eLetters

114 e-Letters

published between 2016 and 2019

  • Response to: Failing to consider Virtual Academic Units within UK infrastructure for research that benefits infants, children and young people

    Dear Editor,

    Re: Professor Andrew N Williams’ letter to ADC “Failing to consider Virtual Academic Units within UK infrastructure for research that benefits infants, children and young people”

    We were pleased to hear the success of the Virtual Academic Unit and invited Professor Andrew Williams to contribute to the RCPCH research bulletin of March 2019.

    At the RCPCH, we know from our research and from speaking to our membership, that paediatricians around the country have little or no allocated funding or designated research time. We, therefore, applaud all those paediatricians who continue to go above and beyond to undertake research to achieve better health outcomes for children and young people.

    The RCPCH is fully committed to strengthening basic science and clinical research and the development of devices, medicines and technologies that address the needs of children. Furthermore, our committment includes supporting our members and growing and promoting opportunities for research within paediatrician’s careers.

    We will continue to work with our partners across the UK to influence, promote and grow child health research.

     

    Lindsey Hunter, Research Development Manager, RCPCH

    Professor Anne Greenough, immediate past Vice President Science and Research, RCPCH and Professor of Neonatology and Clinical Respiratory Physiology, King's College London

  • Response to E Letter titled TRAMADOL: PATIENT SAFETY COMES FIRST IN CHILDREN

    Dear Professor Davendralingam Sinniah Paediatrician
    In response to your letter. We agree with you patient safety comes first in all age groups.
    1. Tramadol is not a full agonist opioid. The issue that we have highlighted with tramadol (and codeine) is when the patient is a CYP2D6 ultrametaboliser there is potential for serious adverse events. The CYP2D6 issue is not at play for the alternative pure opioid agonists oxycodone and morphine (the latter as you suggested). However all these agents have potentially serious adverse effects, including sedation, respiratory depression (in therapeutic doses) and fatality (usually in excessive dosing or at risk patients).
    2. We agree with you that the simple non-opioid analgesics (paracetamol and NSAIDs when not contraindicated) are preferred. We are advocating for tramadol when stronger analgesia is required as a 3rd line alternative to the pure opioid agonists. We each work in tertiary centres where tramadol is used: one a women’s hospital where it is used perioperatively post caesarean and vaginal delivery; and the others where is is used off label in children of all ages (including infants).
    3. There are few data concerning respiratory depression and tramadol in neonates. However concentrations in breast fed neonates are low and not expected to cause respiratory depression after usual doses.
    4. Please point to evidence in the literature that tramadol administered to women who are breastfeeding cause...

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  • Failing to consider Virtual Academic Units within UK infrastructure for research that benefits infants, children and young people

    I was deeply surprised that this leading paper in citing the 2018 ‘Turning the tide 5 years on’ does not mention ‘virtual Biomedical Research Units and Centres’ (1,2). The establishment of such centres had been specifically recommended in the seminal 2012 RCPCH Report ‘Turning the Tide: Harnessing the power of child health research’ (3).
    We in Northampton established a Virtual Academic Unit (VAU) in 2004, and published our experience of its first 10 years experience in Archives in 2015 (4).
    Among the articles published through the VAU there is ‘Ethical Research Involving Children.’ (2013) UNICEF, which predates the College own Children’s and Young People’s Child Health Research Charter. (5)

    The Virtual Academic Unit is continuing to collaborate on and publish in clinical child health research to this day. (6) However, it has remained totally unfunded with no allocated research time in spite of every possible endeavour to address this.

    We have to be pragmatic and recognise that with present and future increasing pressures within the NHS having any research time within a job plan is seen by most NHS managers as an unproductive luxury given the immediate pressing necessities of delivering a clinical service.

    As my 2015 article relates

    ‘A VAU has its place and in a present and future environment where resources are continuing to be constrained, a method of working that allows something meaningful to be produced, from where previousl...

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  • Additional considerations for future modelling of paediatric intensive care retrieval teams in England and Wales

    We commend the DEPICT group for gathering evidence to support or refute the current set of performance standards for specialist paediatric intensive care retrieval teams (PICRTs), for which there is currently limited evidence base.

    A key tenet of ‘the paper’ was geographical distance as the sole reason for a breach in the 180 minute to bedside standard.[1] In our experience, the commonest reason to breach was ‘team availability’. In 2018 South Thames Retrieval Service (STRS) performed 824 emergency retrievals. In 4% of these, the team did not reach the bedside within 180 minutes. On 33/36 occasions, the reason for delay was lack of availability of retrieval team due to concurrent deployment.

    STRS is commissioned to staff two teams on every shift. In 2018 32% of retrievals were performed concurrently. STRS is the second busiest PICRT in the UK, however on 29 % of shifts, no retrieval team was launched. STRS is a fully integrated retrieval service –all staff are based in the intensive care unit, and when not on retrieval work clinically in the PICU. This allows flexible staffing and in times of high demand, helps support increased PICU bed capacity. In 2018, 98.8% of patients were kept within region.

    The authors highlight the importance of mobilisation time. Despite the integration of our service within a busy PICU, STRS recorded the highest national compliance with the mobilisation standard for 2017.[2]

    In our region 90% of intubations are p...

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  • Response to Grosse and Lanzieri's comment on "Economic cost of congenital CMV in the UK"

    The response to our article was received with interest. Grosse and Lanzieri raise important points in connection with our recent paper [1], noting concerns that the paper overestimates the financial cost burden associated with congenital cytomegalovirus (cCMV). These points are contingent on our estimate that at least 50% total costs associated with cCMV stemmed from the cost of autism spectrum disorder (ASD) among individuals with cCMV.

    First, Grosse and Lanzieri point out that an association between cCMV and ASD has not been conclusively established, citing a systematic review and meta-analysis by Maeyama et al. (2017) [2]. We agree that there is uncertainty over this association and the prevalence estimates used (along with many of the other estimates), and have emphasised throughout our article that (i) the model is limited by the validity of the inputs, and (ii) more research is required to fully understand the epidemiology, aetiology and prognosis of cCMV. Indeed, Maeyama et al. (2017) [2] report a significant association between cCMV and ASD, but caution that these calculations are seriously limited by the infrequent number of events in the included studies. As we do, they stress the need for further research to clarify this issue.

    Second, Grosse and Lanzieri suggest that the prevalence calculation of ASD attributable to cCMV should have been calculated as the proportion of cCMV individuals with ASD minus the proportion of non-cCMV individuals with AS...

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  • Response to: Over-estimation of association between SUDIC and chronic conditions

    We thank Dr. Garstang and Dr. Debelle for their comments on our article in ADC (1).

    We are pleased that the correspondents support our finding of a strong association between chronic conditions and respiratory tract Infection mortality in children which, though well-recognised by clinicians, has not previously been quantified.

    The correspondents rightly highlight that our analyses concentrate only on unexpected deaths after age 2 months. We chose this definition because these early deaths are more prone to linkage error and more importantly, tend to be related to maternal health during pregnancy and delivery, preterm birth, intrapartum events and congenital anomalies, and therefore may not be avoidable through improved care after postnatal discharge.

    As our paper highlights, an indication of whether a death was expected or not on a death certificate or in hospital records is necessary in order to assess whether a death was avoidable or amenable to healthcare intervention. A classification of whether a death was expected or unexpected could also be notified to Child Death Overview Panels and other agencies by those completing the death certificates. This would be helpful to Child Death Overview Panels in their deliberations as well as feeding into the collation of mortality statistics‎.

    References:

    1.     1. Verfürden ML, Gilbert R, Sebire N, Hardelid P. Arch Dis Child 2018;103:1125–1131.

  • RheumMates is already there

    I was very pleased to read this letter on involving children and young people (CYP) which is so important.

    RheumMates (https://www.facebook.com/groups/rheumates/) is a group which was already set up together with young people with rheumatological conditions (based on the highly successful NeoMates model, which provides parent peer support for neonatal unit parents) for this purpose.
    This came about after we presented NeoMates at the Royal College of Paediatrics and Child Health annual conference at the same time that an inspirational young person presented her work on setting up Raiise (https://raiise.co.uk) to improve care and provide support for young people with "invisible illnesses".
    It is a place where CYP can chat to each other safely, knowing that everyone in the group has a common link.
    It is also a source of expert knowledge and information.

    To complement it, we also set up RheumMatesParents where parents can also chat, gaining the peer support that the NeoMates parents have had for many years.

    I wonder if these could in some way be combined to help improve peer support and patient engagement?

  • Reply to Prof. Matti Korppi

    Thank you for your attention to this research. Firstly, this systematic review showed that LOS was decreased in the HFNC group comparing with SOT group in low-income and middle-income countries. As you mentioned in the letter that even in high-income countries, it’s not realistic to treat all bronchiolitis patients with HFNC during RSV peaks. The inconsistent result of LOS in different countries may be caused by the level of medical practice in different areas because the LOS in low-income and middle-income countries was significantly longer than in high-income countries. So the clinical heterogeneity suggested that the level of medical practice was also important for bronchiolitis. Secondly, two studies showed that patients with treatment failures in SOT group could be treated with HFNC in the wards. This meta-analysis showed that there was a significant increase in the incidence of treatment failure in HFNC group compared with nCPAP group (RR 1.61, 95% CI 1.06 to 2.42, p=0.02). Therefore, we need more research to explore which choice (HFNC or nCPAP) is better for patients with treatment failures in standard oxygen supplementation.

  • Comment on “Economic cost of congenital CMV in the UK” by Retzler et al.

    Retzler et al. report estimates of the economic cost of congenital cytomegalovirus (cCMV) in the United Kingdom.1 The projected costs of autism spectrum disorder (ASD) among persons with cCMV accounted for at least 50% of the total costs attributed to cCMV. However, an association between cCMV and ASD has not been conclusively established,2 and, in their analysis, Retzler et al. did not take into account the cost of ASD among children without cCMV.

    Retzler et al. used published ASD prevalence estimates from a Dutch study of >30,000 children screened for cCMV at 6 years of age using stored dried blood specimens, of whom 133 were CMV-positive. Of 26 children classified with symptomatic cCMV, 2 (7.7%) had ASD, as did 2/107 (1.9%) with asymptomatic cCMV.3 Retzler et al. assumed 11% of children with cCMV are symptomatic, which implies a weighted average ASD prevalence of 2.5% among children with cCMV. Five of 274 (1.8%) matched children without cCMV in the Dutch study also had ASD. If ASD were causally associated with cCMV, which has not been shown, the cost of ASD attributable to cCMV would be the cost difference of ASD among children with and without cCMV. Therefore, the projected cost of cCMV has been overestimated. Moreover, if the reported association of cCMV with ASD turns out to be non-causal, the total cost of cCMV could be half that estimated by Retzler et al.

    References
    1. Retzler J, Hex N, Bartlett C, et al. Economic cost of congenital CMV...

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  • Recent insights into the role and dose of aspirin in acute Kawasaki disease

    Sir,
    I would like to add to the article ‘What dose of aspirin should be used in the initial treatment of Kawasaki disease?’ by Luke Guo Yang Ho and Nigel Curtis (Archives, 2017, 102, 1180-1182). Fifteen months have passed since this article concluded that low-dose aspirin is not inferior to higher doses in reducing the risk of coronary artery abnormalities in acute Kawasaki disease. Since then, it is worth considering what and if anything has changed in the field. A recent study not included in the review is a retrospective cohort study by Huang et al1 (2018), where 910 patients followed up for 2 years, which showed that there was no significant difference between 3 groups in terms of anti-inflammation or prevention of coronary artery abnormalities. This paper concluded that the role of aspirin in the treatment of the acute phase of Kawasaki disease should be questioned, as a definite benefit has not been shown. Therefore, in concordance with the conclusion of the review, this rapid response poses that current data remains unchanged with regards to the role and effects of administration of higher doses of aspirin on coronary outcome in acute Kawasaki disease. In the absence of evidence to support higher doses in prevention of coronary artery abnormalities, low-dose aspirin (3–5 mg/kg) may be the safest, most rational approach until better evidence becomes available.

    There are currently three prospective randomised control trials in process to continue this inv...

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