I commend Dr Shield and colleagues for their 9 year-old
multidisciplinary obesity service for children and adolescents and I am
delighted that a bariatric surgeon is now part of the team. Longterm
results are still awaited to prove the benefits of this approach to weight
loss in teenagers, but short-term evidence is very promising as the
authors have pointed out.
I commend Dr Shield and colleagues for their 9 year-old
multidisciplinary obesity service for children and adolescents and I am
delighted that a bariatric surgeon is now part of the team. Longterm
results are still awaited to prove the benefits of this approach to weight
loss in teenagers, but short-term evidence is very promising as the
authors have pointed out.
I would like to describe my experience with bariatric surgery as a
'pure' paediatric surgeon in the hope that more of my colleagues will
become involved with their local childhood/adolescent obesity service. I
began to attend monthly 'adult' bariatric multidisciplinary team meetings
(MDTs) in my 5th year of SpR training in paediatric surgery in London.
This gave me an insight into the evaluation and selection process that
obese adults undergo prior to any procedure.
Since I finished my training in paediatric surgery in April last, and
with the support of my senior colleagues, I have combined locum
consultancy in paediatric surgery with a bariatric clinical fellow post
here in London. I organise the 'adult' MDTs, assess new patients
considering bariatric surgery, and follow up patients post-operatively in
clinic. I have assisted with 11 bariatric procedures to date (one in a 19
year-old) and there are 2 cases per week for the forthcoming months.
I have helped to establish a group of interested professionals at St.
George's to provide an adolescent obesity service much like the authors
describe. I have visited the adolescent bariatric units at Cincinnati
Children's hospital, New York University Medical Center and Lucille
Packard Children's Hospital in Stanford. Each centre was very welcoming
and helpful.
Everybody agrees that bariatric surgery should be offered to
teenagers within an MDT setting. Close co-operation with an 'adult'
service is essential for access to expertise and equipment. I urge
paediatric surgeons to be part of this process (particularly
Laparoscopists) and to attend their unit's obesity service meetings. If a
service does not exist, create one!
Yours respectfully,
Niall Jones MD FRCSI(Paed)
Bariatric Clinical Fellow and Honorary Consultant Paediatric Surgeon
Dear Experts,
What behaviour,symptoms, tests etc absolutely concluded that the children
were suffering from Asperger's and not the effects of emotional abuse?
If the children had Asperger's, would you expect their blood to have less
stress hormones than a similar child that was emotionally abused?
If the children were treated for Asperger's but actually were emotionally
abused, would you expect their behaviour/symptoms to...
Dear Experts,
What behaviour,symptoms, tests etc absolutely concluded that the children
were suffering from Asperger's and not the effects of emotional abuse?
If the children had Asperger's, would you expect their blood to have less
stress hormones than a similar child that was emotionally abused?
If the children were treated for Asperger's but actually were emotionally
abused, would you expect their behaviour/symptoms to become more
challenging and difficult?
Yours sincerely,
Tricia McGill
Although UK and international high income country practice has been
to recommend ceftriaxone or cefotaxime as first line therapy for the
initial treatment of paediatric sepsis, the US FDA has issued an alert (1)
that has led to changes in the US label for ceftriaxone (2). Due to
concerns regarding the potential for calcium chelation in vivo,
ceftriaxone must no longer be administered within 48 hours o...
Although UK and international high income country practice has been
to recommend ceftriaxone or cefotaxime as first line therapy for the
initial treatment of paediatric sepsis, the US FDA has issued an alert (1)
that has led to changes in the US label for ceftriaxone (2). Due to
concerns regarding the potential for calcium chelation in vivo,
ceftriaxone must no longer be administered within 48 hours of the
completion of infusions of calcium-containing solutions, including
parenteral nutrition, regardless of whether the drugs are administered by
different infusion catheters (1,2). In the UK, the current Drug Safety
bulletin (3) states that ceftriaxone must not be given simultaneously with
calcium-containing infusions.
We would therefore like to update the antibiotic recommendation made
in our meningococcal therapy guideline update published in the April 2007
edition of ADC (4) as follows: “Cefotaxime should be used as the first
line antibiotic in meningococcal sepsis due to the high incidence of
calcium replacement requirement in severe disease. However, ceftriaxone
may still be considered as first line therapy in children with clinical
meningitis, and for continuation of sepsis therapy after the acute phase
when calcium infusions are no longer required. Where children are admitted
for observation following cefotaxime for suspected sepsis and are
subsequently assessed as being well enough for discharge on ambulatory
intravenous antibiotics, the antibiotic may be changed to ceftriaxone
(where the once/day dose regimen may be of benefit) and the first dose
administered 8 hours following the last dose of cefotaxime given, assuming
no calcium containing infusions have been used or are planned.” The
Meningitis Research Foundation will be making appropriate changes to their
educational literature.
Yours faithfully,
Saul N. Faust, Andrew J. Pollard, Simon Nadel, Nelly Ninis and Michael
Levin
(1 http://www.fda.gov/cder/drug/InfoSheets/HCP/ceftriaxone.htm
(2) http://www.rocheusa.com/products/rocephin/rocephin-hcp-letter.pdf
(3) http://www.nelm.nhs.uk/Record%20Viewing/viewRecord.aspx?id=587080
(4) Pollard AJ, Nadel S, Ninis N, Faust SN, Levin M. Archives of Disease
in Childhood 2007;92:283-286
The Archimedes offering by Khashu and Balusubramaniam contains a
serious error as well as a somewhat eccentric spelling of gelofusine. They
suggest in their 'Clinical Bottom Line' (bullet point 3) that "Weak
evidence suggests and increased risk of necrotising enterocolitis with use
of Gelofuscine (sic) in neonates (Grade B)". In fact there is no such
evidence, weak or otherwise.
The Archimedes offering by Khashu and Balusubramaniam contains a
serious error as well as a somewhat eccentric spelling of gelofusine. They
suggest in their 'Clinical Bottom Line' (bullet point 3) that "Weak
evidence suggests and increased risk of necrotising enterocolitis with use
of Gelofuscine (sic) in neonates (Grade B)". In fact there is no such
evidence, weak or otherwise.
Analysis 05.11 in Osborn & Evans Cochrane review of 2004 (Khashu
& Balusbaramaniam's reference 1) shows no difference in the incidence
of NEC in infants treated with Gelofusine when compared with placebo.
Analysis 05.12 shows no difference in sepsis with Gelofusine compared with
no treatment. I would suggest that they have confused the evidence of
Analysis 06.11 which suggested that when Gelofusine was compared with
Fresh Frozen Plasma there was significantly less NEC in the FFP group -
however, Analysis 06.12 suggests that there was more sepsis in the FFP
group when compared with Gelofusine.
However, the true 'clinical bottom line' on this should be that
little can be read into this data - none of these comparisons were pre-
stated outcomes of the randomised studies whose data was subsequently
interrogated to produce these analyses. As the authors of the Cochrane
Review state - "The observations from one study that that infants who
received fresh frozen plasma had a lower incidence of NEC and a higher
incidence of sepsis shoud be treated with caution. The overall rate of
mortality and disability were not different between infants who received
FFP compared to no treatment in this study". Any data, if raked over by
means of a sufficient number of sub-analyses, will (misleadingly) yield
statistically significant results in the end.
Welcome as an article on this topic is in a high profile paediatric
journal I was disappointed by its contents, especially as a leading
article is often taken to be ‘flying the flag’ of what current opinion is
within the profession.
I agree fully that historical metaphors are useful and have a role in
the public understanding of children,whether sick or well, and also of
childhood.
Welcome as an article on this topic is in a high profile paediatric
journal I was disappointed by its contents, especially as a leading
article is often taken to be ‘flying the flag’ of what current opinion is
within the profession.
I agree fully that historical metaphors are useful and have a role in
the public understanding of children,whether sick or well, and also of
childhood.
However I am concerned that this article omitted mentioning a huge
amount of comparatively recent scholarship from the 1960’s onwards within
the history of childhood that readers of Archives should have been
informed about. For example, scholars such as Cooter and Steadman are not
discussed. [1,2]
The article restricts itself to metaphors from the nineteenth and
twentieth centuries ‘when the discipline of paediatrics was being
established’. It is now well recognised that within the United Kingdom
paediatrics commenced from the sixteenth century with Thomas Phare's ‘boke
of chyldren,’ (whose image is used by the RCPCH in the coat of arms).
Furthermore, there is growing scholarship to demonstrate children were
being admitted into hospitals from the eighteenth century. [3]
My concern is that this article has too limited a perspective and
should not be taken as indicative of the whole. It states that ‘metaphors
arose in the medical literature both in the United Kingdom and United
States’ but does not mention the long preceding and ongoing history of
metaphors relating to children and childhood. Metaphors of children being
in the image of God, or having Original Sin, the tabula rasa of Locke
(initially suggested by Willis - itself taken from Plato), Rousseau’s
Emile, the Romantic poets and the sentimalisation leading to
sanctification of childhood are all omitted.
The point should not have been that it is ‘time to acknowledge that
children and adults belong to the human race.’ Instead it should have been
to open the readerships’ eyes to the rich seam of historical metaphors
used in different ages and cultures to describe childhood. These metaphors
not only still have a role in informing us within our own practice but
also in enlightening Society as to what we do, for whose greater interest
as paediatricians, we serve.
References:
1] I. Ritzmann, ‘Children as Patients in German Speaking Regions in
the Eighteenth Century’, in A. Müller, Fashioning Childhood in the
Eighteenth Century (Ashgate, 2006).
2] R. Cooter (ed) In the Name of the Child (London, 1992).
3] C. Steedman, Childhood Culture and Class in Britain. Margaret
McMillan 1860-1932, (London, 1990).
Gillis and Loughlan make important points but, with respect, their
metaphor could be extended - with profit.
The limitations of clinical assessment, especially history taking and
symptom analysis, experienced by physicians attending infants and children
may also beguile those attending the elderly and younger adults with
learning difficulties. Furthermore even so-called competent adults may
behave in child like ways when...
Gillis and Loughlan make important points but, with respect, their
metaphor could be extended - with profit.
The limitations of clinical assessment, especially history taking and
symptom analysis, experienced by physicians attending infants and children
may also beguile those attending the elderly and younger adults with
learning difficulties. Furthermore even so-called competent adults may
behave in child like ways when they are ill and require some versatility
in approach to clinical assessment - which increasingly involves a third
party who may occupy the parental role with which we as physicians for
children are familiar. Hence the essential work of doctors - the
formulation of a diagnosis - uses tools which are generic, with some age
specific variations. The same applies to physiology, clinical pharmacology
etc. Perhaps adults are just large children - or maybe the distinction
should be abandoned in favour of a common humanity, evolving with age. In
that way any general difference in standards of clinical care between
"children" and "adults" would become impossible to justify. More specific
differences could be acceptable across the ages on a needs defined basis.
Hence "the totality of medical knowlege and experience" and care could
become universal.
It was my pleasure to read important notes on blood pressure in UK
children. I tried to see the chart but couldn't locate it. May I request
you to provide the chart for our reference?
We commend the authors for evaluating HPA axis in patients with
nephrotic syndrome. They have concluded that patients with good Synacthen
response have less relapse. However, most of the patients with good
Synacthen response were receiving Cyclosporin. Therefore, use of
Cyclosporin can be a confounding factor and the good nephrotic control may
be related in large part to the use of this drug. Low adrenocortical
suppressi...
We commend the authors for evaluating HPA axis in patients with
nephrotic syndrome. They have concluded that patients with good Synacthen
response have less relapse. However, most of the patients with good
Synacthen response were receiving Cyclosporin. Therefore, use of
Cyclosporin can be a confounding factor and the good nephrotic control may
be related in large part to the use of this drug. Low adrenocortical
suppression may have been an incidental correlate of the use of
Cyclosporin and not the factor responsible for the low relapse rate. To
overcome this confounding, sub-group analysis of patients on Cyclosporin
with and without adrenal suppression, can be used to look at the benefit
of low adrenocortical suppression. The conclusion drawn by the authors
that adrenocortical suppression increases the risk of relapse in patients
with nephrotic syndrome cannot be accepted without caution.
The article by de Louvois et al is very useful in quantifying the long-term effects on achievement of meningitis.1 It adds to their previous work,2, 3 and will be much appreciated by those advising parents of infants who have, or have had, bacterial meningitis; and it should also be useful to those planning for their education and longer-term health care.
The article by de Louvois et al is very useful in quantifying the long-term effects on achievement of meningitis.1 It adds to their previous work,2, 3 and will be much appreciated by those advising parents of infants who have, or have had, bacterial meningitis; and it should also be useful to those planning for their education and longer-term health care.
I suspect that the reason why little evidence is presented regarding the difference between the effects of different bacterial causes of meningitis is because the study was not sufficiently powerful to provide meaningful results. As a Consultant in Communicable Disease Control I was interested to note the signficance of E coli and other "coliform" infections, as all meningitis is "notifiable",4 but my impression is that we see relatively few such cases notified. In contrast, pneumococcal meningitis these is well established (by some of these authors among others) as being more likely to have serious sequelae than other bacterial meningitides, so its mention in the results section did not surprise me.
I recognise that it might not be possible to break down the outcomes by organism, as was done with the same cohort at five years after infection;2 but it would be even more useful if these data could be made available.
Peter English.
References:
1. de Louvois J, Harvey D, Halket S. The effect of meningitis in infancy on school-leaving examination results. Arch Dis Child 2007:adc.2006.105916 (http://adc.bmj.com/cgi/content/abstract/adc.2006.105916v1).
2. Bedford H, de Louvois J, Halket S, Peckham C, Hurley R, Harvey D. Meningitis in infancy in England and Wales: follow up at age 5 years. BMJ 2001;323(7312):533- (http://www.bmj.com/cgi/content/abstract/323/7312/533).
3. Baraff LJ, Lee SI, Schriger DL. Outcomes of bacterial meningitis in children: a meta-analysis. Pediatr Infect Dis J 1993;12(5):389-94.
4. Health Protection Agency. Notifications of Infectious Diseases (NOIDs). 2007;Accessed: 2007(24 October)(http://www.hpa.org.uk/infections/topics_az/noids/menu.htm).
We read with great interest the paper of Anderson and Gibb on the
pharmacodynamics (analgesia, antipyretic response) of paracetamol in
children [1]. It is hereby striking that even more than 100 years after
its discovery, clinical aspects on the use of this drug in children remain
to be unveiled.
We fully agree that the cerebospinal fluid time-concentration (CSF)
profile of paracetamol lik...
We read with great interest the paper of Anderson and Gibb on the
pharmacodynamics (analgesia, antipyretic response) of paracetamol in
children [1]. It is hereby striking that even more than 100 years after
its discovery, clinical aspects on the use of this drug in children remain
to be unveiled.
We fully agree that the cerebospinal fluid time-concentration (CSF)
profile of paracetamol likely more closely reflects the effect compartment
of this drug compared to the plasma compartment. A time delay exists
before drug reaches the effect compartment and the equilibration half-time
(Teq) between central and effect compartment is described by a single
first order parameter, and it reported as approximately 1 h for
paracetamol. These observations are of clinical relevance since the speed
of onset will therefore, as the authors explain, in part depend on the
absorption characteristics, the initial (loading) dose and the route of
administration. We however, would like to add two additional points of
potential clinical relevance.
Firstly, in addition to the oral or rectal route, an intravenous
formulation also became available and – although still much more limited
in number – studies on the pharmacokinetics and –dynamics of this
formulation in various paediatric age categories have been reported, in
part in this journal [2,3,4]. CSF kinetics following intravenous
administration in neonates and children hereby revealed a maximal
paracetamol CSF concentration 1 hour after intravenous bolus
administration, in line with the estimates on Teq mentioned earlier [5,6].
Intravenous administration might also improve prediction of concentration
compared to enteral formulations by elimination of plasma variability due
to absorption and relative bioavailability parameter variability.
Intravenous bolus administration may therefore provide better analgesia,
but this still needs to be proven.
Secondly, in the clinical setting, timing of administration can also
contribute to the effectiveness of paracetamol analgesia, especially when
pain (procedural, surgical intervention) is anticipated. When maximal
analgesia (e.g. at the end of general anesthesia for surgery) is aimed for
at a predefined time interval, paracetamol can be administered in advance.
This time delay will in part depend on the route of administration and
will be longer after rectal (90-120 min) compared to oral administration
(60 min).
We hope that the recent European initiative to stimulate clinical studies
in children and the establishment of research networks to perform these
clinical trials will improve the evidence on which medicines are used in
children, since this should result in the safer and more effective use of
medicines [7]. This even is true for frequently administered drugs like
paracetamol since still important issues on its use remain to be
determined.
References
1.Anderson BJ, Gibb IA. Paracetamol (acetaminophen) pharmacodynamics:
interpreting the plasma concentration. Arch Dis Child 2007 (online).
2.Allegaert K, Van der Marel CD, Pluim MAL et al. Pharmacokinetics of
single dose propacetamol in neonates: effect of gestational age. Arch Dis
Child Fetal Neonat Ed 2004; 89: F25-8.
3.Anderson BJ, Pons G, Autret-Leca E et al. Pediatric intravenous
paracetamol (propacetamol) pharmacokinetics: a population analysis.
Paediatr Anaesth 2005;15: 282-92.
4.Murat I, Baujard C, Foussat C et al. Tolerance and analgesic efficacy of
a new i.v. paracetamol solution in children after inguinal hernia repair.
Paediatr Anaesth 2005; 15: 663-70.
5.Allegaert K, Verbesselt R, Devlieger H, de Hoon J, Tibboel D.
Cerebrospinal fluid pharmacokinetics of intravenous propacetamol in a
former preterm infant. Br J Clin Pharmacol 2004;57: 224-5.
6.Kumpulainen E, Kokki H, Halonen T, Heikkinen M, Savolainen J, Laisalmi
M. Paracetamol (acetaminophen) penetrates readily into the cerebrospinal
fluid of children after intravenous administration. Pediatrics 2007;119:
766-71.
7.Choonara I. Improving children’s medicines. Arch Dis Child 2006;91: 550-
1.
Correspondence to:
K Allegaert, MD PhD
Neonatal Intensive Care Unit
Department of Woman and Child
University Hospitals, campus Gasthuisberg
Herestraat 49
3000 Leuven, Belgium
karel.allegaert@uz.kuleuven.ac.be
tel: 00-32-16-343850
fax: 00-32-16-343209
Dear Editor,
I commend Dr Shield and colleagues for their 9 year-old multidisciplinary obesity service for children and adolescents and I am delighted that a bariatric surgeon is now part of the team. Longterm results are still awaited to prove the benefits of this approach to weight loss in teenagers, but short-term evidence is very promising as the authors have pointed out.
I would like to describe...
Dear Experts, What behaviour,symptoms, tests etc absolutely concluded that the children were suffering from Asperger's and not the effects of emotional abuse? If the children had Asperger's, would you expect their blood to have less stress hormones than a similar child that was emotionally abused? If the children were treated for Asperger's but actually were emotionally abused, would you expect their behaviour/symptoms to...
Dear sir,
Although UK and international high income country practice has been to recommend ceftriaxone or cefotaxime as first line therapy for the initial treatment of paediatric sepsis, the US FDA has issued an alert (1) that has led to changes in the US label for ceftriaxone (2). Due to concerns regarding the potential for calcium chelation in vivo, ceftriaxone must no longer be administered within 48 hours o...
Sir,
The Archimedes offering by Khashu and Balusubramaniam contains a serious error as well as a somewhat eccentric spelling of gelofusine. They suggest in their 'Clinical Bottom Line' (bullet point 3) that "Weak evidence suggests and increased risk of necrotising enterocolitis with use of Gelofuscine (sic) in neonates (Grade B)". In fact there is no such evidence, weak or otherwise.
Analysis 05.11 in...
Welcome as an article on this topic is in a high profile paediatric journal I was disappointed by its contents, especially as a leading article is often taken to be ‘flying the flag’ of what current opinion is within the profession.
I agree fully that historical metaphors are useful and have a role in the public understanding of children,whether sick or well, and also of childhood.
However I am concern...
Gillis and Loughlan make important points but, with respect, their metaphor could be extended - with profit. The limitations of clinical assessment, especially history taking and symptom analysis, experienced by physicians attending infants and children may also beguile those attending the elderly and younger adults with learning difficulties. Furthermore even so-called competent adults may behave in child like ways when...
Respected Sir,
It was my pleasure to read important notes on blood pressure in UK children. I tried to see the chart but couldn't locate it. May I request you to provide the chart for our reference?
Thank you very much.
With best regards,
Sincerely, Dr. Narayan Bahadur Basnet
We commend the authors for evaluating HPA axis in patients with nephrotic syndrome. They have concluded that patients with good Synacthen response have less relapse. However, most of the patients with good Synacthen response were receiving Cyclosporin. Therefore, use of Cyclosporin can be a confounding factor and the good nephrotic control may be related in large part to the use of this drug. Low adrenocortical suppressi...
The article by de Louvois et al is very useful in quantifying the long-term effects on achievement of meningitis.1 It adds to their previous work,2, 3 and will be much appreciated by those advising parents of infants who have, or have had, bacterial meningitis; and it should also be useful to those planning for their education and longer-term health care.
I suspect that the reason why little evidence...
Dear editor,
We read with great interest the paper of Anderson and Gibb on the pharmacodynamics (analgesia, antipyretic response) of paracetamol in children [1]. It is hereby striking that even more than 100 years after its discovery, clinical aspects on the use of this drug in children remain to be unveiled.
We fully agree that the cerebospinal fluid time-concentration (CSF) profile of paracetamol lik...
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