a triad of
micrognathia, glossoptosis and a cleft palate. It has been demonstrated
that there is considerable confusion in the...
We want to congratulate Abel et al. with their recent publication
"The successful use of the nasopharyngeal airway in Pierre Robin sequence:
an 11 year experience".
We do want to make some comments that might be of interest for the
reader. First the authors define Robin Sequence (RS) as a triad of
micrognathia, glossoptosis and a cleft palate. It has been demonstrated
that there is considerable confusion in the literature regarding the
description of RS.1 Abel et al. state that "an obstructed airway is often
present", but do not use it as a required criteria to primarily diagnose
RS. However, all of the 104 included patients with RS suffered some degree
of UAO (27 mild, 77 moderate/severe). To be able to compare outcome
modalities we suggest to use the original description during the initial
diagnosis of RS, thus including breathing problems.1, 2
Secondly, we questioned the approach of the initiation of NPA
treatment and subsequent criteria for removal. No comment was made about
an endoscopic airway evaluation before initiation of NPA. Hence, it is not
ruled out whether the 14 patients who needed a tracheotomy, might have
suffered subglottic or tracheal (e.g. tracheomalacia) pathology before NPA
treatment was started. After removal of the NPA 16 patients (25%) still
had mild UAO and thus suffered a set of at least three saturation dips
between 80-85% during the sleep study. We want to express our concerns of
the effect of these low saturations, as it is probable that they will lead
to increased energy expenditures by the child and effect the developing
brain.
In third place, Abel et al. demonstrate that 82 patients (79%) needed
a nasogastric (NG) tube for a few weeks to months. However, during NPA
treatment there is a high risk of aspiration and persistent malnutrition.3
In contrast, after mandibular distraction osteogenesis (MDO) an
improvement in feeding and swallowing function is seen and the duration
for NG tube placement is much lower.4
Abel et al. describe that only two patients (1.9%) in their study had
undergone MDO, which are still tracheotomy dependent. However, these two
patients already belonged to the subgroup of "undecannulated patients"
(n=5), which makes a clear comparison to the "normal" NPA group
impossible. Moreover, it remains unclear if this subgroup consisted of
patients with an associated syndrome. We suggest that in the syndromal
cases the usage of MDO should always be reconsidered, as the outcome can
be poor due to underlying malformations.5
Finally, mean duration until final removal of the NPA was eight
months. Hence, there rests a relatively long social burden on the parents
and care-takers of the patient. In case of MDO the average time before
removal of the hardware is usually four-10 weeks, which limits the period
that parents are confronted with the associated care and possible
anxieties of an external, visible "device".
In conclusion, some infants can be successfully treated with an NPA
and it has shown to be a feasible, relatively minor invasive treatment
option which should be incorporated in a treatment algorithm for infants
with RS. However, we want to stress that each case should be individually
analysed and that MDO should also be considered as a possible option in a
treatment regime, due to the quick process, less cumbersome home care
situation and good results regarding respiratory and feeding problems.
2. Evans KN, Sie KC, Hopper RA, Glass RP, Hing AV, Cunningham ML.
Robin sequence: from diagnosis to development of an effective management
plan. Pediatrics 2011; May;127(5):936-48.
3. Marques IL, Prado-Oliveira R, Leiriao VH, Jorge JC, de Souza L.
Clinical and fiberoptic endoscopic evaluation of swallowing in robin
sequence treated with nasopharyngeal intubation: the importance of feeding
facilitating techniques. Cleft Palate Craniofac J 2010; Sep;47(5):523-9.
4. Hong P, Brake MK, Cavanagh JP, Bezuhly M, Magit AE. Feeding and
mandibular distraction osteogenesis in children with Pierre Robin
sequence: a case series of functional outcomes. Int J Pediatr
Otorhinolaryngol 2012; Mar;76(3):414-8.
5. Mandell DL, Yellon RF, Bradley JP, Izadi K, Gordon CB. Mandibular
distraction for micrognathia and severe upper airway obstruction. Arch
Otolaryngol Head Neck Surg 2004; Mar;130(3):344-8.
The study by Sheehan and co-workers is important as they rightly
state that longitudinal data of behavioural problems in children with CF
are lacking, and so are data about parent use of health services. Both of
these facts are surprising, given the lifelong character of the disease
and given that standards of care explicitly address the need to offer help
from psychosocial professionals [1].
However, some aspects in thei...
The study by Sheehan and co-workers is important as they rightly
state that longitudinal data of behavioural problems in children with CF
are lacking, and so are data about parent use of health services. Both of
these facts are surprising, given the lifelong character of the disease
and given that standards of care explicitly address the need to offer help
from psychosocial professionals [1].
However, some aspects in their study are questionable:
1) They talk about the "natural history of problems" which implies a
course without interventions. However, parents did seek help from various
professionals and their advice will likely have had an effect on the
"natural course".
2) As there were some parents who did seek help and other parents who did
not, it would have been of interest to know more about possible
differences.
3) Rates of health service utilisation are presented in a way leading to
overestimate parental resistance. For instance, the authors state that
"only 12/102 (12%) caregivers sought help for their child's sleep
problems". However, only 33/102 caregivers ever reported about respective
problems. The true and more favourable rate would then read: 12/33 (36%).
Other child problems are presented similarly.
4) The authors state that internal behaviour problems, i.e. anxiety and
depressive states, are largely unadressed by parents. They interpret this
finding as "a lack of recognition". However, we should acknowledge that
internalising behaviours in a CF child may appear much more in concordance
to parental expectations than disruptive or externalising behaviours.
Therefore, we should speak about lack of parental recognition only if
parents would not worry (i.e. seek advice) in case of PERSISTENT problems.
However, ?caregivers of children with persistent problems were three times
more likely" to seek help!
We commend Wu et al for their work on blood-pressure-ratios. Up
until now hypertension was defined using statistically derived limits
based on gender, age and height specific norms. The formulation of Wu et
al permits assessments of adverse effects at different blood-pressure-
ratios across age, gender and height percentile groups. (1) However given
that multiple readings in an individual fluctuate quite wildly,
identif...
We commend Wu et al for their work on blood-pressure-ratios. Up
until now hypertension was defined using statistically derived limits
based on gender, age and height specific norms. The formulation of Wu et
al permits assessments of adverse effects at different blood-pressure-
ratios across age, gender and height percentile groups. (1) However given
that multiple readings in an individual fluctuate quite wildly,
identification of the 'real BP' for calculation of blood pressure ratio is
still a problem.
The statistically derived limits of normal BP are relatively tight bands.
Conventionally, blood pressure (BP) above the 95th centile is classified
as hypertension. That below the 90th centile is considered normal and BP
between the 90th and 95th percentile is labeled 'pre-hypertension'. The
difference between the 89th percentile (normal BP) and the 95th
percentile, (abnormal BP) is only 3 to 4 mm of Hg. (2).
It is presumed that the average of 4 readings taken in an individual
during at least 2 office visits reflects 'usual blood pressure'
accurately. (3) The validity of this assumption is uncertain. A journal
club discussion around the work of Wu et al prompted the authors to
investigate variability of BP readings in individuals to determine the
confidence limits within which the real blood pressure would lie, given
that the mean of 4 readings is available for an individual. We also
estimate the number of readings of BP that need to be averaged, to be able
to predict the real BP of the individual within a 4 mm of Hg range (95% CI
+/- 2).
Material and Methods
Five researchers comprised the subjects for this study and they had their
BP readings recorded 3 times a day for five days. They were neither known
to be hypertensive nor on any drug that affects BP. A sixth researcher on
anti-hypertensive medication was excluded. The readings were not
disclosed to the study subjects till the end of the observation period.
The protocol for validation of instruments requires BP to be noted 9
times sequentially with a 30 second gap between readings. We recorded BP
sequentially 5 times on each occasion. (4) The procedure for taking blood
pressure prescribed for the National Health and Nutrition Examination
Survey (NHANE) was followed. (5) Readings were taken after a waiting
period of 5 minutes where the subjects sat with their feet flat on the
floor. A 'Planet 50' multi-parameter patient monitoring system, Model 200
(Larsen and Toubro Medical Equipments & Systems, Mysore India) was
used for non-invasive oscillatory BP measurement. An appropriate sized
adult cuff was used for all the measurements. The same BP measuring device
and cuff were used for all the readings. .
For purposes of this study, variability of systolic and diastolic BP
is defined as the difference between the highest and lowest readings
recorded for the individual.
Results
In the individual with the steadiest BP, there was a difference of 26
mm of Hg between her highest and lowest systolic BP recordings (SD 5.4).
We calculated that if the mean of only 4 readings is available, her real
BP would be anywhere within an 11 mm range. The mean of 29 observations
will be required to achieve CI of 4 (+/- 2) or SE =1.
The table gives the data for systolic BP in the five volunteers.
Taking the average from the 5 individuals, if one is to rely on just the
mean of 4 readings from an individual, we calculate the real BP would lie
anywhere within 13 mm range. To be able to estimate BP accurately to
within 4 mm , blood pressure recordings need to be taken 36 times.
Discussion
We found the blood pressure varied a lot during the 5-day study period. On
account of the fact that our readings were taken over a short duration,
the readings are not independent of one another and we anticipate a
certain amount of autocorrelation. This will narrow the SD more than if
the readings were independent variables and we believe that ours is
therefore an underestimation of the real variability.
The difference between the 90th and 95th percentile in the Fourth Report
on High Blood Pressure in Children and Adolescent is only 4 mm of Hg and
that between the 75th percentile and 99th percentile is about 13 mm of Hg
for both systolic and diastolic blood pressures. (2)
Earlier studies have noted big differences between daytime and night time
readings in children. In 5 year old children, the 75th percentile for day
time blood pressure is about 17 mm of Hg higher than the 75th percentile
at night, both for systolic and diastolic blood pressures. (6)
This pilot study has obvious limitations given the small number of
subjects studied. Ambulatory readings taken periodically through out the
day and night must be used to study the full extent of the variance in BP.
Although ambulatory BP monitoring has been available for many years now,
this is arguably the first study to look at the confidence limits within
which the 'real blood pressure' will lie when only a limited number of
readings are available from a person. Larger studies are needed to arrive
at the real average variance in the BP in the population as a whole.
Conclusion
Multiple readings are needed to determine the 'real BP' in a person when
looking at blood pressure ratios. The practice of diagnosing hypertension
based on 4 readings on 2 clinic visits is unreliable. Discussions with
patients must include an acknowledgement of these uncertainties
References
1. Wu HP, Yang WC, Wu YK, Zhao LL, Chen CY, Fu YC. Clinical significance
of blood pressure ratios in hypertensive crisis in children. Arch Dis
Child. 2012;97:200-5
2. National High Blood Pressure Education Program Working Group on
High Blood Pressure in Children and Adolescents. The fourth report on the
diagnosis, evaluation, and treatment of high blood pressure in children
and adolescents. Pediatrics. 2004;114 (2 Suppl 4th Report):555-76.
3. US Department of Health and Human Services. The seventh report of
the Joint National Committee on prevention, detection, evaluation, and
treatment of high blood pressure
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
4. O'Brien E, Pickering T, Asmar R, Myers M, Parati G, Staessen J,
Mengden T, Imai Y, Waeber B, Palatini P, Gerin W; Working Group on Blood
Pressure Monitoring of the European Society of Hypertension. Working Group
on Blood Pressure Monitoring of the European Society of Hypertension
International Protocol for validation of blood pressure measuring devices
in adults. Blood Press Monit. 2002;7:3-17.
5. Center for Disease Control and Prevention. National Health and
Nutrition Examination Survey (NHANE) Health Tech/Blood Pressure Procedures
Manual May 2009. Available at
http://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/BP.pdf. Accessed on
20/4/12.
6. Wuhl E, Witte K, Soergel M, Mehls O, Schaefer F; German Working
Group on Pediatric Hypertension. Distribution of 24-h ambulatory blood
pressure in children: normalized reference values and role of body
dimensions. J Hypertens. 2002;20:1995-2007.
Acknowledgement
This data and the interpretation have been discussed on the Medstats
discussion group. The authors acknowledge the contributions of members of
this group to clarifying some of the statistical concepts utilized in this
paper
Table I
Variability in Systolic and Diastolic BP in the Subjects Studied
(75 observation per subject)
Mean Width of CI if 4 readings are averaged = 13 mm
On an average 45 readings must be obtained to estimate the real BP (Mean
of number of observations (obs.) required to reduce the width of 95% CI to
4 mm of Hg = 45)
McGarvey et al. have done a thorough job of exploring the differences
between the sudden unexplained deaths in infants (SIDS < 1 year) and
children (SUDC 1 - 4 years) in Ireland. However, they should have noted
the following history of SIDS and that the one-year limit for SIDS is an
administrative definition that is not based on any physiological
phenomenon. Indeed, we have shown that these two phenomena (SIDS and SUDC...
McGarvey et al. have done a thorough job of exploring the differences
between the sudden unexplained deaths in infants (SIDS < 1 year) and
children (SUDC 1 - 4 years) in Ireland. However, they should have noted
the following history of SIDS and that the one-year limit for SIDS is an
administrative definition that is not based on any physiological
phenomenon. Indeed, we have shown that these two phenomena (SIDS and SUDC)
are both described by the same age and gender distributions and appear to
be the same deaths (Mage and Donner, 2011).
In 1969, a formal definition of SIDS was first proposed by Beckwith
(1970) as "The sudden death of an infant which was unexpected by history
and in which a thorough postmortem examination failed to demonstrate an
adequate cause of death." Prior to this definition, starting in 1968,
these deaths were coded by WHO in the Eighth Revision, International
Classification of Diseases (ICD8), as 795 (Sudden death (cause unknown)).
In 1973, following the acceptance of Beckwith's definition, WHO revised
their coding as follows: 795.0 (Sudden infant death syndrome, under one
year of age); 795.1 (Sudden infant death syndrome, one year of age); 795.2
(All other sudden death, age two years and over). This coding and
redefinition remained in place from 1973 through 1978, and 554 U.S. SIDS
deaths were recorded as one year and older (CDC, 2012).
In 1979, in the Ninth Revision (ICD9) WHO recoded SIDS as 798.0 with
the provisio that it only applied to infants under one year of age. This
administrative limitation was imposed to guide the SIDS research community
to concentrate their attention on those cases of under one year old
infants because of the rarity of older SIDS and increased likelihood of
false-positive SIDS occurring after one year that could confuse their
research findings. All those infants who died of SIDS after one year of
age were therefore no longer called "SIDS" but were assigned to other
causes of death such as ICD9 799.9 (Other unknown and unspecified cause).
This administrative redefinition applied for all SIDS deaths between 1979
and 1998.
In 1999, in the Tenth revision (ICD10) WHO recoded SIDS as R95 and
retained the administrative cutoff at one year. All SIDS above one year
were reassigned causes of death such as ICD10 R99 (Other ill-defined and
unspecified causes of mortality). This is the current coding for all SIDS
from 1999 through 2012. WHO has recently added new ICD10 codes R95.0 for
SIDS with mention of autopsy and R95.9 for SIDS without mention of
autopsy, to replace R95 - For implementation January 2013
(http://www.who.int/classifications/icd/ICD-10Updates2009.pdf).
Beckwith JB. Observations on the pathologic anatomy of the SIDS. In
Sudden Infant Death Syndrome, Bergman AB, Beckwith JB, Ray CG (Eds.)
University of Washington Press, Seattle, WA 1970 (Conference in September,
1969), page 83.
CDC, Centers for Disease Control and Prevention, National Center for
Health Statistics. Compressed Mortality File 1968-1978. CDC WONDER Online
Database, compiled from Compressed Mortality File CMF 1968-1988, Series
20, No. 2A, 2000. Accessed at http://wonder.cdc.gov/cmf-icd8.html on Jul
21, 2012.
Mage DT, Donner EM. 2011. The universal age distribution of the
sudden infant death syndrome. Scand J Foren Sci. 17(1): 7-10.
I read with interest the recent article (1) wherein the authors use
variable definitions for moderately preterm (MP) infants as 32-35 weeks of
gestational age (GA) and 32-36 weeks GA. In the methods however , the
authors categorize infants born at 32-35weeks gestation as MP infants and
do not include 36 0/7-36 6/7 weeks of gestation due to study design.
Upon review of the brief history of this terminology, it was found...
I read with interest the recent article (1) wherein the authors use
variable definitions for moderately preterm (MP) infants as 32-35 weeks of
gestational age (GA) and 32-36 weeks GA. In the methods however , the
authors categorize infants born at 32-35weeks gestation as MP infants and
do not include 36 0/7-36 6/7 weeks of gestation due to study design.
Upon review of the brief history of this terminology, it was found that
until 2005, the National Center for vital statistics reported MP infants
as infants 32-36wks GA(2,3). The National Institutes of Health (NIH) in
2005 recommended that births between 34 and 37 completed weeks GA be
referred to as late preterm (LP) (4). The most recent definition of
moderately preterm infants, however, is infants 32 0/7-33 6/7 weeks GA(5).
In the study methods, including some of the LP infants (34 0/7-35 6/7
weeks GA) as MP infants causes confusion for the readers, especially when
comparing outcomes from other studies. Interestingly, the National Center
for vital statistics uses the definition 'very preterm' for infants <32
0/7 weeks GA, 'early preterm' for infants <34 0/7 weeks GA and LP for
infants 34 0/7-36 6/7weeks GA(6). Also, in this paper, children born at
term included 38-41 weeks GA, however the WHO definition of term infants
includes births at 37 0/7-41 6/7 weeks GA. Excluding the children born at
37 0/7-37 6/7 weeks GA(which is a subset of early term infants) from the
term cohort is also not ideal. Due to ongoing concerns regarding
outcomes of these preterm infants, the use of consistent terminology is
critical to designing further studies. I would like to make a humble plea
and call for standardized nomenclature that is accepted worldwide.
References
1. Potijk MR, De Winter AF, Bos AF, Kerstjens JM, Reijneveld SA.
Higher rates of behavioural and emotional problems at preschool age in
children born moderately preterm. Arch Dis Child 2012;97:112-117.
2. Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2003.
Natl Vital Stat Rep. 2005;54:1-116
3. Davidoff MJ, Dias T, Damus K, et al. Changes in the gestational age
distribution among U.S. singleton births: impact on rates of late preterm
birth, 1992 to 2002. Semin Perinatol 2006;30:8-15
4. Raju TN. Epidemiology of late preterm (near-term) births. Clin
Perinatol 2006; 33(4):751-63
5. Harijan P, Boyle EM. Health outcomes in infancy and childhood of
moderate and late preterm infants. Semin Fet Neonat Med 2012;17(3):159-62.
6. Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2009.
Natl Vital Stat Rep.2011;60:1-70
As far as I can ascertain (having not yet accessed the full text),
this study did not specifically examine maternal request caesareans, and
in fact found that "after all factors were taken into account there was a
stronger link with emergency caesarean than with pre-planned ones,
although the numbers were small for this calculation."(1)
It is very concerning therefore that the authors appear to be
presenting th...
As far as I can ascertain (having not yet accessed the full text),
this study did not specifically examine maternal request caesareans, and
in fact found that "after all factors were taken into account there was a
stronger link with emergency caesarean than with pre-planned ones,
although the numbers were small for this calculation."(1)
It is very concerning therefore that the authors appear to be
presenting this study to the media as potential evidence to dissuade women
from choosing a planned caesarean.
For example, "A mother who chooses caesarean delivery on maternal
request should be aware of [these] potential health risks... including
childhood obesity."(1)
And, "An association... would provide an important rationale to avoid
non-medically indicated caesarean section".(2)
Hypothetical theories about the potential impact of gut bacteria
remain unproven, and women choosing a caesarean are weighing up other
perinatal risks such as stillbirth, asphxiation, shoulder dystocia and
serious intrapartum injuries, as well as maternal risks including pelvic
organ prolapse, incontinence, psychological trauma and unpredictability of
care.
Ideological opposition to maternal request caesarean is very
unhelpful in the current debate. If the authors genuinely found a causal
link with maternal request, fair enough, but if they only found a possible
link with ALL caesareans, and especially emergency caesareans, then the
study should not be used to criticise maternal request.
Otherwise, and despite NICE recommending last year that maternal
request should be supported,(3) we have a situation where the Royal
College of Midwives' education and research manager, Sue Macdonald, is
quoted as saying, "This [study] highlights the need to avoid caesarean
sections that are not medically needed."(1)
No, rather it highlights the problem with using irrelevant study
findings to try and restrict what is an entirely legitimate birth choice
for informed women planning a small family.
References
(1) "Babies born by caesarean 'more likely to be obese'," The
Telegraph,May 24, 2012.
http://www.telegraph.co.uk/health/healthnews/9284827/Babies-born-by-
caesarean-more-likely-to-be-obese.html
(2) "Caesarean Section Delivery May Double Risk of Childhood Obesity: May
Be Due to Different Gut Bacteria," Science Daily,May 23, 2012.
http://www.sciencedaily.com/releases/2012/05/120523200749.htm
(3) NHS National institute for Clinical Excellence, "Caesarean
Section:Full Guideline" November 2011.
Conflict of Interest:
Co-author of Choosing Cesarean, A Natural Birth Plan.
I suggest the explanation of the findings of Huh, et al., involves
dehydroepiandrosterone (DHEA). The fetus does not produce significant
DHEA until just before birth. Prior to birth, the fetus is dependent upon
maternal DHEA. I suggest a combination of maternal and fetal DHEA combine
to initiate birth. If insufficient DHEA exists, then caesarean section
would be necessary.
I suggest the explanation of the findings of Huh, et al., involves
dehydroepiandrosterone (DHEA). The fetus does not produce significant
DHEA until just before birth. Prior to birth, the fetus is dependent upon
maternal DHEA. I suggest a combination of maternal and fetal DHEA combine
to initiate birth. If insufficient DHEA exists, then caesarean section
would be necessary.
Low DHEA is connected with obesity. Therefore, it could be that the
mother is low DHEA which could increase weight in the mother and the
fetus. Since DHEA is known to protect against all types of infections,
the finding that Firmicutes bacteria is increased in children born via
caesarean section may indicate low DHEA.
Lim et al(1) understandably interpret the results of their
retrospective study with caution. However they only consider one possible
chain of causation in seeking to explain their findings, namely that
children with worse chest radiographs who made poorer antibody responses
did so as a consequence of an underlying primary immunodeficiency. An
alternative explanation would be that previous, chronic lower and/or upper
resp...
Lim et al(1) understandably interpret the results of their
retrospective study with caution. However they only consider one possible
chain of causation in seeking to explain their findings, namely that
children with worse chest radiographs who made poorer antibody responses
did so as a consequence of an underlying primary immunodeficiency. An
alternative explanation would be that previous, chronic lower and/or upper
respiratory tract infection with pneumococci of the relevant serotypes had
induced hyporesponsiveness to the corresponding polysaccharide antigens.
This has previously been shown with respect to responses to conjugated
polysaccharide antigens in children with documented previous colonisation
(2). The way children respond to these antigens may have more to do with
their personal history of infection than their genetics.
References
1. Lim MT, Jeyarajah K, Jones P, et al. Specific antibody deficiency in
children with chronic wet cough. Arch Dis Child. 2012; 97:478-80
2. Dagan R, Givon-Lavi N, Greenberg D, Fritzell B, Siegrist CA.
Nasopharyngeal carriage of Streptococcus pneumoniae shortly before
vaccination with a pneumococcal conjugate vaccine causes serotype-specific
hyporesponsiveness in early infancy. J Infect Dis 2010; 201:1570-9
Conflict of Interest:
AF undertakes clinical research, educational and advisory work for vaccine manufacturers including those making pneumococcal vaccines but receives no personal remuneration for this. All funding is paid to his employers.
We appreciate the interesting article by Erlewyn-Lajeunesse1 on
homeopathy in children. We would like to make the following points about
the safety and efficacy associated with the use of homeopathic medicines
among children with a wide spectrum of clinical diseases.1 Surprisingly,
the author did not mention the potential severe adverse outcomes of
homeopathy in children. Sometimes the reaction ca...
We appreciate the interesting article by Erlewyn-Lajeunesse1 on
homeopathy in children. We would like to make the following points about
the safety and efficacy associated with the use of homeopathic medicines
among children with a wide spectrum of clinical diseases.1 Surprisingly,
the author did not mention the potential severe adverse outcomes of
homeopathy in children. Sometimes the reaction can be so severe that it
require hospitalization.2 The case reported by Kuenzli and colleagues2 of
bullous pemphigoid in association with homeopathic medicinal products
confirms the potential risks of homeopathy in children.2 Although the
cause of bullous pemphigoid is uncertain, homeopathic metal remedies
(e.g.; mercury) might have trigger the autoimmune bullous pemphigoid in
the child.2 In fact, it is well-known that exposure to mercury may be
associated with blistering diseases of the skin.3 We firmly believe that
there is an high rate of underreporting of adverse reactions among
patients who receive homeopathic treatment.4 We challenge the unduly
optimistic view expressed from many homeopaths that ultra-low doses and
high dilution medications are gentle and generally safe.5
Physicians should be aware of the possible - not rare - adverse health
outcome of homeopathic treatment, especially in children.
REFERENCES
1. Erlewyn-Lajeunesse M. Homeopathic medicines for children. Arch Dis
Child 2012;97:135-8.
2. Kuenzli S, Grima?tre M, Krischer J, et al. Childhood bullous
pemphigoid: report of a case with life-threatening course during
homeopathy treatment. Pediatr Dermatol 2004;21:160-3.
3. Abr?u V?lez AM, Warfvinge G, Herrera WL, et al. Detection of mercury
and other undetermined materials in skin biopsies of endemic pemphigus
foliaceus. Am J Dermatopathol 2003;25:384-91.
4. Fisher P, Dantas F, Rampes H. The safety of homeopathic products. J R
Soc Med 2002;95:474-5.
5. Ernst E. Intangible risks of complementary and alternative medicine. J
Clin Oncol 2001;19:2365-6.
Thank you for your interesting review of the literature. The problem is wider than just recreational use of screens and is so pervasive it is difficult to see how limitations on screen time can be effectively implemented. For pre-school children, many screen devices or programmes for e.g. ipads, are marketed as educational or to help children develop, so parents think they are doing their children a service. Equally, in...
We want to congratulate Abel et al. with their recent publication "The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11 year experience".
We do want to make some comments that might be of interest for the reader. First the authors define Robin Sequence (RS) as a triad of micrognathia, glossoptosis and a cleft palate. It has been demonstrated that there is considerable confusion in the...
The study by Sheehan and co-workers is important as they rightly state that longitudinal data of behavioural problems in children with CF are lacking, and so are data about parent use of health services. Both of these facts are surprising, given the lifelong character of the disease and given that standards of care explicitly address the need to offer help from psychosocial professionals [1]. However, some aspects in thei...
We commend Wu et al for their work on blood-pressure-ratios. Up until now hypertension was defined using statistically derived limits based on gender, age and height specific norms. The formulation of Wu et al permits assessments of adverse effects at different blood-pressure- ratios across age, gender and height percentile groups. (1) However given that multiple readings in an individual fluctuate quite wildly, identif...
McGarvey et al. have done a thorough job of exploring the differences between the sudden unexplained deaths in infants (SIDS < 1 year) and children (SUDC 1 - 4 years) in Ireland. However, they should have noted the following history of SIDS and that the one-year limit for SIDS is an administrative definition that is not based on any physiological phenomenon. Indeed, we have shown that these two phenomena (SIDS and SUDC...
I read with interest the recent article (1) wherein the authors use variable definitions for moderately preterm (MP) infants as 32-35 weeks of gestational age (GA) and 32-36 weeks GA. In the methods however , the authors categorize infants born at 32-35weeks gestation as MP infants and do not include 36 0/7-36 6/7 weeks of gestation due to study design. Upon review of the brief history of this terminology, it was found...
As far as I can ascertain (having not yet accessed the full text), this study did not specifically examine maternal request caesareans, and in fact found that "after all factors were taken into account there was a stronger link with emergency caesarean than with pre-planned ones, although the numbers were small for this calculation."(1)
It is very concerning therefore that the authors appear to be presenting th...
I suggest the explanation of the findings of Huh, et al., involves dehydroepiandrosterone (DHEA). The fetus does not produce significant DHEA until just before birth. Prior to birth, the fetus is dependent upon maternal DHEA. I suggest a combination of maternal and fetal DHEA combine to initiate birth. If insufficient DHEA exists, then caesarean section would be necessary.
Low DHEA is connected with obesity....
Lim et al(1) understandably interpret the results of their retrospective study with caution. However they only consider one possible chain of causation in seeking to explain their findings, namely that children with worse chest radiographs who made poorer antibody responses did so as a consequence of an underlying primary immunodeficiency. An alternative explanation would be that previous, chronic lower and/or upper resp...
Dear Editor,
We appreciate the interesting article by Erlewyn-Lajeunesse1 on homeopathy in children. We would like to make the following points about the safety and efficacy associated with the use of homeopathic medicines among children with a wide spectrum of clinical diseases.1 Surprisingly, the author did not mention the potential severe adverse outcomes of homeopathy in children. Sometimes the reaction ca...
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