We read with great interest recent study by Vergnano et al.1 investigating the epidemiology, age at infection, clinical characteristics, and outcome of listeria infection in the young infant. We congratulate the authors on providing a novel and interesting study that is relevant to the UK population and agree that the empirical use of amoxicillin in the paediatric infant should be reconsidered given the conclusions of their data.
However, when considering how we might be able to incorporate your novel findings into our centres practice, we required further clarification on table 2. The table describes increased oxygen requirement/respiratory support in 2/27 infants and yet, within results, report a prevalence of increased oxygen requirement/respiratory support of 89%. Furthermore, hypotension requiring inotropes is reported to occur in 4/27 infants but has a reported prevalence of 115%. These reported data appear to be miscalculated.
Clinical identification of invasive listeriosis through the understanding of symptoms within the infant is a key finding of this study given its poor description within the current literature2. We conducted a focused literature search and found scarce information on infant symptom prevalence; one notable exception includes the MONALISA study by Charlier et al.3 which recorded detailed clinical features (appendix p 21). Early diagnosis of invasive listeriosis has been demonstrated to have key prognostic value...
We read with great interest recent study by Vergnano et al.1 investigating the epidemiology, age at infection, clinical characteristics, and outcome of listeria infection in the young infant. We congratulate the authors on providing a novel and interesting study that is relevant to the UK population and agree that the empirical use of amoxicillin in the paediatric infant should be reconsidered given the conclusions of their data.
However, when considering how we might be able to incorporate your novel findings into our centres practice, we required further clarification on table 2. The table describes increased oxygen requirement/respiratory support in 2/27 infants and yet, within results, report a prevalence of increased oxygen requirement/respiratory support of 89%. Furthermore, hypotension requiring inotropes is reported to occur in 4/27 infants but has a reported prevalence of 115%. These reported data appear to be miscalculated.
Clinical identification of invasive listeriosis through the understanding of symptoms within the infant is a key finding of this study given its poor description within the current literature2. We conducted a focused literature search and found scarce information on infant symptom prevalence; one notable exception includes the MONALISA study by Charlier et al.3 which recorded detailed clinical features (appendix p 21). Early diagnosis of invasive listeriosis has been demonstrated to have key prognostic value in the literature4. Consequently, we submit that clearly described clinical presentations, and an understanding of their respective prevalence, could reduce the high mortality associated with invasive listeriosis3 and improve patient outcomes in the future.
Given the relative lack of understanding and the debate within the literature relating to the symptomatic presentation and clinical picture of listeria infection in the infant, especially in a UK population, your article has the potential to clarify clinical signs of useful predictive value. We would be very grateful for clarification on this matter to incorporate into our own practice.
References
1. Vergnano S, Godbole G, Simbo A, et al. Listeria infection in young infants: results from a national surveillance study in the UK and Ireland. Archives of Disease in Childhood 2021;106(12):1207-10. doi: 10.1136/archdischild-2021-321602
2. de Noordhout CM, Devleesschauwer B, Angulo FJ, et al. The global burden of listeriosis: a systematic review and meta-analysis. The Lancet Infectious Diseases 2014;14(11):1073-82. doi: https://doi.org/10.1016/S1473-3099(14)70870-9
3. Charlier C, Perrodeau É, Leclercq A, et al. Clinical features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. The Lancet Infectious Diseases 2017;17(5):510-19. doi: https://doi.org/10.1016/S1473-3099(16)30521-7
4. Hof H. An update on the medical management of listeriosis. Expert Opinion on Pharmacotherapy 2004;5(8):1727-35. doi: 10.1517/14656566.5.8.1727
re Diagnosing urinary tract infection in children: time to ditch the pad?
Harkensee C, Clennett J, Wilkinson S, et al
Arch Dis Child 2021; 106: 935-936
We read with interest the article by Harkensee et al, (1) suggesting that the urinary collection pad (UCP) no longer had a role in obtaining samples for diagnosis of urinary tract infections (UTI). Whilst it is well established that there is an unacceptably high rate of contamination with UCPs making them unsuitable for microbiological culture, and that the preferred (non-invasive) method for obtaining a sample for culture is by 'clean catch' +/- stimulation or Quick-Wee method, we would suggest that the UCP has a role in screening for UTI, by dipstick analysis of the aspirated pad sample for leucocyte esterase (LE) and nitrites (2). It would be useful, in a paediatric 'acute referral clinic' or Emergency Department, in infants or children, with non-specific abdominal pain, or fever without a focus, where a combination of a negative test for both LE and nitrites can be reasonably used to exclude UTI, and equally a positive LE and nitrite result would indicate a high likelihood of a UTI and the need to obtain a 'clean catch' or catheter specimen for microbiological analysis (3). The advantages of the UCP are that it allows 'point of care' dipstick analysis with inf...
re Diagnosing urinary tract infection in children: time to ditch the pad?
Harkensee C, Clennett J, Wilkinson S, et al
Arch Dis Child 2021; 106: 935-936
We read with interest the article by Harkensee et al, (1) suggesting that the urinary collection pad (UCP) no longer had a role in obtaining samples for diagnosis of urinary tract infections (UTI). Whilst it is well established that there is an unacceptably high rate of contamination with UCPs making them unsuitable for microbiological culture, and that the preferred (non-invasive) method for obtaining a sample for culture is by 'clean catch' +/- stimulation or Quick-Wee method, we would suggest that the UCP has a role in screening for UTI, by dipstick analysis of the aspirated pad sample for leucocyte esterase (LE) and nitrites (2). It would be useful, in a paediatric 'acute referral clinic' or Emergency Department, in infants or children, with non-specific abdominal pain, or fever without a focus, where a combination of a negative test for both LE and nitrites can be reasonably used to exclude UTI, and equally a positive LE and nitrite result would indicate a high likelihood of a UTI and the need to obtain a 'clean catch' or catheter specimen for microbiological analysis (3). The advantages of the UCP are that it allows 'point of care' dipstick analysis with information to guide clinical decision-making immediately, is passive with minimal parental effort and disruption to the child, there is less likelihood of missing a sample (compared with 'clean catch') and is the preferred collection method of parents.
Perhaps, it's not time to ditch the pad: pads have a place!
Mervyn S Jaswon
James Diviney
Dept of Paediatrics, Whittington Hospital, London1.Diagnosing urinary tract infection in children: time to ditch the pad?
1.Diagnosing urinary tract infection in children: time to ditch the pad?
Clennett J, Wilkinson S, et al Arch Dis Child 2021; 106: 935-936
2. Urine collection methods and dipstick testing in non-toilet-trained children.
Diviney J, Jaswon M S, Pediatric Nephrology 2021; 36; 1697-1708
3. Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of UTI in children: a systematic review and economic model.
Whiting P, Westwood M, et al HEalth Technol Assess 10:iii-iv, xi-xiii" "
We read with interest the paper by Baines and Colleagues [1] in which
the authors reported a strong inverse relationship between total serum
calcium concentrations and disease severity in 70 critically ill children
with meningococcal disease. Calcitonin concentrations were measured in a
subgroup of 23 children on admission, and significantly correlated with
disease severity. In particular, however, the...
We read with interest the paper by Baines and Colleagues [1] in which
the authors reported a strong inverse relationship between total serum
calcium concentrations and disease severity in 70 critically ill children
with meningococcal disease. Calcitonin concentrations were measured in a
subgroup of 23 children on admission, and significantly correlated with
disease severity. In particular, however, the authors found no relation
between calcitonin concentrations and total or ionised calcium
concentrations.
In a study of 69 adult patients with acute pancreatitis,[2] we have
similarly found no correlation between plasma concentrations of calcitonin
precursors (CTpr) on admission[2] and both the admission and lowest
(within 72 hours of admission) adjusted total serum calcium concentrations
(data unpublished before). The concentrations of CTpr were significantly
higher[2] and of the lowest calcium were significantly lower [median
(IQR): 2.16 (2.0-2.18) mmol/l vs. 2.23 (2.15-2.30) mmol/l, p=0.017] in
patients with severe attacks (n=14, Atlanta criteria) compared with mild
attacks.
Our data and that of Baines and colleagues[1] support the contention that
calcitonin and its precursors have a minor effect on calcium metabolism.
Indeed, previous investigators found no correlation between the serum
concentrations of serum calcitonin and hypocalcaemia in patients with
acute pancreatitis[3,4] or in experimental models of the disease.[5]
Whilst CTpr concentrations were reported to rise significantly in
critically ill patients, they correlated rather weakly with a concomitant
fall in serum ionised calcium.[6] A rise in CTpr concentrations did not
correlate with the fall in serum calcium concentrations in patients with
acute malaria.[7] This suggests that factors other than calcitonin and
CTpr are involved in the homeostasis of calcium in the critically ill.
References
(1) Baines PB, Thomson AP, Fraser WD, Hart CA. Hypocalcaemia in severe meningococcal infections. Arch Dis Child 2000;83:510-3.
(2) BJ Ammori, KL Becker, P Kite, et al. Calcitonin precursors in the prediction of severity of acute pancreatitis on the day of admission. Br J
Surg (in press).
(3) Robertson GM Jr, Moore EW, Switz DM, Sizemore GW, Estep HL. Inadequate parathyroid response in acute pancreatitis. N Engl J Med 1976;294:512-6.
(4) Gillquist J, Larsson J, Sjodahl R. Serum calcitonin in acute
pancreatitis in man. Scand J Gastroenterol 1977;12:21-5.
(5) Izquierdo R, Bermes E Jr, Sandberg L, Saxe A, Oslapas R, Prinz RA.
Serum calcium metabolism in acute experimental pancreatitis. Surgery 1985;98:1031-7.
(6) Muller B, Becker KL, Kranzlin M, et al. Disordered calcium homeostasis
of sepsis: association with calcitonin precursors. Eur J Clin Invest
2000;30:823-31.
(7) Davis TM, Assicot M, Bohuon C, St John A, Li GQ, Anh TK. Serum
procalcitonin concentrations in acute malaria. Trans R Soc Trop Med Hyg
1994;88:670-1.
Thank you authors, for recommending valuable guidelines for
disclosure of diagnosis. I believe they are really useful however I do
feel presence of infants at the time of disclosure of the diagnosis is
good practice but I would like to suggest caution because most of the
times then, the parents are distracted by them and pay most of their
attention in caring for them and making sure they are comfortable. I feel
this mak...
Thank you authors, for recommending valuable guidelines for
disclosure of diagnosis. I believe they are really useful however I do
feel presence of infants at the time of disclosure of the diagnosis is
good practice but I would like to suggest caution because most of the
times then, the parents are distracted by them and pay most of their
attention in caring for them and making sure they are comfortable. I feel
this makes the parents less likely to take in all the information
delivered by the clinician and at times the interview could also be
interrupted by infants at a critical juncture.
I am also not sure about the effects of breaking bad news infront of
the babies if they see their parents distressed or tearful, as could be
the case or how much they could understand whats going on?
Further, I would also like to suggest that any junior doctors who may
not have a clear role in future management but who had a significant role
in the previous management of the infant could be allowed to be present at
the time of disclosure as it may well be the case that parents are
familiar with the junior doctor more than the consultant and this would
also be a useful training experience for the junior doctors.
The paper by Cappendijk and Hazebroek[1] successfully demonstrates
the problems with diagnosis of appendicitis in the young child.
It makes the important point that diarrhoea may be a feature of
appendicitis and lead to misdiagnosis. In addition, children can have
coexisting pathologies leading to delayed diagnosis. We have seen a cystic
fibrosis child with DIOS (distal intestinal obstruction...
The paper by Cappendijk and Hazebroek[1] successfully demonstrates
the problems with diagnosis of appendicitis in the young child.
It makes the important point that diarrhoea may be a feature of
appendicitis and lead to misdiagnosis. In addition, children can have
coexisting pathologies leading to delayed diagnosis. We have seen a cystic
fibrosis child with DIOS (distal intestinal obstruction syndrome) and
appendicitis. Urinary tract infection and appendicitis can also occur
together.
Children with communication problems and learning difficulties are
another high risk group for delay in diagnosis.
The differential diagnosis of appendicitis is large[2] and a child
who presented with abdominal pain and subsequently had appendectomy need
not necessarily have suffered from appendicitis. We would be interested to
know whether the histopathological results were in agreement with clinical
diagnosis.
References
1. Cappendijk VC, Hazebroek FWJ. The impact of diagnostic delay on
the course of acute appendicitis. Arch Dis Child 2000;83:64-6
2. Hutson JM, Woodward AA and Beasley SW. Jones' Clinical Paediatric
Surgery - Diagnosis and management. Blackwell Science Asia publications.
Fifth Edition. 1999;Chapter 20:page 142.
We read with interest the study and recommendations by Brogan and
colleagues (Arch Dis Child 2000;83:506-507). We agree with them on a
number of issues and wish to draw attention to the following points.
(1) Previous international studies do not support a temperature of
>37.4oC as an inclusion criteria of significant fever for significant bacterial sepsis (SBS).[1][2] A minimum tempe...
We read with interest the study and recommendations by Brogan and
colleagues (Arch Dis Child 2000;83:506-507). We agree with them on a
number of issues and wish to draw attention to the following points.
(1) Previous international studies do not support a temperature of
>37.4oC as an inclusion criteria of significant fever for significant bacterial sepsis (SBS).[1][2] A minimum temperature of
38oC for 0 to 2 month old and 39oC for 3-36 month old children is recognised as an indicator of SBS. Hypothermia may also be significant. In children older than 3 years, the highest recorded temperature of 40oC or more in association with other
parameters may be more significant. Interestingly, in their own series, 4/5 with SBS had temperatures of 38.9 to 40.4oC. We propose
that a temperature of at least 38oC should be considered as significant fever.
(2) Lethargy has been mentioned as one of the diagnostic criteria of SBS.
As a diagnostic criterion, it should be defined more objectively rather
than as proposed by the authors. It may be defined as "a
level of consciousness characterised by poor or absent eye contact or as
the failure of a child to recognise parents or caregivers or to interact
with persons or objects in the environment."[3]
(3) Although we fully agree with the cautious interpretation of total WBC
count in relation to serious sepsis, we would like to mention the
importance of absolute neutrophil count (ANC) more than 10000/microlitre, especially in pneumococcal and to some extent in meningococcal sepsis. ANC
of more than 10000 has 76% sensitivity, 78% specificity and 99.2% negative
predictive value in pneumococcal sepsis.[4]
(4) The term toxic needs to be defined as a clinical picture consistent
with a varied constellation of lethargy, poor perfusion or marked
hypo/hyperventilation.[3]
We therefore suggest that the aide-memoir of significant bacterial sepsis
should be modified from ILL to ILLNESS: Irritability, Lethargy, Low capillary refill, Neutrophilia/Neutropenia, Elevated (or low) temperature suggests Significant Sepsis.
Dr S Mukherjee
Senior House Officer
Dr L Patel
Senior Lecturer and Honorary Consultant
References
(1) Baker MD. Evaluation and management of infants with fever. Pediatr Clin North Am 1999;46:1061-72.
(2) McCarthy PL, Lembo RM, Fink HD, Baron MA, Cicchetti DV. Observation, history and physical examination in diagnosis of serious illness in febrile children of less than or equal to 24 months. J Pediatr 1987;110:26-30.
(3) Baraff Lj, BassJW, Fleisher RF, Klein JD, McCracken GH, Powel KR, Schringer DL. Practice guideline for management of infants & children 0-36 months of age with fever without focus. Pediatrics 1993;92:1-12.
(4) Kuppermann N, Fleisher GR, Jaffe DM. Predictor of occult pneumococcal bacteremia in young febrile children. Ann Emerg Med 1998;31:679-87.
In reply to the comments by Yim Yee Chan and R Lakshman in which they
ask if all patients truely suffered from appendicitis in our study group.
The answer is that histopathological investigation confirmed the diagnosis
appendicitis in all cases.
Yours sincerely,
VC Cappendijk, MD and FWJ Hazebroek, MD, PhD
Department of Paediatric Surgery, Sophia Children's Hospital...
In reply to the comments by Yim Yee Chan and R Lakshman in which they
ask if all patients truely suffered from appendicitis in our study group.
The answer is that histopathological investigation confirmed the diagnosis
appendicitis in all cases.
Yours sincerely,
VC Cappendijk, MD and FWJ Hazebroek, MD, PhD
Department of Paediatric Surgery, Sophia Children's Hospital University
Hospital Rotterdam The Netherlands
The treatment of childhood asthma is controversial: although
oral glucocorticoid treatment in children with asthma was
associated with clinical improvement.[1] There are concerns
about corticosteroids, since stopping drug treatment in
children with asthma results in clinical deterioration,[2]
or in the return of bronchial hyperresponsiveness within two
weeks,[3] with the obvious conclusion that the nat...
The treatment of childhood asthma is controversial: although
oral glucocorticoid treatment in children with asthma was
associated with clinical improvement.[1] There are concerns
about corticosteroids, since stopping drug treatment in
children with asthma results in clinical deterioration,[2]
or in the return of bronchial hyperresponsiveness within two
weeks,[3] with the obvious conclusion that the nature of
drug treatment is suppressive rather than curative. More
importantly, despite prednisolone treatment in acute asthma,
reduction of symptoms and normalisation of pulmonary
function there is evidence of continuing airway inflammation .[1]
However such negative results could be greatly reduced
if more and more pediatricians adopted the practice of
prescribing reduced doses.[4,5] Using the lowest possible
dose and/or alternate-day dosing appears to be safer,[4]
and growth rates[4] and endocrine and lung function return
to normal.[5]
To reduce the risk of systemic effects, it
has been suggested to prefer long acting drugs and start
treatment at 3 PM, since there are no differences compared
to qid dosing, nor influences on 24-h cortisolemia and
cortisoluria.[6]
Completely ignored[1] or disregarded[7] is the issue of
specific immunotherapy (SIT) in children. We have recently
demonstrated that 27/29 (93,1%) controlled studies in 2.042
children and as many controls have shown the effectiveness
of SIT in pediatric age in the treatment of asthma due to
pollens, house dust mites (Der p), epidermal derivatives,
and moulds (p<_0.0001.8 in="in" all="all" studies="studies" the="the" children="children" of="of" control="control" groups="groups" were="were" treated="treated" with="with" available="available" drugs="drugs" and="and" cared="cared" for="for" by="by" their="their" doctors="doctors" as="as" study="study" group.="group." therefore="therefore" _931="_931" have="have" confirmed="confirmed" sit="sit" positive="positive" influence="influence" on="on" natural="natural" history="history" a="a" total="total" remission="remission" asthmatic="asthmatic" symptoms="symptoms" who="who" regularly="regularly" completed="completed" cycle.8="cycle.8" addition="addition" severe="severe" adverse="adverse" reactions="reactions" during="during" are="are" almost="almost" non="non" existent="existent" children.9p="children.9p"/>
From an immunological point of view, oral glucocorticoid
treatment in the children with asthma was associated with
significant reductions in serum concentrations of IL-5,
sCD25, and ECP. However, serum concentrations of IL-5,
sCD25, and ECP remained significantly higher than in
controls, even after treatment with oral glucocorticoids
(p=0.03).[1] Regarding SIT, allergen-induced, in vitro
production of certain cytokines such as IL-4 and IL-10
decreased after SIT; IL-13 (which can induce IgG4 and IgE
antibody production by B cells) increased after SIT.[10]
Therefore IL-13 might play an important role in the
generation of IgG4-blocking antibody during SIT.[10] More
consistent with the reversal of Th2 T cells and associated
cytokines (IL-4 and IL-5) into TH1 T cells and Th1-like
cytokines (IL-2 and IFN-gamma) is the production of IL-12.[11] Thus, the potential ability to shift the Th1/Th2
balance of immune response to allergens creates a favourable
cytokine microenvironment to suppress the allergic reaction
in the asthmatic airway.[12] Accordingly, the production of
IL-5 in asthmatic children treated with corticosteroids[1]
does not appear to be a positive effect.
Arnaldo Cantani, MD, PhD
Professor of Pediatrics
Allergy and Clinical Immunology Division
Monica Micera, MD
University of Roma "La Sapienza"
Viale Regina Elena 324, I 00161 Roma
References
(1) El-Radhi AS, Hogg CL, Bungre JK, Bush A, Corrigan CJ.
Effect of oral glucocorticoid treatment on serum
inflammatory markers in acute asthma. Arch Dis Child 2000;83:158-62.
(2) Waalkens HJ, Van Essen-Zandvliet EE, Hughes MD, et al.
Cessation of long-term treatment with inhaled corticosteroid
(budesonide) in children with asthma results in
deterioration. Am Rev Respir Dis 1993;148:1252-7.
(3) Simons FER, Dolovic J, Moothe DW, et al. A comparison of
beclomethasone, salmeterol, and placebo in children with
asthma. N Engl J Med 1997;337:1659-65.
(4) Kamada AK, Szefler SJ. Glucocorticoids and growth in
asthmatic children. Pediatr Allergy Immunol 1995;6:145-54.
(5) Nicolaizik WH, Marchart JL, Pearce MA, Warner JO.
Endocrine and lung function in asthmatic children on inhaled
corticosteroids. Am J Respir Crit Care Med 1994;150:624-8.
(6) Pincus DJ, Szefler SJ, Ackerson LM, Martin RJ.
Chronotherapy of asthma with inhaled steroids: The effect of
dosage timing on drug efficacy. J Allergy Clin Immunol
1995;95:1173-8.
(7) WHO Position Paper Allergen immunotherapy: therapeutic
vaccines for allergic diseases. Allergy 1998;53(suppl 44):1-42.
(8) Cantani A, Arcese G, Lucenti P, Gagliesi D, Bartolucci M.
A three year prospective study of allergen immunotherapy to
inhalant allergens: evidence of safety and efficacy in 300
children with allergic asthma. J Invest Allergol Clin
Immunol 1997;7:90-7.
(9) Cantani A, Gagliesi D. Specific immunotherapy in
children. Allergy 1996;51:265-6.
(10) Lu FM, Chou CC, Chiang BL, Hsieh KH. Immunologic changes
during immunotherapy in asthmatic children: increased IL-13
and allergen-specific IgG4 antibody levels. Ann Allergy
Asthma Immunol 1998;80:419-23.
(11) Durham SR, Till SJ. Immunological changes associated
with allergen immunotherapy. J Allergy Clin Immunol 1998;102:157-64.
(12) Wang CR, Liu ST, Liu MF, Lee GL, Wang GR, Chuang CY. The
effect of allergen immunotherapy on in vitro IL-4 and
IFN-gamma production by peripheral mononuclear cells in
house dust-sensitive Chinese patients with bronchial asthma.
Asian Pac J Allergy Immunol 1999;17:249-54.
This article tells us that over the last 30 years the US youth
has shown a decrease in total energy consumed, as well as the percentage
of energy from fat and in particular saturated fats. So what are the
conclusions of the article? That "these trends .... may compromise the
health of future US populations". In the discussion section worries are
expressed about low iron and fibre intakes: despite the fact th...
This article tells us that over the last 30 years the US youth
has shown a decrease in total energy consumed, as well as the percentage
of energy from fat and in particular saturated fats. So what are the
conclusions of the article? That "these trends .... may compromise the
health of future US populations". In the discussion section worries are
expressed about low iron and fibre intakes: despite the fact that both
have risen steadily in the past 30 years. Concern is also expressed about
falling calcium intake, due to a decrease in consumption of dairy
products. US milk intake has always been exceptionally high, and being
rich in saturated fat a reduction was probably desirable. However, the
current lower intake still supplies levels of calcium much higher than
those for children in other developed countries.
There seems little doubt that US children are growing fatter, but I
am at a loss to see in what way their dietary intake explains this.
Presumably the reduction in energy intake is offset by an even greater
reduction in activity, but the effect is that the diet of today's
adolescents, though supplying more energy than required for current levels
of activity, in composition terms appears to be healthier than it has ever
been.
The old fashioned disciplinarian mother used to shout to her children
in the next room "whatever you're doing: stop it!". This appears to
still be our attitude to young people as a group. It is sad to see a
scientific article falling back onto the accepted paradigm that the youth
of today are decadent and unhealthy. Could they not have had the
imagination to actually explore the meaning of these results and even dare to suggest that some things might be improving instead of getting worse?
If sleep studeis are worth doing, they are worth doing well. The study of
sleep disordered breathing is another area of paediatrics that the UK has
stumbled to embrace.[1, 2] Sleep medicine has exponentially increased in
adults in recent years, yet in paediatrics many questions remain
unanswered.
While, van Someren et al made a valiant attempt to answer an
important question,[3] they did...
If sleep studeis are worth doing, they are worth doing well. The study of
sleep disordered breathing is another area of paediatrics that the UK has
stumbled to embrace.[1, 2] Sleep medicine has exponentially increased in
adults in recent years, yet in paediatrics many questions remain
unanswered.
While, van Someren et al made a valiant attempt to answer an
important question,[3] they did so by assessing clinical scores in
relation to a standard which was far from gold, and as such accuracy could
not be determined, only inferred. Clinical scores or simple oximetery are
limited in their ability to identify obstructive sleep apnoea (OSA), being
able to identify significant OSA but not mild/moderate cases.[4, 5] Data
is now accumulating that even mild OSA may be associated with significant
neurocognitive morbidity in children.[6, 7] Full polysomnography is the
current gold standard. The Visilab has not been satisfactorily validated
against full polysomnography, and the results presented in the paper
demonstrated a discrepancy in 2 of 10 simultaneous recordings (a 20% error
rate) with important differences in mean oxygen saturation between the two
systems (93% vs 95%). It is true that full polysomnography may not be
required in all children for the diagnosis of OSA, however this process
should be one of working down from a gold standard rather than edging up
towards it. The arguments used by van Someren against the use of full
polysomnography are weak. Children in dedicated sleep areas tolerate full
polysomnography well: In the 54 full polysomnographic OSA studies
performed in the past 6 months in this unit, sleep efficiency was a mean
of 90% (sd 8%), which includes children with frequent wakening as a result
of their OSA!
Centres in both North America and Australia have dedicated
significant funding in recent years to paediatric sleep laboratories and
the appropriate training of both nursing and medical staff through
specific specialist training criteria; the UK sadly lacks such support.
With the exception of one paediatric unit (concentrating on sleep in rare
disorders) sleep related research in the UK is linked to adults centres.
UK paediatrics needs a sleep medicine wake up call, so that standards can
be set from gold.
Steve Cunningham Margaret Harris Consultants in Paediatric Respiratory Medicine
Department of Paediatric Respiratory and Sleep Medicine Mater
Children’s Hospital Brisbane, Australia
References
(1) Shann F. Australian view of paediatric intensive care in Britain.
Lancet 1993;342:68.
(2) Wheeler R, Foote K. Pectus excavatum: studiously ignored in the
United Kingdom? Arch Dis Child 2000;82:187-8.
(3) van Someren V, Burmeister M, Alusi G, Lane R. Are sleep studies
worth doing? Arch Dis Child 2000;83:76-81.
(4) Carroll JL, McColley SA, Marcus CL, Curtis C, Loughlin GM.
Inability of clinical history to distinguish primary snoring from
obstructive sleep apnea syndrome in children. Chest 1995;108:610-8.
(5) Brouilette RT, Morielli A, Leimanis A, Waters KA, Luciano R,
Ducharme FM. Nocturnal pulse oximetry as an abbreviated testing modality
for pediatric obstructive sleep apnea. Pediatrics 2000;105:405-12.
(6) Kennedy D. Neurocognitive function in childhood obstructive sleep
apnoea syndrome (OSAS). 6th World Congress on Sleep Apnea. March 2000;
Sydney, Australia.
(7) Ali NJ, Pitson D, Stradling JR. Sleep disordered breathing: effects
of adenotonsillectomy on behaviour and psychological functioning. Eur J
Pediatr 1996;155:56-62.
Dear Editor,
We read with great interest recent study by Vergnano et al.1 investigating the epidemiology, age at infection, clinical characteristics, and outcome of listeria infection in the young infant. We congratulate the authors on providing a novel and interesting study that is relevant to the UK population and agree that the empirical use of amoxicillin in the paediatric infant should be reconsidered given the conclusions of their data.
However, when considering how we might be able to incorporate your novel findings into our centres practice, we required further clarification on table 2. The table describes increased oxygen requirement/respiratory support in 2/27 infants and yet, within results, report a prevalence of increased oxygen requirement/respiratory support of 89%. Furthermore, hypotension requiring inotropes is reported to occur in 4/27 infants but has a reported prevalence of 115%. These reported data appear to be miscalculated.
Clinical identification of invasive listeriosis through the understanding of symptoms within the infant is a key finding of this study given its poor description within the current literature2. We conducted a focused literature search and found scarce information on infant symptom prevalence; one notable exception includes the MONALISA study by Charlier et al.3 which recorded detailed clinical features (appendix p 21). Early diagnosis of invasive listeriosis has been demonstrated to have key prognostic value...
Show More26th January 2022
To the Editor
Archives of Disease in Childhood
re Diagnosing urinary tract infection in children: time to ditch the pad?
Harkensee C, Clennett J, Wilkinson S, et al
Arch Dis Child 2021; 106: 935-936
We read with interest the article by Harkensee et al, (1) suggesting that the urinary collection pad (UCP) no longer had a role in obtaining samples for diagnosis of urinary tract infections (UTI). Whilst it is well established that there is an unacceptably high rate of contamination with UCPs making them unsuitable for microbiological culture, and that the preferred (non-invasive) method for obtaining a sample for culture is by 'clean catch' +/- stimulation or Quick-Wee method, we would suggest that the UCP has a role in screening for UTI, by dipstick analysis of the aspirated pad sample for leucocyte esterase (LE) and nitrites (2). It would be useful, in a paediatric 'acute referral clinic' or Emergency Department, in infants or children, with non-specific abdominal pain, or fever without a focus, where a combination of a negative test for both LE and nitrites can be reasonably used to exclude UTI, and equally a positive LE and nitrite result would indicate a high likelihood of a UTI and the need to obtain a 'clean catch' or catheter specimen for microbiological analysis (3). The advantages of the UCP are that it allows 'point of care' dipstick analysis with inf...
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We read with interest the paper by Baines and Colleagues [1] in which the authors reported a strong inverse relationship between total serum calcium concentrations and disease severity in 70 critically ill children with meningococcal disease. Calcitonin concentrations were measured in a subgroup of 23 children on admission, and significantly correlated with disease severity. In particular, however, the...
Thank you authors, for recommending valuable guidelines for disclosure of diagnosis. I believe they are really useful however I do feel presence of infants at the time of disclosure of the diagnosis is good practice but I would like to suggest caution because most of the times then, the parents are distracted by them and pay most of their attention in caring for them and making sure they are comfortable. I feel this mak...
Dear Editor
The paper by Cappendijk and Hazebroek[1] successfully demonstrates the problems with diagnosis of appendicitis in the young child.
It makes the important point that diarrhoea may be a feature of appendicitis and lead to misdiagnosis. In addition, children can have coexisting pathologies leading to delayed diagnosis. We have seen a cystic fibrosis child with DIOS (distal intestinal obstruction...
We read with interest the study and recommendations by Brogan and colleagues (Arch Dis Child 2000;83:506-507). We agree with them on a number of issues and wish to draw attention to the following points.
(1) Previous international studies do not support a temperature of >37.4oC as an inclusion criteria of significant fever for significant bacterial sepsis (SBS).[1][2] A minimum tempe...
Dear Editor
In reply to the comments by Yim Yee Chan and R Lakshman in which they ask if all patients truely suffered from appendicitis in our study group. The answer is that histopathological investigation confirmed the diagnosis appendicitis in all cases.
Yours sincerely,
VC Cappendijk, MD and FWJ Hazebroek, MD, PhD
Department of Paediatric Surgery, Sophia Children's Hospital...
The treatment of childhood asthma is controversial: although oral glucocorticoid treatment in children with asthma was associated with clinical improvement.[1] There are concerns about corticosteroids, since stopping drug treatment in children with asthma results in clinical deterioration,[2] or in the return of bronchial hyperresponsiveness within two weeks,[3] with the obvious conclusion that the nat...
This article tells us that over the last 30 years the US youth has shown a decrease in total energy consumed, as well as the percentage of energy from fat and in particular saturated fats. So what are the conclusions of the article? That "these trends .... may compromise the health of future US populations". In the discussion section worries are expressed about low iron and fibre intakes: despite the fact th...
Dear Editor:
If sleep studeis are worth doing, they are worth doing well. The study of sleep disordered breathing is another area of paediatrics that the UK has stumbled to embrace.[1, 2] Sleep medicine has exponentially increased in adults in recent years, yet in paediatrics many questions remain unanswered.
While, van Someren et al made a valiant attempt to answer an important question,[3] they did...
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