Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin a...
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin as a
diagnostic adjunct in necrotising enterocolitis2.
JFB Houston
1. Bin-Nun A, Booms C, Sabag N, Mevorach R, Algur N, Hammerman C.
Rapid
fecal calprotectin (FC) analysis: point of care testing for diagnosing
early necrotizing enterocolitis. Am J Perinatol. 2015;32:337-42.
2. Houston JFB, Morgan JE. Question 2: Can faecal
calprotectin be used as an effective diagnostic aid for necrotising
enterocolitis in neonates? Arch Dis Child. 2015;100:1003-6
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree en...
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree entirely that
it is important to know where to target policy, and their data moves us on
considerably in determining priorities. This is precisely the sort of
approach needed on the Countdown technical committee and we look forward
to further collaboration.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
Colvin correctly notes that we are interested in solution-focused
research, and expresses some anxiety about our recommendations for
improving child survival. There are two issues to consider in addressing
his concerns: determining causality, and the burden of proof required to
take action.
First, Bradford Hill's criteria for considering causality are helpful
in demonstrating why the association between poverty...
Colvin correctly notes that we are interested in solution-focused
research, and expresses some anxiety about our recommendations for
improving child survival. There are two issues to consider in addressing
his concerns: determining causality, and the burden of proof required to
take action.
First, Bradford Hill's criteria for considering causality are helpful
in demonstrating why the association between poverty and social
inequalities, and many child health outcomes including mortality, is
convincing[3]. The correlation between poverty and mortality is strong and
consistent, and there is a clear gradient; poor children are more likely
to die, and the greater the gap between rich and poor, the greater the
risk[4]. Most of the other criteria are either self-evident (temporality)
or are more relevant and appropriate to simpler questions of causality,
(specificity, experiment). However Colvin also questions the plausibility
and coherence of the associations, focusing on low birth weight, preterm
birth, and teenage pregnancy as intermediary factors. The links between
poverty, social inequalities, and adverse child health outcomes are more
of a causal web than simple chain, so examination from multiple
perspectives is helpful and indeed the associations are plausible,
supported by epidemiological association, and other studies including
intervention [5, 6].
There is specific data for England and Wales, based on individual
parents' social status, demonstrating a clear social gradient in preterm
birth rates of 6.8 per cent for babies with at least one parent in a
managerial or professional occupation, compared with 7.8 per cent of
babies with parents in routine or manual occupations[7]. Socio-economic
adversity during pregnancy is also associated with an increased risk of
having a low birth weight baby [6, 8].
Plausibility is supported by other associations and evidence too. For
example, families from lower socio-economic backgrounds are likely to be
more stressed[9] and acute and chronic antenatal maternal stress and poor
maternal mental health are linked with preterm births and low birth weight
[10, 11] Depression may also lead to negative maternal behaviours, and
poor prenatal care, substance abuse, poor nutrition during pregnancy and
smoking are associated with both socio-economic disadvantage, and with
lower birth weight [12-15]. Young women from social disadvantaged
backgrounds and low educational attainment are more likely to have a
teenage pregnancy; teenage pregnancy rates are higher in more
disadvantaged areas, approximately twice as high for women living in the
most deprived areas compared with least deprived. Teenage pregnancy is
associated with an increased risk of preterm birth compared with women in
their 20 and 30s; in 2013, the overall rate of preterm births was 7.4 per
cent, but among women under 20 years the rate was 8.0 per cent [16-19].
Infant mortality rates among babies born preterm to mothers under 20 years
are higher (22.4 per thousand preterm births among mothers under 20 years)
than among older mothers (15.1 per thousand among mothers aged 35-39)[7,
16-18, 20]. Colvin's suggestion that differences in teenage pregnancy
rates are an alternative explanation ignores the strong association
between teenage pregnancy rates and deprivation on both an individual and
an area level, and the ample evidence that social disadvantage contributes
to poor outcome at birth and in childhood.
The second issue relates to the burden of proof required before
taking action. Epidemiology and health systems research are important
tools in the search for explanations and solutions, and there are
different methods and standards according to the questions asked[21].
Applying an epidemiological standard to a health systems or social policy
question is neither always sufficient nor appropriate.The logical
consequence of Colvin's argument is that a randomised controlled trial
would be necessary before taking action to reduce social inequalities.
There has never, to our knowledge, been any evidence published suggesting
detrimental health effects of reducing poverty, narrowing the gap between
rich and poor, or introducing policies promoting social protection. By
contrast, there is plenty of evidence demonstrating good. It would seem
remiss to wait for a purported but misguided epidemiological standard of
evidence. The burden of proof suggests that our recommendations are likely
to be safe and do more good than harm.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
1. EURO-PERISTAT Project with SCPE and EUROCAT, European Perinatal
Health Report. The health and
care of pregnant women and babies in Europe in 2010,. 2013.
2. Viner, R., et al., Deaths in young people aged 0-24 years in the
UK compared with the EU15+ countries, 1970-2008: analysis of the WHO
Mortality Database. . Lancet. , 2014 384(9946): p. 880-92.
3. Bradford Hill, A., The environment and disease: association or
causation? Proceedings of the Royal Society of Medicine, 1965. 58(5): p.
295-300.
4. Marmot, M., WHO European review of social determinants of health
and the health divide. . The Lancet. , 2012. 380: p. 1011-1029.
5. Cattaneo, A., et al., Child Health in the European Union
2012, European Commission: Luxembourg.
6. Ohlsson, A. and Shah P, Determinants and prevention of low birth
weight: a synopsis of the evidence. 2008, Institute of Health Economics
Alberta, Canada
7. Office for National Statistics. Gestation-specific infant
mortality in England and Wales, 2013. 2015; Available from:
http://www.ons.gov.uk/ons/publications/re-reference-
tables.html?edition=tcm%3A77-39593
http://www.ons.gov.uk/ons/dcp171778_419800.pdf.
8. Dibben, C., M. Sigala, and A. Macfarlane, Area deprivation,
individual factors and low birth weight in England: is there evidence of
an "area effect"? J Epidemiol Community Health, 2006. 60(12): p. 1053-9.
9. Duncan, G.J., J. Brooks-Gunn, and P.K. Klebanov, Economic
deprivation and early childhood development. Child Dev, 1994. 65(2 Spec
No): p. 296-318.
10. Talge, N.M., et al., Antenatal maternal stress and long-term
effects on child neurodevelopment: how and why? J Child Psychol
Psychiatry, 2007. 48(3-4): p. 245-61.
11. Hoffman, S. and M.C. Hatch, Stress, social support and pregnancy
outcome: a reassessment based on recent research. Paediatr Perinat
Epidemiol, 1996. 10(4): p. 380-405.
12. Bradley, R.H. and R.F. Corwyn, Socioeconomic status and child
development. Annu Rev Psychol, 2002. 53: p. 371-99.
13. Brooks-Gunn, J., et al., Enhancing the cognitive outcomes of low
birth weight, premature infants: for whom is the intervention most
effective? Pediatrics, 1992. 89(6 Pt 2): p. 1209-15.
14. Korenman, S.M., JE. Sjaastas J., Long term poverty and child
development in the United States: results from the NLSY. Institute for
research on Poverty Discussion paper, . 1994, Institute for research on
Poverty.
15. Marmot, M., Marmot M. Fair Society, Healthy Lives: the Marmot
Review. Strategic review of health inequalities in England post 2010.
2010.
16. Office for National Statistics. Teenage pregnancies at lowest
level since records began. 2013 [cited 2015 April]; Available from:
http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-
wales/2011/sty-conception-estimates-2011.html.
17. Office for National Statistics. Teenage pregnancies at record
low: how does your local area compare? 2014 [cited 2015 April]; Available
from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-
and-wales/2012/sty-conception-rates.html.
18. Office for National Statistics. Conception statistics, England
and Wales, 2013. . 2015; Available from:
http://www.ons.gov.uk/ons/rel/regional-trends/area-based-
analysis/conceptions-deprivation-analysis-toolkit/conceptions-deprivation-
measures--2009-11.html.
19. Right Care, Atlas of Variation: Children. 2012.
20. Office for National Statistics, Teenage conceptions are highest
in the most deprived areas. 2014.
21. Ghaffar, A., et al., Changing mindsets in health policy and
systems research. Lancet, 2013. 381(9865): p. 436-7.
We are so sorry not to have included cerebral arterio-venous fistula
in the aetiology of unexplained tachypnoea because it is of course a rare
but classic cause. Typically the symptoms begin almost immediately after
birth if there is a large fistula and the pulmonary artery pressure
remains elevated. The fistula allows a large systemic artery to systemic
venous shunt with right atrial and right vent...
We are so sorry not to have included cerebral arterio-venous fistula
in the aetiology of unexplained tachypnoea because it is of course a rare
but classic cause. Typically the symptoms begin almost immediately after
birth if there is a large fistula and the pulmonary artery pressure
remains elevated. The fistula allows a large systemic artery to systemic
venous shunt with right atrial and right ventricular volume overload and
increased pulmonary blood flow. There is almost always a systolic or
continuous murmur over the occiput or anterior fontanel allowing a
clinical diagnosis to be made in the majority; but absence of any murmur
in the case described by your correspondent is unusual.
We would like to thank Dr Levene for her letter, and the Editors for
the opportunity to respond. The authors are familiar with the Infant
Sleeplab App; we are both associated with the Durham University Parent-
Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as
the Founder and Director). The Infant Sleep Info Source Website (ISIS,
www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her...
We would like to thank Dr Levene for her letter, and the Editors for
the opportunity to respond. The authors are familiar with the Infant
Sleeplab App; we are both associated with the Durham University Parent-
Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as
the Founder and Director). The Infant Sleep Info Source Website (ISIS,
www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her
colleague Dr Charlotte Russell, developed with ESRC funding, and launched
in March 2012 in collaboration with UNICEF UK Baby Friendly Initiative,
NCT, and La Leche League GB. Following the launch the Breastfeeding
Network, Lactation Consultants GB, and Association of Breastfeeding
Mothers approached us to support and endorse the ISIS website. The aim of
the website is to make research-based evidence on normal infant sleep
available to parents and health professionals, and help bridge the
research-to-practice gap.
Due to the popularity of the website, and data indicating that many
users accessed it via their smartphones, we proposed creating an Infant
Sleep app, based on the website information, in 2013. With support from
the Wolfson Institute for Health & Wellbeing the development of the
app was funded by Durham University who launched the app in 2014 with the
name 'Infant Sleeplab'. It is available for free for both Apple and
Android platforms and can be downloaded from the relevant app stores. We
incorporated a bed-sharing decision tool that we developed and evaluated
in collaboration with NHS Lancashire and Blackpool (Russell et al., 2015),
and of course are pleased to hear Dr Levene found this helpful in making
her own parenting decisions. More information about the app can be found
here: www.isisonline.org.uk/app.
We thank Dr Cohn and his colleagues for their interest in our article
and agree - as stated within our paper - that there is considerable
variability in the reported fracture yield of skeletal surveys. This
variability is not only dependent on methods of data display (as Dr Cohn
et al illustrate), but also on epidemiological and demographic differences
between reported study populations and on the process by which clinicia...
We thank Dr Cohn and his colleagues for their interest in our article
and agree - as stated within our paper - that there is considerable
variability in the reported fracture yield of skeletal surveys. This
variability is not only dependent on methods of data display (as Dr Cohn
et al illustrate), but also on epidemiological and demographic differences
between reported study populations and on the process by which clinicians
identify and refer children for skeletal survey.
On the latter issue of patient selection, a recent systematic review
showed that there was insufficient evidence to draw any conclusions as to
the benefits or otherwise of screening children for physical abuse where
there is no prior suspicion [1]. Furthermore, although Sittig et al have
developed a checklist for use in the Emergency Department to aid
identification of abused children [2], as far as we are aware, there is as
yet no validated algorithm to determine which children should progress to
skeletal survey and which should not.
Such an algorithm might be expected to improve the fracture yield of
skeletal surveys and the evidence to support its development should come
from a multi-centre (preferably UK) study, which will require both time
and funding. Meanwhile, we conclude as we previously concluded,
"History and examination are key to screening for abuse. A decision
on the precise investigations must be influenced by clinical need and
judgement and by the specific circumstances in each individual case.
In children under the age of 2 years who are seen for suspected physical
abuse, until better evidence is available, RCR/RCPCH guidelines should be
adhered to and initial and full skeletal surveys performed."
References:
1. Hoytema van Konijnenburg EMM et al Insufficient evidence for the
use of physical examination to detect maltreatment in children without
prior suspicion: A systematic review
http://www.systematicreviewsjournal.com/content/2/1/109
2. Sittig JS et al Child Abuse Inventory at Emergency Rooms: Chain-ER
Rationale and Design
http://www.biomedcentral.com/1471-2431/11/91
We would like to thank Dr Clifford for his interest in our research.
We do not agree with him that the title and abstract are misleading. The
study was a longitudinal one and the results reflect that; for example we
looked at the children over time and assessed the importance of within-
child variation over time compared to between-child variation. It is very
important to distinguish between a collection, that is a point...
We would like to thank Dr Clifford for his interest in our research.
We do not agree with him that the title and abstract are misleading. The
study was a longitudinal one and the results reflect that; for example we
looked at the children over time and assessed the importance of within-
child variation over time compared to between-child variation. It is very
important to distinguish between a collection, that is a point in time at
which data were collected, and the child on whom the data were collected,
since a single child may have multiple collections. In summarising the
data by collections we were reflecting the occurrence of bruising over the
whole study.
The situation most closely resembling the presentation of a child to
a clinician is the first collection on that child. The prevalence of
bruising at the first collection, that is the percentage of children who
had at least one bruise, was 5.3%, (95% CI 2.6 - 10.5) in pre-mobile
children, and only 1.3%, (95% CI 0.2 - 6.9) for those infants who are not
yet rolling. The percentage of pre-mobile children who experienced a
bruise at some time in up to 12 collections is necessarily much higher,
but that does not estimate the prevalence. The situation is analogous to
the occurrence of the common cold. At any one time during the year, the
prevalence is quite low - probably below 10% - but most people have a cold
at some time during a year.
We agree that each case must be assessed on its own merit with a
clear and detailed history taken for the cause of bruising, a careful
examination and appropriate investigations to determine the cause of the
injury; indeed that is the message of the concluding paragraph of the
paper. Undertaking this type of work is indeed challenging and did require
a high level of co-operation from our group of parents for which we are
most grateful. The author of the letter is right to point out that a more
intrusive approach would be unethical and impractical'.
In future work we will compare patterns between the children in this
study, those with bleeding disorders and those who have been confirmed as
victims of child abuse to seek methods for discriminating between them.
Thank you for your helpful response to the Archivist feature on
neonatal Vitamin A supplementation, pointing out the difficulty in
attributing any benefit to pre-existing deficiency. Obviously it is not
possible to include a full discussion of the conflicting literature on
this subject in a short article. I did not intend to endorse any
conclusions from the editorial, but merely to stimulate...
Thank you for your helpful response to the Archivist feature on
neonatal Vitamin A supplementation, pointing out the difficulty in
attributing any benefit to pre-existing deficiency. Obviously it is not
possible to include a full discussion of the conflicting literature on
this subject in a short article. I did not intend to endorse any
conclusions from the editorial, but merely to stimulate interest amongst
readers, in the hope that they will read the articles and draw their own
conclusions. I am sure that there will be much discussion about this in
The Lancet.
Robert Scott-Jupp
Associate Editor
Lucina and Archivist
Drs Bajaj and Offiah present compelling reasons for performing
skeletal surveys in all children under 2 years of age with unexplained
injury, as recommended by the RCPCH guidelines. We have followed this
practice
for a number of years but an audit of our skeletal surveys came to a very
different conclusion.
We reviewed the results of the skeletal surveys requested in our
hospital over a period of 7 years and 4...
Drs Bajaj and Offiah present compelling reasons for performing
skeletal surveys in all children under 2 years of age with unexplained
injury, as recommended by the RCPCH guidelines. We have followed this
practice
for a number of years but an audit of our skeletal surveys came to a very
different conclusion.
We reviewed the results of the skeletal surveys requested in our
hospital over a period of 7 years and 4 months - from the time of
introducing a computerised radiology programme till the time of the study
(November 2007-January 2015). During this time 135 skeletal surveys were
requested. Of these 28 were for the investigation of medical conditions,
27 were performed following infant death and 80 were performed for
suspected abuse. In 30 cases the skeletal survey
included a CT of the head.
Of the 80 children with suspected abuse 31 presented with an injury
shown to be a fracture on initial X-ray who then proceeded to a skeletal
survey and 49 had a presenting injury that did not obviously include
a fracture. The age range was from 1-102 months, mean age 13.6 months. 45
children were less than one year of age. None had a second skeletal survey
performed.
Of the skeletal surveys performed 3 identified fractures additional
to the presenting injury. The remaining 77 skeletal surveys did not detect
any
additional fractures.The three children in this series that had additional
fractures all presented with features to suggest that they had been
subjected to
very serious assaults -a long bone fracture in a non -ambulant child,
bilateral subdural haematomata, and widespread bruising-.
In those children with an equivocal presentation the skeletal survey
, in our experience, did not identify any unexpected injuries. It might be
argued that delayed skeletal surveys may have been more useful.
The value of a skeletal survey may be determined by
how the figures are prepared. So, in our study 31/80 (39%) of children
undergoing a skeletal survey had fractures. This is within the range
quoted for postive skeletal surveys of 10-55% and could therefore be
considerd as a support for skeletal survey. However in these cases it was
the evidence of a fracture in a single X ray that prompted further
investigation and the fracture was identified before the skeletal survey
was requested.
As regards information beyond the index injury, as
mentioned ,we found additional fractures in 3 studies (3.75% of the total
or 10% of those with one fracture). In all cases there was clinical
evidence to suspect multiple injuries.
We believe that if the figures are interpreted in this way, there is
scope to suggest that current guidelines may overstate the value of
skeletal survey -especially
given the radiation risk as highlighted by Bajaj and Offiah, and the use
of clinical judgement and limited skeletal surveys may have a place in the
management of these children.
We highlight the recent case of a term female neonate aged 9 days who
was referred by her community midwife on account of features of mild
respiratory distress symptoms. Initially sepsis was suspected and
treatment with antibiotics was initiated. Tachypnoea persisted though
there were no other abnormal physical signs; laboratory studies were
normal. An echocardiogram, performed to exclude a primary cardiac cause
showed...
We highlight the recent case of a term female neonate aged 9 days who
was referred by her community midwife on account of features of mild
respiratory distress symptoms. Initially sepsis was suspected and
treatment with antibiotics was initiated. Tachypnoea persisted though
there were no other abnormal physical signs; laboratory studies were
normal. An echocardiogram, performed to exclude a primary cardiac cause
showed pulmonary hypertension, with right to left flow through a small
atrial septal defect. There was no echo evidence of heart failure and the
pulmonary hypertension could not be explained by heart abnormalities.
Cranial ultrasound was performed and showed a large midline vascular
abnormality posterior to brainstem, with turbulent Doppler flow,
suggestive of vein of Galen malformation. There was no cranial bruit.
Urgent transfer to a specialist centre was arranged for endovascular
embolization therapy. The case emphasises the importance of correct
identification of the cause of respiratory distress in young infants, even
if symptoms are initially mild; also to explain the finding of pulmonary
hypertension which may have an underlying pathological basis which is not
primarily cardiac or respiratory.
Many thanks for the recent letter regarding a rapid assay technique for testing fecal calprotectin1. This would indeed be useful in the clinical setting if it allows the transmission of accurate and rapid fecal calprotectin levels to treating clinicians. As discussed in the original archimedes report, the difficulties surrounding the need for an adequate cut-off remain the main barrier to the use of fecal calprotectin a...
We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree en...
Colvin correctly notes that we are interested in solution-focused research, and expresses some anxiety about our recommendations for improving child survival. There are two issues to consider in addressing his concerns: determining causality, and the burden of proof required to take action.
First, Bradford Hill's criteria for considering causality are helpful in demonstrating why the association between poverty...
Dear Editor
We are so sorry not to have included cerebral arterio-venous fistula in the aetiology of unexplained tachypnoea because it is of course a rare but classic cause. Typically the symptoms begin almost immediately after birth if there is a large fistula and the pulmonary artery pressure remains elevated. The fistula allows a large systemic artery to systemic venous shunt with right atrial and right vent...
We would like to thank Dr Levene for her letter, and the Editors for the opportunity to respond. The authors are familiar with the Infant Sleeplab App; we are both associated with the Durham University Parent- Infant Sleep Lab (Dr Volpe as an Honorary Fellow, and Professor Ball as the Founder and Director). The Infant Sleep Info Source Website (ISIS, www.isisonlineorg.uk) was conceived of in 2010 by Professor Ball and her...
We thank Dr Cohn and his colleagues for their interest in our article and agree - as stated within our paper - that there is considerable variability in the reported fracture yield of skeletal surveys. This variability is not only dependent on methods of data display (as Dr Cohn et al illustrate), but also on epidemiological and demographic differences between reported study populations and on the process by which clinicia...
We would like to thank Dr Clifford for his interest in our research. We do not agree with him that the title and abstract are misleading. The study was a longitudinal one and the results reflect that; for example we looked at the children over time and assessed the importance of within- child variation over time compared to between-child variation. It is very important to distinguish between a collection, that is a point...
Dear Professor Aaby
Thank you for your helpful response to the Archivist feature on neonatal Vitamin A supplementation, pointing out the difficulty in attributing any benefit to pre-existing deficiency. Obviously it is not possible to include a full discussion of the conflicting literature on this subject in a short article. I did not intend to endorse any conclusions from the editorial, but merely to stimulate...
Drs Bajaj and Offiah present compelling reasons for performing skeletal surveys in all children under 2 years of age with unexplained injury, as recommended by the RCPCH guidelines. We have followed this practice for a number of years but an audit of our skeletal surveys came to a very different conclusion.
We reviewed the results of the skeletal surveys requested in our hospital over a period of 7 years and 4...
We highlight the recent case of a term female neonate aged 9 days who was referred by her community midwife on account of features of mild respiratory distress symptoms. Initially sepsis was suspected and treatment with antibiotics was initiated. Tachypnoea persisted though there were no other abnormal physical signs; laboratory studies were normal. An echocardiogram, performed to exclude a primary cardiac cause showed...
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