eLetters

1527 e-Letters

  • Identifying paediatric sepsis: audit of the assessment of children aged

    Powell and Jeavons undertook a hospital-based audit(1) comparing the new guidelines for identifying paediatric sepsis(2) to previous cases that had attended the emergency department. By contrast, our recent sepsis audit investigating the assessment of under 5s with fever ≥37.5°C (before possible referral to hospital) was done in primary care.

    The National Institute for Health and Care Excellence (NICE) guidelines for sepsis assessment outlines four signs that should be recorded: temperature, pulse, respiratory rate and capillary refill time. An initial audit looking at compliance to these guidelines was conducted looking at data in computerised records from May 2014 – May 2018 at an inner-city general practice. Results showed that in only 15% of 111 consecutive consultations with feverish children aged <5 were all four signs recorded. More specifically, pulse was recorded in 81%, respiratory rate in 49%, and capillary refill time in only 32% of consultations.

    Following presentation of these findings to the general practitioners and practice nurses, a re-audit was undertaken assessing 48 consecutive consultations from June 2018 – June 2019. Results showed a slight improvement from 15% to 25% of consultations recording all four signs, with 94% of consultations recording pulse, 42% recording respiratory rate, and 50% recording capillary refill time.

    Powell and Jeavons have now created a simple ED paediatric sepsis pathway to minimise unnecessary inv...

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  • How many blind children in the world? – Author’s response

    We thank Dr Woodruff for the opportunity to ensure that the correct figure is being used for the burden of childhood blindness.

    As indicated in a correction(1) published alongside our original article,(2) the correct figure for the estimate of the global burden of childhood blindness is 1.4 million children.

    1. Solebo AL, Teoh L, Rahi J. Correction: Epidemiology of blindness in children Archives of Disease in Childhood 2017;102:995
    2. Solebo AL, Teoh L, Rahi J. Epidemiology of blindness in children Archives of Disease in Childhood 2017;102:853-857

  • A Bird in the Hand is worht (literally) Two in the Bush

    We thank Professor Connett for his ornithological expertise, the extent of which we had not previously realised. There is indeed a wealth of literature about psychological stress to mothers affecting foetal outcomes [1], and stress being associated with asthma attacks [2] and worsening the effects of allergen challenge [3], and the importance of addressing this is emphasised by ourselves and many others [4]. Acknowledging this in no way contradicts the need also to address refractory airway pathology by the reductionist approach we advocate [5]. A holistic approach to severe asthma deploying the skills of a multidisciplinary team is essential. Render unto Caesar the things that are Caeser’s.

    Andrew Bush
    Ian Pavord

    References
    1. Wright RJ, Visness CM, Calatroni A, Grayson MH, Gold DR, Sandel MT, et al. Prenatal maternal stress and cord blood innate and adaptive cytokine responses in an inner-city cohort. Am J Respir Crit Care Med. 2010; 182: 25-33.
    2. Sandberg S, Paton JY, Ahola S, McCann DC, McGuinness D, Hillary CR, Oja H. The role of acute and chronic stress in asthma attacks in children. Lancet. 2000; 356: 982-7.
    3. Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW. School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med. 2002; 165: 1062-7.
    4. Cook J, Beresford F, Fainardi V, Hall P, Housley G, Jamalzadeh A, Nightingale M, Winch D, Bush A, Fleming L, Saglani S. Managing the paediatr...

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  • 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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  • The canary might once have been a very stressed chick

    Professors Bush and Parvord usefully highlight key recommendations from their Lancet commission on asthma and acknowledge they are deliberately controversial. They accept the benefits of inhaled corticosteroids, but cite current shortcomings in meeting the needs of asthma sufferers as a reason to shift from a reductionist to a more detailed phenotyic approach to drive the development and use of new biological ‘precision medicines’.
    We do have a problem with our current approach and especially in the UK, which like the US, Australia and New Zealand, has an asthma death rate amongst adolescents at least three times higher than other European countries for which there is reliable data.1 However, emphasizing a need for basic science to focus on developing new drugs for specific patient groups, risks underestimating and misunderstanding the importance of psycho-social factors in determining all asthma phenotypes and especially those at risk of fatal asthma.
    Social and environmental factors are more than co-morbidities causing dysfunctional breathing and poor adherence to prescribed therapies. Systematic reviews and meta-analyses consistently show that pre-natal stress and stress in early childhood significantly increase the risk of subsequent wheeze and asthma.2 In prospective studies, depression in adults is associated with developing asthma and there are many studies demonstrating that anxiety can cause bronchoconstriction and lung inflammation.3,4 Mechanistic st...

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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.

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