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This study was published online in Archives of Disease in Childhood after peer review in September 2017. The trial tested the effectiveness of a neurolinguistic programming intervention (used widely but never formally tested) in children and young people with chronic fatigue recruited between 2010 and 2013. Though the number of participants was small, analysis suggested a benefit in terms of physical function (measured by the standard SF 36 scale) at both 6 and 12 months after intervention.
Since publication, the study has been criticised for failing to meet ICMJE and BMJ policy on trial registration and for not fully adhering to CONSORT guidance on trial reporting. The journal has been criticised for not detecting these issues during editorial and peer review. We have acknowledged these comments and reviewed our processes in relation to this paper and relating to EQUATOR guidance in general. In addition, we have received clarifications from the authors which are under editorial consideration.
I was interested to read the articles in this month’s journal exploring the difficulties of end of life decisions when parents and their doctors cannot agree.(1–3) These articles reflect the global media attention focused upon several recent tragic cases in the UK, where differences in view between parents and the clinical team led to confrontation and an unfolding tragedy in the public arena. Whilst all these articles describe the complexity they offer little in terms of solutions. Is it possible to prevent future cases from degenerating into public dispute, or is it an inevitable consequence of modern medicine? Have we advanced to a point where children that would have succumbed now live, and so the focus of care has shifted towards how they live rather than if they live or die?
At least part of the solution should be a shift in focus shift toward prevention of conflict in these high stakes clinical areas rather than finding a remedy once conflict has occurred. This is not just about being better at communicating with families. Conflict prevention will require cultural change, the identification of early warning signs and the use of mediation to facilitate communication between parents and doctors at an early stage.
Communication is not just about what we say, but about how we act and the social networks that we live and work in. It was interesting that there was also an article on Family Integrated Care in the same issue of the journal (4). Patel and colle...
I was interested to read the articles in this month’s journal exploring the difficulties of end of life decisions when parents and their doctors cannot agree.(1–3) These articles reflect the global media attention focused upon several recent tragic cases in the UK, where differences in view between parents and the clinical team led to confrontation and an unfolding tragedy in the public arena. Whilst all these articles describe the complexity they offer little in terms of solutions. Is it possible to prevent future cases from degenerating into public dispute, or is it an inevitable consequence of modern medicine? Have we advanced to a point where children that would have succumbed now live, and so the focus of care has shifted towards how they live rather than if they live or die?
At least part of the solution should be a shift in focus shift toward prevention of conflict in these high stakes clinical areas rather than finding a remedy once conflict has occurred. This is not just about being better at communicating with families. Conflict prevention will require cultural change, the identification of early warning signs and the use of mediation to facilitate communication between parents and doctors at an early stage.
Communication is not just about what we say, but about how we act and the social networks that we live and work in. It was interesting that there was also an article on Family Integrated Care in the same issue of the journal (4). Patel and colleagues describe a new way of working in intensive care medicine, where parents are integrated into the clinical team as primary caregivers. They describe how cultural changes to clinical practice enhance the wellbeing of parents and reduce length of stay of their new-borns. Parental integration will surely improve communication between parents and staff. It reduces barriers to effective communication and creates a shared problem rather than adopting sides.
Despite everyone’s best efforts, there will be times when dissatisfaction and conflict arise. To prevent communication breakdown we should identify risk factors within the situation that would lead to early intervention. Forbat et al identified three distinct phases of escalation in paediatric conflicts from mild, through, moderate to severe.(5) The mild stage focussed on conflict triggers, for example, the inappropriate use of language, conflicting messages given to parents by clinical staff, staff making assumptions about parents and a history of previous unresolved conflict. Training clinical staff to recognise conflict early and use mediation skills to de-escalate and resolve it is another intervention. Six month follow up of a cohort of staff trained in one tertiary children’s hospital reported that 57% of respondents had experienced conflict in the six months following the training. Of these, 91% reported that the training had enabled them to de-escalate the conflict.(6) Formal testing of a framework for the early recognition and management of conflicts between families and health professionals is being undertaken by four tertiary hospitals in the UK later this year.
Only after these foundations are in place, where parents are empowered as part of the clinical team, and an open and safe environment for communication already exists, that local hospital review panels and clinical ethics committees and the courts may be able to help when complex clinical decisions need to be considered. These panels should be introduced as part of the wider clinical team. Doctors and parents should approach them together as a united front to listen to their deliberations.
It is vital that we learn how to prevent these high-profile cases from occurring again. There are no winners or losers in these situations, only victims and casualties: parents whose chance of coping with bereavement has been broken, and a career curtailing event for the doctors and nurses who cared for them. When parents and doctors are in conflict, once sides have been drawn the battle is lost. Changing the way that we work with families, mediation as routine practice, and the early identification of the warning signs of conflict is the only way to prevent this from happening again.
References
1. Wallis C. When paediatricians and families can’t agree. Arch Dis Child. 2018 May;103(5):413–4.
2. Wheeler R. Response to “When paediatricians and families can”t agree’. Arch Dis Child. 2018 May;103(5):410–1.
3. Lagercrantz H. Observations on the case of Charlie Gard. Arch Dis Child. 2018 May;103(5):409–10.
4. Patel N, Ballantyne A, Bowker G, Weightman J, Weightman S, Helping Us Grow Group (HUGG). Family Integrated Care: changing the culture in the neonatal unit. Arch Dis Child. 2018 May;103(5):415–9.
5. Forbat L, Teuten B, Barclay S. Conflict escalation in paediatric services: findings from a qualitative study. Arch Dis Child. 2015 Aug;100(8):769–73.
6. Forbat L, Simons J, Sayer C, Davies M, Barclay S. Training paediatric healthcare staff in recognising, understanding and managing conflict with patients and families: findings from a survey on immediate and. Arch Dis Child. 2017 Mar;102(3):250–4.
The story of Charlie, like that of the little Alfie, are events on which everything has been said, but without an adequate reflection on some basic principles that concern precisely the respect for life and the quality of care that daily thousands of health workers try to provide terminal patients. We can discuss for a long time what is best for the interest of the individual patient and family, but the value of the scientific method that constitutes the cornerstone of the medical profession can not be ignored.
Likewise it is the duty of the community to uphold the moral integrity of clinical practice by refusing to provide treatments that do not meet a reasonable scientific justification based on evidence of efficacy. Not thinking according to these principles are also betraying the dictates of the heart and not only those of a reasonable science, which should always be at the service of the patient's good, even in the face of death, in a society that should be defined as "civil".
If it is true that the heart has its reasons that reason does not know, it is the heart that, in the case of terminal children, makes the best choices.
He wrote anonymously one of the two hundred health care workers who followed Charlie: "We did not want to lose Charlie, but it was our legal and moral obligation, our job, to become his spokesman when it was time to say enough".
I read with great interest the article titled “Off-label use of tacrolimus in children with Henoch-Schönlein purpura nephritis: a pilot study” by Zhang et al.(1). To my great astonishment the authors did not discuss any of the studies published on the use of another calcineurin inhibitor Cyclosporine A (CyA) in the treatment of Henoch Schönlein purpura in children.
In the first chapter of the discussion section they refer to our report where we compared methylprednisolone pulse treatment (MP) and CyA in a randomized trial (2) stating that “Remission was achieved slowly and only in 53% of patients with methylprednisolone” (1).
I would like to draw the readers´s attention to the fact that in the same paper we showed that another calcineurin inhibitor i.e. CyA was by no means inferior to MP for the treatment of severe HSN (2). Indeed, CyA was even more efficacious than MP, since remission was achieved within 3 months in all CyA-treated patients (N=11) compared to 54% (7/13) in MP group (p=0.016). All the CyA treated patients responded to the treatment with no need for additional immunosuppressive therapy. In contrast, in MP group 6/13 (46%) needed additional immunosuppressive treatment. The remission rates in the MP treated patients were 85% (11/13) and 77% (10/13) after 1 and 2 years, respectively in contrast to 100 % in CyA-treated patients. The renal survival rate in the CyA group was 100%, as against 85% in the...
I read with great interest the article titled “Off-label use of tacrolimus in children with Henoch-Schönlein purpura nephritis: a pilot study” by Zhang et al.(1). To my great astonishment the authors did not discuss any of the studies published on the use of another calcineurin inhibitor Cyclosporine A (CyA) in the treatment of Henoch Schönlein purpura in children.
In the first chapter of the discussion section they refer to our report where we compared methylprednisolone pulse treatment (MP) and CyA in a randomized trial (2) stating that “Remission was achieved slowly and only in 53% of patients with methylprednisolone” (1).
I would like to draw the readers´s attention to the fact that in the same paper we showed that another calcineurin inhibitor i.e. CyA was by no means inferior to MP for the treatment of severe HSN (2). Indeed, CyA was even more efficacious than MP, since remission was achieved within 3 months in all CyA-treated patients (N=11) compared to 54% (7/13) in MP group (p=0.016). All the CyA treated patients responded to the treatment with no need for additional immunosuppressive therapy. In contrast, in MP group 6/13 (46%) needed additional immunosuppressive treatment. The remission rates in the MP treated patients were 85% (11/13) and 77% (10/13) after 1 and 2 years, respectively in contrast to 100 % in CyA-treated patients. The renal survival rate in the CyA group was 100%, as against 85% in the MP group (2). Several reports have shown that CyA is effective also as a rescue therapy for Henoch Schönlein nephritis when other treatments have failed (3-5). Faul et al. have suggested that the beneficial effect of CyA on proteinuria is not dependent on T-cell function, but rather results from stabilization of the actin cytoskeleton in the kidney podocytes (6).
2. Jauhola O, Ronkainen J,Autio-Harmainen H, et al. . Cyclosporine A vs methylprednisolone for Henoch-Schönlein nephritis: a randomized trial. Pediatr Nephrol 2011;26:2159-66.
3. Ronkainen J, Autio-Harmainen J, Nuutinen M. Cyclosporin A for treatment of severe Henoch-Schönlein glomerulonephritis. Pediatr Nephrol 2002;18:1138-42.
4. Someya T, Kaneko K, Fujinaga S, Ohtaki R, Hira M, Yamashiro Y. Cyclosporine A for heavy proteinuria in a child with Henoch-Schönlein purpura nephritis. Pediatr Int 2004;46:111-3.
5. Park J, Won S, Shin J, Yim H, Pai K (2010) Cyclosporin A therapy for Henoch-Schönlein nephritis with nephrotic-range proteinuria. Pediatr Nephrol 2010;26:411-7.
6. Faul C, Donnelly M, Merscher-Gomez S et al. The actin cytoskeleton of kidney podocytes is a direct target of the antiproteinuric effect of cyclosporine A. Nat Med 2008;14:931-938.
The evidence that nasal mask continuous positive airway pressure (CPAP) is better than bilateral, short nasal prong CPAP is convincing.1 However the evidence of benefit is only for short-term outcomes. I have significant concerns about using nasal mask CPAP continuously over many days in extremely preterm or extremely low birth weight infants. These babies have soft malleable skulls. We saw that this was a problem decades ago when small babies were primarily nursed with their head on the side; and subsequent dolichocephaly was very common as a result.2 The hat and straps needed to keep a mask in place put pressure on a baby's soft, malleable skull in a different way to the hat used during nasal prong CPAP. The long term effects of this pressure on boney development, particularly of the midface, are unknown, but they could be considerable. Because of these concerns I do not use nasal mask CPAP continuously. I alternate the use of masks with nasal prongs.
1. Kieran EA, Twomey AR, Molloy EJ, et al. Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics 2012;130:e1170–6.doi:10.1542/peds.2011-3548.
2. Ifflaender S, Rüdiger M, Konstantelos D, Wahls K, Burkhardt W. Prevalence of head deformities in preterm infants at term equivalent age. Early Human Development 2013;89(12):1041-1047.
I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.
Previous research:
CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]
I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.
Previous research:
CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]
Practical issues:
At the time of study onset, reliable POC tests were available for CRP only, providing test results within 4 minutes.[3, 4] As mentioned by Professor Blair in his e-letter, other tests such as the Brahms PCT-Q, a semi-quantitative point-of-care procalcitonin test, was available at the time, but required additional manipulation of the sample (centrifugation needed to obtain serum or plasma), a sample volume of 200µL (which was 133 times the volume used in the CRP point-of-care test (merely 1.5 µL, roughly a small drop of blood, especially useful in children)) and an incubation period of at least 30 minutes, which would not be manageable within a single acute care consultation. Therefore, it was not deemed suitable for application in our trial.
Study characteristics & findings:
In the present study, we only included children who were not referred by their general practitioner. Taking into account the organization of healthcare services in Belgium, children and parents may present to A&E directly or a consultant paediatrician of their choice, without the need for a letter of referral. This might explain why some children presented at an early stage of their illness to A&E services, potentially reducing the difference in patient spectrum between GP and hospital paediatric settings.
Furthermore, we found that children with a CRP between 20-75mg/L, should be assessed on seven features, including fever duration <1 day, which reflects the effect of disease onset on the CRP level.
In this particular CRP range, children could still have a serious infection if fever was only present for 1 day.
Conclusion:
Procalcitonin has been introduced as an earlier and more accurate diagnostic markers than currently available tests, however evidence of superior clinical accuracy in diagnosing serious infection in children in ambulatory care is still lacking.
I agree with Professor Blair that further prospective studies are needed to compare the clinical effectiveness of using point-of-care CRP and procalcitonin to guide clinical assessment in acute paediatric care.
REFERENCES
1. Van den Bruel A, Thompson M, Haj-Hassan T, et al. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011;342:d3082
2. Verbakel JY, Lemiengre MB, De Burghgraeve T, et al. Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial. BMC Med. 2016;14(1):131 doi: 10.1186/s12916-016-0679-2published Online First: Epub Date]|.
3. Minnaard MC, van de Pol AC, Broekhuizen BD, et al. Analytical performance, agreement and user-friendliness of five C-reactive protein point-of-care tests. Scand. J. Clin. Lab. Invest. 2013;73(8):627-34 doi: 10.3109/00365513.2013.841985published Online First: Epub Date]|.
4. Verbakel JY, Aertgeerts B, Lemiengre MB, De Sutter A, Bullens DM, Buntinx F. Analytical accuracy and user-friendliness of the Afinion point-of-care CRP test. J. Clin. Pathol. 2014;67:83 - 86
With great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
The algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show traine...
With great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
The algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show trainees how they can assess the pre-test probability for SI in acutely ill children without resorting to pricking children’s fingers to obtain their “inorganic” CRP value.
I assume that the authors' algorithm will function as insurance for children with suspected SI; however, debriefing and reflection by trainees and attending physicians alike after each patient encounter is essential even after implementing this technique.
References:
1. Verbakel JY, Lemiengre MB, DeBurghgraeve T, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-312384.
2. Williams HS and Zenel JA. Commentary: When Doing Less Is Best. Pediatr Rev. 2013;34;423-8.
3. Cornfield DN. Bronchiolitis: Doing Less and Still Getting Better. Pediatrics. 2014;133: e213-4.
4. Taylor JA. Oral rehydration: in pediatrics, less is often better. Arch Pediatr Adolesc Med. 2004;158:420-1.
I read the article with interest and wish to congratulate the authors for their genuine work on a little known subject.
However there are certain points which require elaboration:
(a) It is likely that there are independent genetic factors that are responsible for a baby being born SGA and the same factors may be playing a role in affecting cognitive outcomes.These factors have not been addressed in the study.
(b) Cognitive outcome of a child is the result of certain internal and certain extraneous factors (eg environmental stimulation).The extraneous factors may confound the results of the above study.
(c) Open heart surgery per se may be detrimental to the cognitive development of a child .But there are certain factors such as Bypass time,duration of mechanical ventilation,exposure to hypotensive milieu,etc that need to be explored in order to get an indepth insight into the subject.
To summarize, the article is a praiseworthy effort into a novel field which opens up potentials of further avenues of research.
I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders...
I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders that affect adults and children, the latter with a markedly heterogeneous range of seizure types, syndromes, causes, treatments and outcomes, all of which can be used to provide an individualised care plan. Failure to do so in certain situations might constitute discrimination against children with an epilepsy.
The authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.
References
1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
S. Rainbow, R. Wall and M. Blair
Is procalcitonin a discriminant marker of early
invasive bacterial infection in children?
Current Paediatrics (2003) 13, 399
2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from:...
The authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.
References
1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
S. Rainbow, R. Wall and M. Blair
Is procalcitonin a discriminant marker of early
invasive bacterial infection in children?
Current Paediatrics (2003) 13, 399
2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from: http://adc.bmj.com/lookup/doi/10.1136/archdischild-2016-310863.232
This study was published online in Archives of Disease in Childhood after peer review in September 2017. The trial tested the effectiveness of a neurolinguistic programming intervention (used widely but never formally tested) in children and young people with chronic fatigue recruited between 2010 and 2013. Though the number of participants was small, analysis suggested a benefit in terms of physical function (measured by the standard SF 36 scale) at both 6 and 12 months after intervention.
Since publication, the study has been criticised for failing to meet ICMJE and BMJ policy on trial registration and for not fully adhering to CONSORT guidance on trial reporting. The journal has been criticised for not detecting these issues during editorial and peer review. We have acknowledged these comments and reviewed our processes in relation to this paper and relating to EQUATOR guidance in general. In addition, we have received clarifications from the authors which are under editorial consideration.
I was interested to read the articles in this month’s journal exploring the difficulties of end of life decisions when parents and their doctors cannot agree.(1–3) These articles reflect the global media attention focused upon several recent tragic cases in the UK, where differences in view between parents and the clinical team led to confrontation and an unfolding tragedy in the public arena. Whilst all these articles describe the complexity they offer little in terms of solutions. Is it possible to prevent future cases from degenerating into public dispute, or is it an inevitable consequence of modern medicine? Have we advanced to a point where children that would have succumbed now live, and so the focus of care has shifted towards how they live rather than if they live or die?
At least part of the solution should be a shift in focus shift toward prevention of conflict in these high stakes clinical areas rather than finding a remedy once conflict has occurred. This is not just about being better at communicating with families. Conflict prevention will require cultural change, the identification of early warning signs and the use of mediation to facilitate communication between parents and doctors at an early stage.
Communication is not just about what we say, but about how we act and the social networks that we live and work in. It was interesting that there was also an article on Family Integrated Care in the same issue of the journal (4). Patel and colle...
Show MoreThe story of Charlie, like that of the little Alfie, are events on which everything has been said, but without an adequate reflection on some basic principles that concern precisely the respect for life and the quality of care that daily thousands of health workers try to provide terminal patients. We can discuss for a long time what is best for the interest of the individual patient and family, but the value of the scientific method that constitutes the cornerstone of the medical profession can not be ignored.
Likewise it is the duty of the community to uphold the moral integrity of clinical practice by refusing to provide treatments that do not meet a reasonable scientific justification based on evidence of efficacy. Not thinking according to these principles are also betraying the dictates of the heart and not only those of a reasonable science, which should always be at the service of the patient's good, even in the face of death, in a society that should be defined as "civil".
If it is true that the heart has its reasons that reason does not know, it is the heart that, in the case of terminal children, makes the best choices.
He wrote anonymously one of the two hundred health care workers who followed Charlie: "We did not want to lose Charlie, but it was our legal and moral obligation, our job, to become his spokesman when it was time to say enough".
I read with great interest the article titled “Off-label use of tacrolimus in children with Henoch-Schönlein purpura nephritis: a pilot study” by Zhang et al.(1). To my great astonishment the authors did not discuss any of the studies published on the use of another calcineurin inhibitor Cyclosporine A (CyA) in the treatment of Henoch Schönlein purpura in children.
In the first chapter of the discussion section they refer to our report where we compared methylprednisolone pulse treatment (MP) and CyA in a randomized trial (2) stating that “Remission was achieved slowly and only in 53% of patients with methylprednisolone” (1).
I would like to draw the readers´s attention to the fact that in the same paper we showed that another calcineurin inhibitor i.e. CyA was by no means inferior to MP for the treatment of severe HSN (2). Indeed, CyA was even more efficacious than MP, since remission was achieved within 3 months in all CyA-treated patients (N=11) compared to 54% (7/13) in MP group (p=0.016). All the CyA treated patients responded to the treatment with no need for additional immunosuppressive therapy. In contrast, in MP group 6/13 (46%) needed additional immunosuppressive treatment. The remission rates in the MP treated patients were 85% (11/13) and 77% (10/13) after 1 and 2 years, respectively in contrast to 100 % in CyA-treated patients. The renal survival rate in the CyA group was 100%, as against 85% in the...
Show MoreThe evidence that nasal mask continuous positive airway pressure (CPAP) is better than bilateral, short nasal prong CPAP is convincing.1 However the evidence of benefit is only for short-term outcomes. I have significant concerns about using nasal mask CPAP continuously over many days in extremely preterm or extremely low birth weight infants. These babies have soft malleable skulls. We saw that this was a problem decades ago when small babies were primarily nursed with their head on the side; and subsequent dolichocephaly was very common as a result.2 The hat and straps needed to keep a mask in place put pressure on a baby's soft, malleable skull in a different way to the hat used during nasal prong CPAP. The long term effects of this pressure on boney development, particularly of the midface, are unknown, but they could be considerable. Because of these concerns I do not use nasal mask CPAP continuously. I alternate the use of masks with nasal prongs.
1. Kieran EA, Twomey AR, Molloy EJ, et al. Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics 2012;130:e1170–6.doi:10.1542/peds.2011-3548.
2. Ifflaender S, Rüdiger M, Konstantelos D, Wahls K, Burkhardt W. Prevalence of head deformities in preterm infants at term equivalent age. Early Human Development 2013;89(12):1041-1047.
I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.
Previous research:
CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]
Practical...
Show MoreWith great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
Show MoreThe algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show traine...
I read the article with interest and wish to congratulate the authors for their genuine work on a little known subject.
However there are certain points which require elaboration:
(a) It is likely that there are independent genetic factors that are responsible for a baby being born SGA and the same factors may be playing a role in affecting cognitive outcomes.These factors have not been addressed in the study.
(b) Cognitive outcome of a child is the result of certain internal and certain extraneous factors (eg environmental stimulation).The extraneous factors may confound the results of the above study.
(c) Open heart surgery per se may be detrimental to the cognitive development of a child .But there are certain factors such as Bypass time,duration of mechanical ventilation,exposure to hypotensive milieu,etc that need to be explored in order to get an indepth insight into the subject.
To summarize, the article is a praiseworthy effort into a novel field which opens up potentials of further avenues of research.
I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders...
Show MoreThe authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.
References
1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
S. Rainbow, R. Wall and M. Blair
Is procalcitonin a discriminant marker of early
invasive bacterial infection in children?
Current Paediatrics (2003) 13, 399
2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from:...
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