eLetters

1513 e-Letters

  • Milk and respiratory problems. Why is the myth persisting over the facts? The power of information

    Authors (full names and academics degrees)
    • Laura Moreno-Galarraga1 MD PhD
    • Miguel Ángel Martínez-González2 MD PhD MPH
    • Diego Mauricio Peñafiel Freire3 MD
    • Elsie M Taveras4 MD MPH

    Affiliations
    1) Department of Pediatrics, Complejo Hospitalario de Navarra. IdisNa; Instituto de Investigación Sanitaria de Navarra, Health Research Institute of Navarra, Pamplona, Spain.
    2) Department of Preventive Medicine and Public Health, University of Navarra Pamplona, Spain. Dpt. Nutrition, Harvard TH Chan School of Public Health, Boston, MA. CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain.
    3) Department of Pediatrics, Complejo Hospitalario de Navarra, Pamplona, Spain
    4) Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.

    Dear Editor;

    We have read the article about myths, milk and mucus, and we couldn’t agree more.1 We have observed the prevalence of the same myth and the same concern that many parents are limiting their child’s consumption of dairy products or replacing milk with vegetable drinks, despite the current recommendations.2

    We conducted a study in 169 school-age children in Spain and we did not find any association between dairy products consumption (milk, cheese or yo...

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  • Palivizumab for children with Down syndrome: is the time right for a universal recommendation?

    We thank Drs Bok et al. for their comments on our recent editorial about the use of palivizumab in children with Down syndrome (DS).[1] However, most of their arguments are not pertinent to DS. First, they describe the general incidence of respiratory syncytial virus (RSV) in children aged <5years. Second, they discuss the efficacy of palivizumab based on the IMpact trial [2] that did not include children with DS. We provided concrete evidence from [3] metanalyses conducted in 1.1 million children with DS, that the risk of RSV-related hospitalisation (RSVH) is 6.1–8.7- fold higher than children without DS.1 Drs Bok et al. also fail to appreciate that the overall relative risk of RSVH without palivizumab, is 5.5-fold (95% CI 3.97 to 7.7) higher based on robust, high quality evidence.[3] In our previous study we also reported that for every 1000 children with DS with RSV there will be 200 more (95% CI,131-297) hospitalisations compared with 1000 children without DS with RSV (RR, 5.53; 95% CI,3.97-7.73; high GRADE).[4] Moreover, Drs Bok et al. have extrapolated the number needed to treat (NNT) with prophylaxis to prevent one RSVH in children with DS using sub-optimal data. In a prospective case-control, cohort study conducted in the Netherlands and Canada, the estimated NNT in children with DS, adjusted for confounding variables, is 12 and not 20.[5] This number also aligns with the report from the CARESS registry [6] and compares favourably with the NNT of 16 for preter...

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  • Comment to Response by M Nadeem to Letter ‘Meningococcal Meningitis Post-Infant Group B Meningococcal Immunisation’

    Dear Sir,

    We thank Dr Nadeem, for highlighting that the clinical features of drowsiness and infant focal seizures in our case report indicates that early treatment for viral/herpes encephalitis was an imperative.

    We would like to reassure Dr Nadeem that our infant did indeed receive a combination of early intravenous antiviral treatment (acyclovir) and antibiotics (cefotaxime and amoxicillin) and this was continued until final viral/bacterial PCR and CSF culture results were obtained. The use of acyclovir and amoxicillin was omitted from the original report due to word count limitations.

    Viral PCR tested was negative for a range of viruses including herpes simplex (HSV). Although PCR assay is an important diagnostic modality for viral encephalitis HSV, we would add that due to focal seizures, our infant case received investigations and treatment as per national (1) and local guidelines: immediate brain CT imaging was performed to exclude neurosurgical conditions, and a later cranial MRI scan did not show selective damage to the mesial temporal lobe structures or the hippocampus. In addition, an early electroencephalogram (EEG) was normal. The EEG severity and the presence of epileptic seizures at the initial presentation would be significant indicators for predicting the 6-month clinical outcome in patients with HSE.

    The seriousness of HSV CNS infections suggests that clinicians maintain a high index of suspicion to initiate evaluation under s...

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  • Response to letter re: ‘Improving newborn and infant screening’

    We thank Dr Cliona M Ni Bhrolchain  for her interest in our paper and her comments.  With the exceptions of newborn hearing and blood spot screening,  there is unacceptably wide variation at local level and a lack of commitment at national level in implementation and monitoring of preventive child health programmes.   We suggest that this is just one manifestation of a wider problem - the serious inadequacy of NHS investment  in leadership, education and training, both in general practice and in the specialties.  Morale is low and there are chronic shortages of staff with the relevant skills, when medicine is changing and public expectations rising faster than ever before. 

    David Hall and David Sowden (affiliations as on our original paper)

  • TRAMADOL: PATIENT SAFETY COMES FIRST IN CHILDREN

    I refer to the paper published by Palmer et al in Archives Diseases Childhood March 20181 that states the recommendation to avoid tramadol when breastfeeding and the contraindication to its use in children (including neonates) is inappropriate in their view. 1
    I disagree with the authors that tramadol is a safe for babies of breastfeeding mothers. Their conclusion, in my opinion, is premature and not adequately evidence-based. While they acknowledge, the US Food and Drug Administration (FDA) reported cases, they ignore the serious warnings by both Manufacturer and FDA about administering tramadol to children and breast-feeding mothers. There is increasing concern that narcotics used for treating pain in breastfeeding mothers may increase the risk of adverse effects in newborns, including excessive sedation and respiratory depression. The American Academy of Pediatrics (AAP), the FDA and the American College of Obstetricians and Gynecologists (ACOG) advocate against the use of codeine and tramadol in women who are breastfeeding because their babies may suffer adverse reactions, including excessive sleepiness, difficulty breathing, and potentially fatal breathing problems. 2-5 Patient safety should be foremost in our minds in making any recommendations that are contrary to Manufacturer, FDA, and AAP recommendations. It would be difficult to justify use of tramadol in a breastfeeding mother in the event of litigation arising from adverse effects of tramadol in the baby...

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  • Over-estimation of association between SUDIC and chronic conditions

    We welcome the paper by Verfurden et al1 on avoidable mortality from RTI and SUDIC with chronic conditions. We do not doubt the conclusion that chronic conditions are strongly associated with deaths from RTI, but disagree with the conclusion that chronic conditions are also associated with SUDIC or the need for changes to death certification.
    The study excludes deaths of infants less than 2 months old; however the peak age for unexplained infant deaths (classified as SIDS or unascertained) is 6 weeks. Data from England for the years 2004-10 show that 45% of unexpected infant deaths occurred prior to 2 months of age2, with the exception of those infants with congenital anomalies it is unlikely that these infants will have been diagnosed with a chronic condition by the time of death. Due to these issues, the study is likely to have significantly over-estimated the association of chronic conditions with SUDIC and we would invite the authors to revise their conclusion.
    The authors suggest that death registrations and hospital databases should categorise deaths as expected or unexpected to help identify potentially preventable deaths. Child Death Overview Panels in England review all deaths, determining modifiable factors; and these reviews are to be collated nationally by the new established National Child Mortality Database. A similar system of Child Death Reviews has already been recommended by the Scottish Government. It would seem more sensible to fully embrace...

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  • Palivizumab for children with Down syndrome: is the time right for a universal recommendation?

    In their editorial Paes and Mitra suggest that all patients with down syndrome (DS) <2 years should be considered to give palivizumab (Synagis®) to prevent respiratory syncytial virus (RSV) infection. We agree with the authors that DS children are at increased risk to develop RSV infections. However, we do not agree with their recommendation for palivizumab prevention in all DS children <2 years. In our opinion there is insufficient evidence on the efficiency and cost effectiveness and the recommendation is therefore premature.
    For the evaluation of preventive interventions the incidence and the absolute risk of acquiring the disease, and the effectiveness of the proposed intervention are important factors. The reported incidence of clinical relevant RSV infections in the general population in western countries is about 18/1,000 in newborns <2 months, 17/1,000 in children <6 months and 3/1,000 in children <5 years ( 2,3). Considering a relative extra risk of 5.5 in DS children (1) the calculated RSV incidence is 99/1,000 <2 months ( one out of 10) , 94/1,000 <6 months and 17/1,000 <5 years, respectively. The effectiveness of prevention of clinical treatment in premature children with palivizumab is about 50% (4). The extrapolated number needed to treat (NNT) for newborns with DS is 20 to prevent one hospitalization due to RSV infection. But what is the harm of this treatment as 19 out of 20 DS newborns will be given 114 injections per year...

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  • Relevance of specific HLA-DQ allelic components in the screening strategies for pediatric Celiac Disease

    We read with interest the recent article published by Binder E et al. [1], describing the HLA-DQ analysis performed in 1624 asymptomatic children affected with type I Diabetes Mellitus (DMT1), in order to assess their predisposition to develop Celiac Disease (CD). They reported that 1344 (82.8%) patients resulted to be "HLA-DQ2 and/or -DQ8 positive", whereas 280 (17.2%) were negative: among the former group, a biopsy-proven CD diagnosis was documented in 3.6% of cases and, interestingly, even 7 patients in the second group (corresponding to 2.5%) resulted to be celiac. [1]
    Thus, these two percentages are not so different and one might conclude that the HLA-DQ asset is not a necessary - even if not sufficient - genetic background, contrary to what is well known. [2] Indeed, the absence of alleles coding MHC-DQ2 and/or MHC-DQ8 heterodimers, is associated with an almost absolute negative predictive value with respect to CD. Therefore, in order to solve this apparent mismatch, it would be useful if the authors can show the complete and high-resolution HLA-DQA1 and, in particular, HLA-DQB1 typing: indeed, these 7 “HLA-DQ2 and/or -DQ8 negative” CD children may not carry all alleles coding any complete MHC-DQ2 and/or MHC-DQ8 molecule, but they may have one or two allelic variants conferring CD risk anyway, such as HLA-DQB1*02, which codes the beta chain of MHC-DQ2 heterodimer. Indeed, according to several studies, the isolate presence of one or two copies of this...

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  • The educational value of Saccades

    Many thanks for your response to the editorial ‘What are you looking at?’, which highlights some important principles for this extensively studied research area (despite being a relatively new field in healthcare) [1]
    Despite the emergence of new methods to analyse gaze behaviour terminology has not been revised to reflect scientific advances. A recent article by Hessels et al. outlined significant inconsistencies in the definitions of fixations and saccades held by eye movement researchers and highlighted the conceptual confusion surrounding these terms.[2]

    The term saccade is derived from the French for ‘jerk’. The phrase appears to have been coined by Emile Javal, a French ophthalmologist, in the 1800’s.[3] By 1916 it had been accepted into the English literature.[4]

    Saccades are frequently defined in the literature as rapid, ballistic movements of the eyes that abruptly change the point of fixation.5 Definitions have included;

    ‘Rapid eye movements used to voluntarily move gaze from one target of interest to another.’[6]

    ‘Ballistic movements, 20-150ms long, reaching a velocity up to 800°/s. They direct the eye so that external visual objects are projected onto the fovea.’[7]

    ‘Rapid eye movements used in repositioning the fovea to a new location in the visual environment.’[8]

    The term ballistic refers to the fact that the saccade-generating system cannot respond to subsequent changes in the position of a target during th...

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  • Improving newborn and infant screening

    Hall and Sowdon regret that the Newborn Infant Physical Examination (NIPE)/child health surveillance (CHS) programme fails to deliver improved outcomes for developmental dysplasia of the hip (DDH), contrasting with the success of other screening programmes. I would like to make some proposals for improvement.

    Current NIPE standards are focused on timeliness of the screening pathway and explicitly exclude treatment outcomes as ‘outside the screening pathway’1. Yet potential outcome measures are routinely available for three of the four NIPE screening programmes and shown to be measurable for two of these. McAllister et have demonstrated that records of surgical intervention for DDH can be used to show variation in outcomes2. Similarly, the NHS Atlas of Variation has demonstrated that age at orchidopexy can be used for undescended testis (UDT)3. Surgery for congenital cataract could be used in the same way. While I accept that definitions and actual measures might need some discussion to reach a national consensus, measuring these outcomes is possible from routine data.

    McAllister et al conclude that dedicated leadership of the DDH screening programme is associated with improved outcomes. This has also been shown for UDT4. Unfortunately, clinical leadership of the Healthy Child Programme (HCP) has been dismantled in recent years and the RCPCH recorded a community paediatric HCP lead in only 16% of services in 2015.

    Lastly poor outcomes may indicate...

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