Professor Modi's excellent review has a curious omission that of the
International Charter for Ethical Research Involving Children (ERIC) 2013.
http://childethics.com/ accessed November 2nd 2014
Its project partners include, amongst others, the UNICEF Office for
Research and Childwatch International Research Network.
This Charter addresses the issues raised in her review about moving
forward the ethical foundation on which research in children is
undertaken. It provides a crucial resource for any institution/individual
considering undertaking such research and also for the parents/carers of
such children, as well as the children who may be subject to it.
Conflict of Interest:
I was an expert reviewer and contributor to the International Charter for Ethical Research Involving Children (ERIC) 2013.
Authors: Francis J Gilchrist1,2 ,Mark G Pritchard1, Warren Lenney1,2.
1. Academic Department of Child Health, University Hospital of North
Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, United Kingdom
2. Institute for Science and Technology in Medicine, Keele
University, Guy Hilton Research Centre, Thornburrow Road, Stoke-on-Trent
ST4 7QB, United Kingdom
Authors: Francis J Gilchrist1,2 ,Mark G Pritchard1, Warren Lenney1,2.
1. Academic Department of Child Health, University Hospital of North
Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, United Kingdom
2. Institute for Science and Technology in Medicine, Keele
University, Guy Hilton Research Centre, Thornburrow Road, Stoke-on-Trent
ST4 7QB, United Kingdom
Correspondence
Dr Francis J Gilchrist, Academic Department of Child Health, University
Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG,
United Kingdom.
Tel: 01782 675289
Email: francis.gilchrist@uhns.nhs.uk
We thank Professors Chang and Grimwood for their response to our
letter. Only 10 years ago, protracted bacterial bronchitis (PBB) was not
considered an entity by many of our Paediatric Respiratory colleagues.
Although most now recognise PBB as a cause of wet cough in children, there
is variation in the diagnostic criteria and treatment regimens used across
the world. We wholeheartedly agree that there is an urgent need for
prospective longitudinal studies to inform clinical practice.
In response to their specific comments. Of the ten children that did
not fully respond to the initial course of antibiotics; three subsequently
had complete resolution of their cough after further antibiotic courses.
Suppurative lung disease was considered in the remaining seven and when
clinically indicated a CT scan was undertaken. All of these were reported
as normal. With regards to the use of prophylactic antibiotics; these
were only started in children who had multiple relapses, especially when
these relapses occurred very quickly after stopping treatment.
Anecdotally these children have done very well but we refer again to the
need for prospective studies to investigate the best treatment regimen.
We congratulate Dr Pritchard and colleagues for reporting on a
retrospective follow-up of their patient cohort with protracted bacterial
bronchitis (PBB) and thank them for acknowledging the importance of PBB as
a cause of chronic cough. The diagnostic criteria of PBB do however need
clarification as the 10 children whose wet cough failed to resolve with
antibiotics do not have PBB. Instead, they may have bronchiectasis,...
We congratulate Dr Pritchard and colleagues for reporting on a
retrospective follow-up of their patient cohort with protracted bacterial
bronchitis (PBB) and thank them for acknowledging the importance of PBB as
a cause of chronic cough. The diagnostic criteria of PBB do however need
clarification as the 10 children whose wet cough failed to resolve with
antibiotics do not have PBB. Instead, they may have bronchiectasis,
chronic suppurative lung disease or another cause of wet cough. Recently
we showed (in a retrospective cohort of 144 children) that children whose
wet cough did not improve after 4-weeks of antibiotics are significantly
more likely to have radiolographically-proven bronchiectasis (adjusted
odds ratio 5.86; 95%CI 1.20-28.5) [Arch Dis Child 2014; 99:522-5]. This
observation supports published statements [Pediatr Pulmonol 2008;43:519-
31] that children whose wet cough does not respond to 4-weeks of
antibiotics should undergo further investigation. Importantly, the
clinical diagnosis of PBB is based upon three criteria (a) presence of a
chronic (>4-weeks) wet cough; (b) resolution of the cough following 2-
weeks of antibiotics; and (c) absence of other symptoms and signs
suggestive of an alternative cause of wet cough [Med J Aust 2006;184:398-
403].
In Prichard and colleagues' study, 33 children did have PBB and some
had recurrent episodes. Anecdotally, we find that ~50% of children with
PBB have recurrent (>3) episodes, some of whom are found to have
bronchiectasis. While prescribing prophylactic antibiotics is arguably
justified in children with >3 episodes per year, we remain uncertain
whether prophylactic antibiotics are warranted when these are less
frequent and especially now with ongoing concerns over increasing
antibiotic resistance. Clearly, a prospective longitudinal study is
required to follow-up children with PBB to help inform clinical practice
and is something we are pursuing currently.
Prof Anne B Chang and Prof Keith Grimwood
Conflict of Interest:
AC has potential intellectual competing interest as an author of many papers on PBB
Acute bronchiolitis and asthma come under the category of obstructive
airway disease while bronchopneumonia does not. The main clinical
manifestation of an obstructive airway disease would be hyperinflation
that would have the clinical features of viscero-ptosis (upper border of
liver pushed down), and loss of cardiac dullness on chest percussion.The
other clinical feature of obstructive airway disease is prolonged
expi...
Acute bronchiolitis and asthma come under the category of obstructive
airway disease while bronchopneumonia does not. The main clinical
manifestation of an obstructive airway disease would be hyperinflation
that would have the clinical features of viscero-ptosis (upper border of
liver pushed down), and loss of cardiac dullness on chest percussion.The
other clinical feature of obstructive airway disease is prolonged
expiration that can be recognized both from careful clinical observation
and auscultation.
Acute bronchiolitis can be excluded in children older than 18 - 24 months.
Recurrent attacks, family history, history of atopy, response to broncho-
dilators, and recognized trigger factors help strengthen the diagnosis of
asthma, but we need to understand that bronchiolitis can be recurrent due
to causation by viruses other than respiratory syncitial virus.
A practical method of distinguishing between bacterial and viral infection
can be based on the presence of fever, runny nose, cough - the cardinal
features of a viral upper respiratory tract infection. A chest x-ray is
neither desirable nor required for the diagnosis of any of the three
conditions unless complications are suspected. It would be expensive and
lead to unnecessary exposure of children to radiation.
Health workers can be trained to recognize prolonged expiration by holding
their hand before them and have it follow the upward and downward movement
of the infant or child's chest. Observation of the movement of their own
hand would make recognition of prolonged expiration much easier. All three
groups of patients would have fast breathing that health workers are
trained to recognize.
We were pleased to read Dr Davison's review of the two recently
published guidelines for managing chronic Hepatitis B infection in
children [1]. We have recently audited our practice against both of these
guidelines.
As Dr Davison points out; "The level of Alanine transaminase (ALT) at
which treatment should be considered highlights a fundamental difference
between the guidelines".
NICE suggests that ALT in males above 3...
We were pleased to read Dr Davison's review of the two recently
published guidelines for managing chronic Hepatitis B infection in
children [1]. We have recently audited our practice against both of these
guidelines.
As Dr Davison points out; "The level of Alanine transaminase (ALT) at
which treatment should be considered highlights a fundamental difference
between the guidelines".
NICE suggests that ALT in males above 30 IU/L and in females above 19 IU/L
is considered abnormal [2]. The ESPGHAN guidelines suggest a threshold of
more than 1.5 times the upper limit of normal (or more than 60 IU/L) [3].
In our cohort of 12 children with chronic hepatitis B, all the children
had an abnormal ALT using NICE guidance, but only 7 had abnormal ALT by
ESPHGAN criteria, of which only 4 remain abnormal 6 months later.
The number of children in our audit is small, but suggests that using the
NICE criteria for abnormal ALT could lead to over investigation for
children with chronic hepatitis B. NICE guidance extrapolated adult ALT
values to children. We agree that "further research is needed to review
the appropriateness of these values in children and young people when
making decisions to start treatment".
References
1. Davison S. Management of chronic hepatitis B infection. Arch Dis
Child. 2014 May 8. doi: 10.1136/archdischild-2013-304925. [Epub ahead of
print]
2. National Institute for Health and Care Excellence (NICE).
Diagnosis and management of chronic hepatitis B in children, young people
and adults, 2013. guidance.org.uk/cg165.
3. Sokal EM, Paganelli M, Wirth S, et al. Management of chronic
hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus
of an expert panel on behalf of the European Society of Pediatric
Gastroenterology, Hepatology and Nutrition. J Hepatol 2013;59:814-29.
Conflict of Interest:
Dr Davison comes to do a Hepatitis clinic with me once a year.
There are a few ways in which we can induce funny turns in our microbiology colleagues. One of the easiest is to say, within their earshot: "We'll stop the antibiotics if the cultures are negative".
Blood cultures are a terrible gold standard. If they're positive, for a plausible organism, then they're useful - they allow you to refine antimicrobial therapy, and make decisions about duration etc. But negative cultures?
My pr...
There are a few ways in which we can induce funny turns in our microbiology colleagues. One of the easiest is to say, within their earshot: "We'll stop the antibiotics if the cultures are negative".
Blood cultures are a terrible gold standard. If they're positive, for a plausible organism, then they're useful - they allow you to refine antimicrobial therapy, and make decisions about duration etc. But negative cultures?
My practice was strongly influenced by McWilliam and Riordan's review of CRP. http://ep.bmj.com/content/95/2/55.full In short, if you have two CRPs, more than 18 hours apart, and both 10 or lower, you can be pretty sure that you're not dealing with serious bacterial sepsis. The exception to this is the child who looked genuinely dreadful when they came in.
We use the following hierarchy:
- the clinical status of the child
- paired CRP
- cultures at 48 hours
The sepsis 6 principles (http://survivesepsis.org/the-sepsis-six/) will undoubtedly improve our management of the child with true sepsis - but they will also promote over treatment, unless we're really good at stopping antibiotics too.
Conflict of Interest:
I'm an editor at ADC, with responsibility for the Education and Practice edition
The Department of Health (DoH) recommends universal vitamin D
supplementation for non-formula-dependent children aged 6 months to 5
years [1]. Following the report by Jamieson et al. [2], we share similar
data from North Tyneside, showing that few children are being supplemented
with vitamin D and that parental awareness of current recommendations is
poor.
We distributed questionnaires to consecutive parents an...
The Department of Health (DoH) recommends universal vitamin D
supplementation for non-formula-dependent children aged 6 months to 5
years [1]. Following the report by Jamieson et al. [2], we share similar
data from North Tyneside, showing that few children are being supplemented
with vitamin D and that parental awareness of current recommendations is
poor.
We distributed questionnaires to consecutive parents and carers of
children aged 6 months to 5 years, presenting acutely to the Children's
Assessment Unit at North Tyneside General Hospital earlier this year. We
defined children at high-risk of vitamin D deficiency as those receiving
less than 500 ml formula milk per day. The hospital serves a predominantly
White British population at risk of vitamin D deficiency owing to the
negative impact of reduced sunlight exposure in the higher latitudes of
Northeast England.
The median age of the surveyed population was 27 months. Overall
10.5% (4/38) took Vitamin D supplements or 15.4% (4/26) in the high risk
group. Only 18.5% (7/38) of carers were aware of current DoH
recommendations with regard to vitamin D supplementation.
In view of the resurgence of vitamin D deficiency and its paediatric
manifestations [3-4], we support the suggestion that a health promotion
campaign to raise public awareness of DoH recommendations on
supplementation is indicated and argue for universal vitamin distribution
for children from birth to 5 years in primary care.
REFERENCES
1.National Institutes of health. July
2014.<http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional
/>
2.Jamieson K, Braha N, Gritz A, et al. Vitamin D deficiency: are we
preventing the preventable? Arch Dis Child 2014;99(5):486-7.
3.Ladhani S, Srinivasan L, Buchanan C, et al. Presentation of Vitamin
D deficiency. Arch Dis Child 2004;89(8):781-4.
4.Pearce SH, Cheetham TD. Diagnosis and management of vitamin D
deficiency. BMJ 2010;340:b5664.
I read with great interest, Dr Rosenbloom's recent article. He
discusses how difficult issues are raised involving blame when a medical
error is discovered but the process may offer families restitution and
compensation. 'Parental responsibility' is a term used to describe the
legal duty that a parent has to their child (1). Parents act, therefore,
as surrogate decision makers on the basis of what they believe to be in...
I read with great interest, Dr Rosenbloom's recent article. He
discusses how difficult issues are raised involving blame when a medical
error is discovered but the process may offer families restitution and
compensation. 'Parental responsibility' is a term used to describe the
legal duty that a parent has to their child (1). Parents act, therefore,
as surrogate decision makers on the basis of what they believe to be in
the child's best interests. This responsibility includes making decisions
to pursue litigation that may have an effect on their child's future and
weighing up the harms and benefits of pursuing litigation.
Existing regulations and legislation are designed to afford
protection to children receiving medical care. However, in today's
climate, litigation can be viewed as an indispensable form of protection
or compensation against medical carelessness or error. Almost every
hospital and clinician have full insurance coverage which are skyrocketing
annually. Yet, there is no evidence that medical litigation has resulted
in improved healthcare.(2) Studdert et al found that claims which found
no evidence of medical error were often denied compensation but
substantial expenditures go toward litigation over errors and payment of
them. The overhead costs of medical litigation is spiralling (3).
Wood states that 'the law confuses error with negligence and error
should not be the basis for litigation'(4). Litigation based on error is
therefore counter-productive to improving quality of care. Surely, the
ultimate aim of our healthcare system is to enhance safety and quality,
not reduce insurance premiums
1.Children's Act 1989, section 3(1).
2. Morris JA Jr, Carrillo Y, Jenkins JM, Smith PW, Bledsoe S, Pichert J,
White A. Surgical adverse events, risk management, and malpractice
outcome: morbidity and mortality review is not enough. Ann Surg. 2003
Jun;237(6):844-51
3. Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and
compensation payments in medical malpractice litigation. N Engl J Med
2006;354:2024-33.
4. Wood C.The misplace of litigation in medical practice. Aust N Z J
Obstet Gynaecol. 1998 Nov;38(4):365-76.
We read with great interest the recent review article by Creswell,
Waite and Cooper on 'Assessment and management of anxiety disorders in
children and adolescents'. The article brought to the forefront the
importance of accurately identifying and treating anxiety disorders during
development, with an encouraging discussion of new treatment strategies
and delivery approaches to increase access to psychological therapies fo...
We read with great interest the recent review article by Creswell,
Waite and Cooper on 'Assessment and management of anxiety disorders in
children and adolescents'. The article brought to the forefront the
importance of accurately identifying and treating anxiety disorders during
development, with an encouraging discussion of new treatment strategies
and delivery approaches to increase access to psychological therapies for
children with anxiety disorders. We are keen to add to these discussions
by raising awareness of the common co-occurrence and interaction between
anxiety symptomatology and tics for children with Tourette syndrome or
other chronic tic disorders (CTD). Psychiatric diagnoses are commonly
reported for children with CTD , with approximately 50% of children
meeting criteria for at least one anxiety disorder.[1] Obsessive
compulsive disorder (OCD), social phobia and generalised anxiety disorder
are most commonly reported, though separation anxiety may also co-
occur.[1] Interestingly, for children with CTD, behavioural difficulties
(e.g. Attention Deficit Hyperactivity Disorder) are most commonly reported
during the primary school years whilst anxiety disorders are more
prevalent during the teenage years, thus a reduction in externalising
behaviours are associated with an increase in internalising behaviours.[2]
Findings from our own clinical population support this trajectory and
indicate that for children with CTD quality of life is more closely
related to anxiety symptomatology than tic severity.[3] In addition, in
our clinical experience, the effective management of anxiety disorders
with evidence based cognitive-behavioural strategies (as advocated by
Creswell and colleagues) often results in improved in tic control and
reduced interference from tics on day to day life. Thus, there is a
complex interaction between anxiety and tics during development. This
highlights the need for the careful evaluation of anxiety disorders in
children with CTD to ensure that their broader mental health needs are not
overlooked, as for many children often it is not the tics that need
managing but the co-morbid psychiatric conditions.
References:
1. Specht, M. W., Woods, D. W., Piacentini, J., Scahill, L., Wilhelm,
S., Peterson, A. L., ... & Walkup, J. T. Clinical characteristics of
children and adolescents with a primary tic disorder. Journal of
Developmental and Physical Disabilities 2011;23(1):15-31.
2. Rizzo, R., Gulisano, M., Cal?, P. V., & Curatolo, P. (2012).
Long term clinical course of Tourette syndrome. Brain and Development
2012;34(8):667-673.
3. Woods, M., Robinson, S., Brennan, H, Bunton, P., & Hedderly,
T. A Comparison of Clinician and Self-Report Measures of Tics, Co-morbid
Difficulties and Quality of Life [abstract p48]. European Society Study of
Tourette Syndrome, 25-26 April 2014, Pitie-Salpetriere Hospital, Paris
We appreciate the response from Murch(1) and colleagues as it
highlights the dramatic difference in firearm injury rates between the
United Kingdom and the United States. Great Britain's firearm regulation
is among the strictest in the world while there is significant state to
state variability in the United States (2, 3). A study by Fleegler (3),
et al. demonstrated that greater statewide firearm regulations are
asso...
We appreciate the response from Murch(1) and colleagues as it
highlights the dramatic difference in firearm injury rates between the
United Kingdom and the United States. Great Britain's firearm regulation
is among the strictest in the world while there is significant state to
state variability in the United States (2, 3). A study by Fleegler (3),
et al. demonstrated that greater statewide firearm regulations are
associated with a lower rate of firearm fatalities within the state both
for suicides and homicides, which may partially account for the
differences in rates between the countries.
Other factors that may contribute to the differing rates between the
two countries include the differences in firearm availability and
ownership. It has been shown that large cities with more federal firearms
licensees (individuals or stores licensed by the federal government to
sell firearms) have higher rats of gun homicide (4). Additionally, a
recent study demonstrated that countries with higher numbers of guns per
capita had higher rates of firearm-related deaths(5).
These studies along with our own (6) support the notion that the
United States has far to go in terms of improving firearm regulations and
safety. By looking to other countries, we can learn which legislative
models and injury prevention strategies have been most successful in
reducing firearm-related injuries worldwide.
1. Murch H, Heatman B, Naughton A, Sibert JR. Epidemiology of
paediatric firearm injuries. Arch Dis Child. 2014; doi:
10.1136/archdischild-2014-306861 [published Online First: 2014/06/22].
2. Firearms-Control Legislation and Policy: Great Britain.
Washington, D.C.: The Law Library of Congress.
3. Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R. Firearm
legislation and firearm-related fatalities in the United States. JAMA
Intern Med. 2013;173:732-40 doi: 10.1001/jamainternmed.2013.1286
[published Online First: 2013/03/08].
4. Wiebe DJ, Krafty RT, Koper CS, Nance ML, Elliott MR, Branas CC.
Homicide and geographic access to gun dealers in the United States. BMC
Public Health. 2009;9:199 doi: 10.1186/1471-2458-9-199 [published Online
First: 2009/06/25].
5. Bangalore S, Messerli FH. Gun ownership and firearm-related
deaths. Am J Med. 2013;126:873-6 Online.
6. Srinivasan S, Mannix R, Lee LK. Epidemiology of paediatric firearm
injuries in the USA, 2001-2010. Arch Dis Child. 2014;99:331-5 doi:
10.1136/archdischild-2013-304642 [published Online First: 2013/12/18].
Professor Modi's excellent review has a curious omission that of the International Charter for Ethical Research Involving Children (ERIC) 2013.
http://childethics.com/ accessed November 2nd 2014
Its project partners include, amongst others, the UNICEF Office for Research and Childwatch International Research Network.
This Charter addresses the issues raised in her review about moving forwa...
Authors: Francis J Gilchrist1,2 ,Mark G Pritchard1, Warren Lenney1,2.
1. Academic Department of Child Health, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, United Kingdom
2. Institute for Science and Technology in Medicine, Keele University, Guy Hilton Research Centre, Thornburrow Road, Stoke-on-Trent ST4 7QB, United Kingdom
Correspondence Dr Francis J Gil...
We congratulate Dr Pritchard and colleagues for reporting on a retrospective follow-up of their patient cohort with protracted bacterial bronchitis (PBB) and thank them for acknowledging the importance of PBB as a cause of chronic cough. The diagnostic criteria of PBB do however need clarification as the 10 children whose wet cough failed to resolve with antibiotics do not have PBB. Instead, they may have bronchiectasis,...
Acute bronchiolitis and asthma come under the category of obstructive airway disease while bronchopneumonia does not. The main clinical manifestation of an obstructive airway disease would be hyperinflation that would have the clinical features of viscero-ptosis (upper border of liver pushed down), and loss of cardiac dullness on chest percussion.The other clinical feature of obstructive airway disease is prolonged expi...
We were pleased to read Dr Davison's review of the two recently published guidelines for managing chronic Hepatitis B infection in children [1]. We have recently audited our practice against both of these guidelines. As Dr Davison points out; "The level of Alanine transaminase (ALT) at which treatment should be considered highlights a fundamental difference between the guidelines". NICE suggests that ALT in males above 3...
The Department of Health (DoH) recommends universal vitamin D supplementation for non-formula-dependent children aged 6 months to 5 years [1]. Following the report by Jamieson et al. [2], we share similar data from North Tyneside, showing that few children are being supplemented with vitamin D and that parental awareness of current recommendations is poor.
We distributed questionnaires to consecutive parents an...
I read with great interest, Dr Rosenbloom's recent article. He discusses how difficult issues are raised involving blame when a medical error is discovered but the process may offer families restitution and compensation. 'Parental responsibility' is a term used to describe the legal duty that a parent has to their child (1). Parents act, therefore, as surrogate decision makers on the basis of what they believe to be in...
We read with great interest the recent review article by Creswell, Waite and Cooper on 'Assessment and management of anxiety disorders in children and adolescents'. The article brought to the forefront the importance of accurately identifying and treating anxiety disorders during development, with an encouraging discussion of new treatment strategies and delivery approaches to increase access to psychological therapies fo...
We appreciate the response from Murch(1) and colleagues as it highlights the dramatic difference in firearm injury rates between the United Kingdom and the United States. Great Britain's firearm regulation is among the strictest in the world while there is significant state to state variability in the United States (2, 3). A study by Fleegler (3), et al. demonstrated that greater statewide firearm regulations are asso...
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