1546 e-Letters

  • Surfactant administration via laryngeal mask in preterm infants: a word of caution

    We read with interest Dr. Smee et al.’s article on surfactant administration via laryngeal mask (LMA) in infants with respiratory distress syndrome: an intriguing topic, suggesting a minimally invasive approach to ensure a well-established therapy.
    The authors stated that “use of LMA to administer surfactant is feasible in infants ≥ 1200g, reducing the need for intubation and mechanical ventilation”. (1) Despite a recent meta-analysis showing that this approach may have some advantages on short term outcomes, (i.e. reduction in need for intubation and mechanical ventilation), available evidence was based on small, poor-quality studies. (2)
    In addition, there are many unanswered questions on the application of this approach in neonates. It is not known which supraglottic airway device (SAD) may be best suited (there are at least 7 different types of commercially available size-1 SADs), the characteristics of the cuff (inflatable or not-inflatable) and the most appropriate size, (3,4) whether a catheter inside the mask should be used and if yes, where the catheter’s tip should be positioned (proximally or distally), under vision or blindly. There is uncertainty on whether the patient needs mild sedation, general or topical anesthesia, or nothing at all, and around the best mode to support respiratory efforts and potential complications (i.e. hypoxia or bradycardia) during the procedure. (1)
    The authors also reported that “LMAs to fit the more immature infan...

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  • Low Prevalence of Kingella kingae Infections in UK Children


    Low Prevalence of Kingella kingae Infections in UK Children

    Pablo Yagupsky, MD
    Clinical Microbiology Laboratory, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel

    Corresponding Author: Pablo Yagupsky, Clinical Microbiology Laboratory, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel 84101. Phone number: (972) 506264359. Fax number: (972) 86403541. e-mail: PYagupsky@gmail.com

    Dear Editor:
    In a recent article, Abeywickrema et al. summarized 10 years of pediatric joint and bone infections in Oxford, and concluded that Staphylococcus aureus was the most common etiology [1]. Although this concept was widely accepted in the past, the increasing use of sensitive nucleic acid amplification tests has demonstrated that Kingella kingae is the leading agent of skeletal system infections in the 6-48 month-old population, causing up to 88% of the cases in this age group [2]. Abeywickrema et al., however, isolated the bacterium in only 3 of the 74 (4%) patients in whom the etiology could be determined [1]. Kingella kingae is notoriously fastidious and the traditional culture methods and microscopy employed by the researchers are usually unable to detect its presence in joint and bone exudates [3]. Invasive K. kingae infections other than endocarditis are characterized by a mild local and systemic inflammation: fev...

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  • In support of safe hospital care of children and staff during the Covid-19 Pandemic

    Since the introduction of the national delay phase response to Covid-19 Coronavirus in the republic of Ireland on March 12th and subsequent advise to stay at home from March 27th, essential paediatric cardiac services have had to continue in a limited capacity.
    In that time, our national tertiary referral centre has seen 428 children in the out-patient's setting, 223 on the cardiac day ward, and performed an intervention (cardiac surgery or cardiac catheterization) in 140 cases. This includes 41 cardiac by-pass cases, 22 non-bypass cases, 49 interventional cardiac catheterization cases and 6 hybrid procedures involving both the cardiac surgery and cardiac catheterization teams.
    Of the 49 patients screened pre-operatively, not one positive (and asymptomatic) case was identified.
    Adhering to government advice on social distancing and appropriate PPE where indicated, not a single member of the extended medical team has been known to cntract Covid-19 Coronavirus from contact with patients or their families in this time.
    This anecdotal case experience from one institution supports the proposal to allow children to return to school regardless of comorbidities, in recognition of the considerable long-term educational and social harm that exclusion would result in.

  • Time to go back to school: several good reasons beyond low infection risk

    Munro APS &  Faust SL, in their viewpoint (1) quite correctly build on the evidence of low risk of contagion and rare complications of Covid-19 infection among children to call for reopening of schools. There are, however, several other good reasons to be considered.

    First, as all international agencies have highlighted, prolonged closure yields serious consequences for all children and particularly for those already living in difficult circumstances, such as extreme poverty, disability, or violent environments (2,3). UNESCO estimates that at least 177 countries have instituted school closures at national level and several other countries have established closings at regional or local level (4). With over 90% of students worldwide (more than 1.5 billion young people) currently out of the educational context, it is clear that the greatest threats from Covid-19 to children and adolescents are to be found in educational loss, poorer nutrition, increased exposure to intrafamiliar violence, rising incidence of mental health disorders and lack of physical activity rather than in the clinical consequences of Covid-19 infection (4-8). Inequality in education and health will increase dramatically as consequences are inevitably greater for vulnerable children due to social, material and educational poverty, disability and chronic diseases, special educational needs, and lack of access to distance learning technologies (1). The risk of dangerous habits, such as increasing...

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  • Children are being kept at home to protect the elderly from COVID-19

    Munro and Faust call for children to return to school despite the outstanding clinical and epidemiological questions outlined in their Viewpoint “Children are not COVID-19 super spreaders: time to go back to school”[1]. We think that their core argument – that children are minimally infected with SARS-CoV2, that they spread it less than adults, and that even children with comorbidities are relatively spared the most serious effects of COVID-19 – can be augmented with the question “is it ethical to confine children to the home for the protection of the elderly?”.

    In England, 11 COVID-19 deaths were reported in 0-19 year olds up to 5 May 2020[2]. For the same period in Germany this number is three[3], and in France five[4]. During that time, the Global Burden of Disease study estimates that in each of those countries, over a thousand 0-19 year olds died from all-causes, including several hundred from road traffic injury and tens from pneumonia[5].

    We do not keep children at home to protect them from these causes of death, so why are we doing this for COVID-19? We think the public, especially parents, need to understand that this is being done mainly for the benefit of adults (and especially the elderly and other vulnerable groups). This is a societal choice with immediate and potentially life-long consequences which needs careful evaluation of risks and benefits. While scientific evaluation takes place and will take time, the communication of our decision clea...

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  • The risk of ibuprofen-related acute kidney injury is just as important

    The question of the safety of ibuprofen in lower respiratory tract infection(LRTI)(1) should be part of a bigger question. That question is the issue of the safety of ibuprofen in a child who is at risk of dehydration. A febrile child with LRTI is at risk of dehydration because of increased insensible fluid loss via the skin. Furthermore, in the presence of LRTI-related tachypnoea, there will be increased insensible fluid loss via the upper respiratory tract . These fluid losses are compounded when the child is too ill to maintain a good oral fluid intake.
    In volume depleted states, such as the scenario depicted above, vasodilatory prostaglandins maintain adequate renal blood flow(RBF) and adequate glomerular filtration rate(GFR)(2). Nonsteroidal anti inflammatory drugs(NSAIDs) undermine those compensatory mechanisms by inhibiting prostaglandin synthesis(2). The consequence is the onset of NSAID-related acute kidney injury(AKI), as postulated by Misurac et al(3). These investigators postulated that NSAID-related inhibition of prostaglandin synthesis was the underlying cause of AKI in 21 of their 27 cases of NSAID-related AKI. In the remaining 6 children with AKI, acute interstitial nephritis(also attributable to NSAIDs) was the underlying cause.. Fifteen of the 20 children for whom dosing data were available took NSAID doses in the recommended range. Ibuprofen was the culprit NSAID in 67% of cases. Misurac et al also identified 54 other cases...

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  • Response letter to Nutritional rickets under 16 years: UK surveillance results

    Dear Editor

    Infant vitamin D supplementation prevents not just rickets but also hypocalcaemic seizures and cardiomyopathy (CMP). The BPSU survey (1) captures rickets incidence which, we feel compelled to highlight, represents only the tip of the iceberg of widespread vitamin D deficiency (VDD) in the population.

    In the UK, child surveillance checks are led by general practitioners (GPs). Most GPs do not receive postgraduate paediatric training and have inadequate undergraduate paediatric exposure, as acknowledged by the RCPCH president: “by any stretch of the imagination, GP training in the UK in paediatrics is woefully inadequate” (2). Recognising rickets requires paediatric experience as exemplified by recent cases of VDD induced CMP- one child’s death was preceded by multiple unfruitful visits to GPs and casualty (3). As the BPSU survey reached out only to paediatricians and not GPs, the extent of underreporting and under diagnosis is likely huge, limiting comparison with countries where paediatricians oversee primary care. The conclusion that rickets incidence in the UK is lower than expected downplays the extent of the underlying public health crisis, particularly when a significant number of cases were excluded [table 2 of (1)]. The true disease burden is unravelled when family members of affected children are investigated (3).

    Similar to previous studies, rickets incidence here is 90 to 166 fold higher in Asian and Black children compared to wh...

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  • Latrogenic adrenal suppression, a risk not be to ignored

    Dear editor

    We write in response to the article "Use of oral corticosteroids in the treatment of alopecia areata" by BJ Cowley and J Dong, published in January's edition of the journal.(1)

    In this article, the authors present a summary of their literature search, concluding that oral corticosteroid pulse therapy may be a safe and effective treatment for sufferers of alopecia areata (AA). The authors highlight the risk of avascular necrosis of the hip with the use of corticosteroids, despite none of their cited studies reporting on this complication specifically.

    We would argue that iatrogenic adrenal suppression (AS) secondary to exogenous corticosteroid administration is also a noteworthy risk in these patients. Symptomatic AS has been well documented in the asthmatic population receiving daily inhaled corticosteroids, occasionally resulting in adrenal crisis and even sadly death. Whilst there is a good level of awareness of AS amongst some colleagues using high doses of daily steroids, for example in the induction phases of leukaemia treatment, AS is not confined to these children and is as pertinent to those receiving pulsed steroids for AA(2,3).

    In our centre we have had personal experience of looking after a child who required intubation and ventilation when they developed a viral illness and presented with hypotension and hypoglycaemia. They had received intralesional steroids to treat AA, which had caused severe adrenal sup...

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  • Observations

    Dear Sanchez et al,

    I read with interest your recent publication “Language in 2-year-old children born preterm and term: a cohort study) in the Archives of Disease in Childhood. I have made certain observations, and would welcome your views on them.

    I notice (Figure 1) that you screened 557 preterm infants for eligibility. Ninety three of these were excluded as they were deemed unsuitable by medical staff and another hundred and seventeen were excluded for other reasons. As those numbers are quite substantial, I am curious to know what those factors were, and think that some details on those factors will further enhance the quality of the paper.

    Your preterm cohort is defined as <30 weeks gestation. The current evidence shows that mortality and morbidity in preterm babies is associated with degree of prematurity. Therefore, I am wondering that what was the distribution of gestational age in the group and was there any further subgroup analysis attempted.

    You mentioned family history having an impact on the likelihood of language delay in the introduction. However, I note that this was not included in list of factors explored. I wonder if there was any particular reason to do so.

    I look forward to hearing from you, and would like to thank you in anticipation for your time.

    Many thanks,
    Dr Anna Howells
    Paediatric SPR
    Community Paediatrics, Bromley

  • Letter to Editor Nebulised hypertonic saline in moderate-to-severe bronchiolitis: a randomised clinical trial. Raphaelle Jaquet-Pilloud, Marie-Elise Verga, Michel Russo, Mario Gehri, Jean-Yves Pauchard

    Dear Editor

    We enjoyed reading the study by Jaquet-Pilloud et al. 1 examining the role of nebulised 3% hypertonic saline (HS) and bronchiolitis. We thank the authors for this excellent pragmatic non-blinded, randomised controlled trial. Their conclusions support the UK evidence from the SABRE study 2 and their systematic review3 which provides evidence of the futility of adding hypertonic saline to the management of bronchiolitis when compared to standard care alone with length of stay (LOS) or ready for discharge as the primary outcome. The article was well written and easy to follow. The study examined 121 infants with bronchiolitis recruited over three years from one tertiary centre in Switzerland. We felt it illustrated the very important problem of underpowered studies concluding no differences between two treatment regimens. The authors used the Korppi et al 3 study to assume that the mean LOS for infants admitted to hospital with bronchiolitis was 5 days [120 hours] with a standard deviation of 1.2 days [28.8 hours]. Reduction in hospital stay by 1 day was considered clinically significant and based on this a minimum sample size of 120 (with 60 in each group) was arrived. However the data from this paper by Jaquet-Pilloud et al show that the mean LOS was 47 hours (± 8.5) for nebulised hypertonic saline group and 50.4 hours (±11) for standard care group. The LOS at the authors’ hospital was less than half of the assumption used for their power calculation....

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