140 e-Letters

published between 2015 and 2018

  • Kawasaki disease: is it time to consider the antiplatelet dose of aspirin even in the acute phase of the disease?

    The results of the British Paediatric Surveillance Unit survey show that aspirin in Kawasaki disease (KD) is used in the UK and Ireland at a medium dose of 30-50 mg/kg/day in the acute phase of the disease (1). The guidelines of the American Heart Association (AHA) of 2017 do not give a clear indication on what dose of aspirin should be used in the acute phase of KD, stating that "there are no data to suggest that one dose of aspirin is superior to the other" (3).
    However, a recent review of the evidence of literature on the use of aspirin in KD (3), clearly shows that, in conjunction with intravenous immunoglobulin, low-dose ASA (3-5 mg/kg/day) in acute KD is not inferior to high-dose ASA (80-100 mg/kg/day) for reducing the risk of coronary artery (CA) abnormalities, duration of fever, responsiveness to IVIG and time of hospitalization (3). These results supports using low-dose (3-5 mg/kg/day) aspirin in the acute phase of KD (3,4). These studies did not consider the concomitant use of steroid therapy, of which the guidelines of AHA do not define a standardized use (2).
    The question of which dose of ASA is used in the acute phase is relevant considering that aspirin treatment exposes a risk of gastrointestinal bleeding, hepatotoxicity and neurosensory hearing impairment and Reye syndrome, and that this effect is strictly dose dependent and related to duration of therapy (3).
    We believe that the time has come to reconsider and update the guideli...

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  • Correct target population for Palivizumab cost-utility analysis

    Dear authors,

    We are kindly observing that the study on hospitalizations for infection due to respiratory syncytial virus should be conducted on infants aged <1 year old [1], and not on infants aged <2 years old. Such a choice is motivated by medical literature and since the prescription of palivizumab on the general population of preterm infants is up to 1 year of age. Moreover, the study does not tightly classify the hospitalization depending on the gestational age, a lack of information that exclude the possibility of a punctual statistical analysis on the infants whose gestational age is between 29-35 weeks, population matter of the analysis, impacted by the AIFA reimbursement limitations.
    In the study infants aged <2 years old have been considered, the same subjects are statistically contributing to two consecutive seasons with different ages. The algebraic sum of the season 2014-2015 / 2015-2016 perpetuate the complexity of analysis of hospitalization for a specific season, if the infant is hospitalized in the season of his/her birth or next year.
    As reported by Medici et al. [2], respiratory syncytial virus infection has a 2-years evolution, with a less critical year following a year with more abundant virus diffusion. By algebraically summing the data from two consecutive years the seasonality, so the stochasticity, is lost. Eventually the season 2016-2017 appear to be the less critical season. Environmental and patient conditions such...

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  • Neonatal Outcome in Italy: a clinical point of view

    Dear authors, dear editors,

    We are writing to respond with our data, that, in the same region (Lazio), indicate a different pattern.
    We have focused on the patients that were previously eligible for palivizumab treatment (only preterm infants, with gestational age>29 weeks), in three different hospitals located in Rome.
    Please consider that the time frame is the year before and the year after of the AIFA reimbursement limitations, the same years where in Figure 1 of your manuscript you show higher hospitalizations before and lower hospitalizations after AIFA limitations.
    At the NICU Casilino Hospital (ref.A) we have noticed an increase in the number of bronchiolitis from the year before (6 bronchiolitis/35 children with 30-32WGA; 17%) to the year after limitations (12/47; 26%).
    At the Sapienza University of Rome we have registered an increase in hospitalizations for bronchiolitis in children with 30-36 WGA from 14 out of 165 hospitalizations (8.5%) during the 2015/16 season to 21/141 hospitalizations in the subsequent season (14.9%, p =0.05). Of them, respectively 8 (14%) and 13 (18.3%) were due to RSV, although the difference is not statistically significant. The total number of VRS+ increased significantly in the second year (ref.B).
    At the OPBG we have analysed only the data from the 2016/17 season and we have noticed a higher incidence of bronchiolitis in the late preterm (13 VRS+/27 children 30-37WGA, not treated with palivizuma...

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  • Resuscitation or maintenance?

    Having just read this article I am concerned about the terminology used as I am not sure it truly reflects the clinical problem posed. The article refers to "maintenance" fluids but the question asked relates more to “resuscitation” fluids.

    It is important to be clear as to the aim of treatment in the individual patient when prescribing fluids rather than just following a guideline. The paper debates the relative merits of 0.9% sodium chloride and balanced fluids as “maintenance” fluids. To my mind “maintenance” fluids are administered to patients who have a replete extracellular fluid (ECF) volume. If ECF volume is low then “resuscitation” fluids are required. “Maintenance” and “resuscitation” fluids have different roles and therefore might be expected to have different characteristics.

    As the article refers to “maintenance” fluids I will deal with these first. This fluid is needed to replicate the fluid that the patient would normally be drinking but for a variety of reasons may not be able to ingest. It should be differentiated in turn from "replacement" fluid which is the fluid given on top of the "maintenance" fluid when patients have fluid losses in excess of those normally anticipated. This includes diarrhoea, vomiting and fluid from surgical drains. The fluid used for "replacement" needs to match the composition and volume of the fluid being lost. Once "resuscitation" and "replacement" fluid...

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  • Antenatal ACP - the document that allowed us to be parents, not doctors.

    Thank you to the authors for bringing the concept of ACPs and their importance to the forefront for consideration in practice. Thankfully, I have never had to utilise one in my professional practice, but having recently been encouraged to use an antenatal ACP for our daughter, I would offer personal support to the intentions that they should be used in practice, when appropriate. Our daughter was given a terminal diagnosis antenatally, and the decisions that followed to prepare for her birth and her death would have been overwhelming and emotionally charged in the immediate aftermath and I can only assume that our journey would have looked very different without one. Instead, the decisions and plans were considered, they were controlled and they were based on our true wishes for our daughter and our family. As the authors relate too in their article, without the ACP there would have been significant likelihood that the decisions we made for our daughter would have been made ad-hoc, under emotional pressure, and the outcome of her peaceful and comfortable death, surrounded by her family and in our arms, would likely have not been as achievable. Furthermore, the authors comment that it guides healthcare providers and parents, in a structured manner to ensure needs and wishes are met and I could not agree more. I think much of the conversations that took place, would have taken place without the ACP document, but the concept as a whole encouraged timely discussions, e...

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  • Identification and prevention of respiratory problems linked to eating and drinking difficulties for children and young people with cerebral palsy.

    I welcome Himmelmann’s editorial concerning the prevention of respiratory problems for individuals with cerebral palsy1. As a speech and language therapist working within a multi-disciplinary nutrition team, I recognise the need to increase our understanding of the complex interactions between risk factors through collaboration across stakeholders. It is of particular concern that solids or liquids in the lungs or windpipe have been identified as the cause of death for almost a quarter of people with cerebral palsy2.

    With this in mind, we developed the Eating and Drinking Ability Classification System (EDACS) for people with cerebral palsy from age 3 years. EDACS classifies limitations to eating and drinking ability in 1 of 5 levels, replacing frequently used terms “mild”, “moderate” and “severe” which lack shared definition. Key features of “safety” and “efficiency” are used to determine 5 distinct levels of ability: from Level I Eats and drinks safely and efficiently through to Level V Unable to eat or drink safely – tube feeding may be considered to provide nutrition. EDACS demonstrated strong content validity and excellent inter-observer reliability when used by speech and language therapists3. EDACS is free to download from www.edacs.org along with sixteen completed translations. Ten other language translations are currently in process.

    Himmelmann1 points out associations between limitations to gross motor function and...

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  • Response to e-letter entitled: Importance of dermatology in paediatric vulval disease


    Thank you for the opportunity to reply, here is our response.

    We would like to thank the authors for their valuable comments, we believe that these comments add to and complement our article. Our article aimed to cover a wide breadth of common gynaecological conditions that can affect children and unfortunately we were therefore not able to go in to great detail for each condition covered. We would certainly agree on the importance of an early diagnosis for lichen sclerosus and collaboration with a dermatologist for treatment if available. The British Association of Dermatologists guidelines for the management of lichen sclerosus was not published when we wrote our article, we can see that this is a very valuable resource.

    Kind Regards

    Jo Ritchie

  • Importance of dermatology in paediatric vulval disease

    Dear Sir,

    We read with interest the review on ‘The paediatrician and the management of common gynaecological conditions’ (1). This is an important topic but we have concerns about incorrect information in this paper with respect to vulval disorders. Most vulval conditions are dermatological rather than gynaecological and the involvement of a dermatologist in the management of these children is vital. The breadth of paediatric vulval disease is not reflected in this paper including the concept of vulval presentation of various skin conditions (eg. psoriasis, chronic bullous dermatosis of childhood, erythema multiforme) and the need to examine the rest of the skin including the hair, nails and mucosa.

    There appears to be some confusion within the article, for example, a vaginal discharge is not a vulval disorder. While a discharge can lead to a vulvitis, the two problems of vaginitis and vulvitis should be distinguished as the investigation and management of each is very different.

    The commonest condition seen in children presenting with vulval symptoms is an irritant dermatitis which is not specifically mentioned in the section on vulval irritation. This is often seen in those with a background of atopy and requires emollients and a mild topical steroid application intermittently with good hygiene measures. Other important disorders such as Lipschutz ulcers and genital warts have been omitted.

    However, our major concerns relate to the section o...

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  • Editor's note

    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.

  • Prevention of conflict is better when there is no cure

    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...

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