The study by Kirk et al (1) highlights important issues regarding the
crucial role of the paediatric medical examination in cases of alleged or
suspected maltreatment. The authors rightly note that a comprehensive
medical assessment is integral to the child protection process and should
additionally aim to serve as a tool for health surveillance in this at-
risk group.
The study by Kirk et al (1) highlights important issues regarding the
crucial role of the paediatric medical examination in cases of alleged or
suspected maltreatment. The authors rightly note that a comprehensive
medical assessment is integral to the child protection process and should
additionally aim to serve as a tool for health surveillance in this at-
risk group.
Our own 10-year retrospective case-note analysis of children
attending for a medical assessment in an inner London borough, following a
referral for possible abuse, lends support to the findings by Kirk et al
and we agree it is important to exercise diagnostic vigilance. Using
stratified random sampling, we identified 142 children, (3 months - 16
years), and of these, 55% presented with physical abuse, 15% sexual abuse,
7% neglect, 1% emotional abuse and 22% mixed categories.
14 were found to have a newly diagnosed medical condition, and 18 an
unmanaged on-going problem (Table 1). 18 children were given medical
advice at the consultation and a further 34 required follow up by: the
general practitioner (n=16), dentist (n=6), general paediatrician (n=4),
audiology (n=4), ophthalmology (n=2), surgery (n=1), and the disability
team (n=1). An additional 16 children were found to have behavioural or
psychiatric problems sufficient to warrant referral. In summary, nearly
31% (n=44) required supplementary input and management not relating to the
presenting maltreatment concern.
The study by Kirk et al and our audit show that vulnerable children
presenting for assessment of alleged or suspected abuse commonly have
under-diagnosed, undertreated and under-reported co-morbidities. The
medical assessment should be used as an opportunity to identify health
needs that might otherwise go unrecognised, and may initiate follow-up and
inform social care about medical neglect. The focus on treatment,
prevention, and the promotion of children's health should always be
paramount.
Table 1. Newly diagnosed or unmanaged ongoing co-morbidities revealed
during a child protection medical assessment
________________________________________________________________
Unmanaged ongoing problems: Clinical finding (No. of children):
References:
1. Kirk CB, Lucas-herald A, Mok J. Child protection medical assessments:
why do we do them? Archives of Disease in Childhood 2010; 95: 336-340
We appreciate the response from Murch(1) and colleagues as it
highlights the dramatic difference in firearm injury rates between the
United Kingdom and the United States. Great Britain's firearm regulation
is among the strictest in the world while there is significant state to
state variability in the United States (2, 3). A study by Fleegler (3),
et al. demonstrated that greater statewide firearm regulations are
asso...
We appreciate the response from Murch(1) and colleagues as it
highlights the dramatic difference in firearm injury rates between the
United Kingdom and the United States. Great Britain's firearm regulation
is among the strictest in the world while there is significant state to
state variability in the United States (2, 3). A study by Fleegler (3),
et al. demonstrated that greater statewide firearm regulations are
associated with a lower rate of firearm fatalities within the state both
for suicides and homicides, which may partially account for the
differences in rates between the countries.
Other factors that may contribute to the differing rates between the
two countries include the differences in firearm availability and
ownership. It has been shown that large cities with more federal firearms
licensees (individuals or stores licensed by the federal government to
sell firearms) have higher rats of gun homicide (4). Additionally, a
recent study demonstrated that countries with higher numbers of guns per
capita had higher rates of firearm-related deaths(5).
These studies along with our own (6) support the notion that the
United States has far to go in terms of improving firearm regulations and
safety. By looking to other countries, we can learn which legislative
models and injury prevention strategies have been most successful in
reducing firearm-related injuries worldwide.
1. Murch H, Heatman B, Naughton A, Sibert JR. Epidemiology of
paediatric firearm injuries. Arch Dis Child. 2014; doi:
10.1136/archdischild-2014-306861 [published Online First: 2014/06/22].
2. Firearms-Control Legislation and Policy: Great Britain.
Washington, D.C.: The Law Library of Congress.
3. Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R. Firearm
legislation and firearm-related fatalities in the United States. JAMA
Intern Med. 2013;173:732-40 doi: 10.1001/jamainternmed.2013.1286
[published Online First: 2013/03/08].
4. Wiebe DJ, Krafty RT, Koper CS, Nance ML, Elliott MR, Branas CC.
Homicide and geographic access to gun dealers in the United States. BMC
Public Health. 2009;9:199 doi: 10.1186/1471-2458-9-199 [published Online
First: 2009/06/25].
5. Bangalore S, Messerli FH. Gun ownership and firearm-related
deaths. Am J Med. 2013;126:873-6 Online.
6. Srinivasan S, Mannix R, Lee LK. Epidemiology of paediatric firearm
injuries in the USA, 2001-2010. Arch Dis Child. 2014;99:331-5 doi:
10.1136/archdischild-2013-304642 [published Online First: 2013/12/18].
Dear Sir
I absolutely agree with your conclusions about demand feeding being
something “we might all be able to live with”, but we should really
respect the children’s “demand”. I also agree that there is no strong
evidence to support exclusive breast feeding for six months, but there is
neither strong evidence about the optimal complementary diet and there is
not any certainty that the child introduced to solid foods wi...
Dear Sir
I absolutely agree with your conclusions about demand feeding being
something “we might all be able to live with”, but we should really
respect the children’s “demand”. I also agree that there is no strong
evidence to support exclusive breast feeding for six months, but there is
neither strong evidence about the optimal complementary diet and there is
not any certainty that the child introduced to solid foods will accept
them assuming the pediatrician's "scientifically" prescribed doses. On the
contrary this is the least likely event, in the sense that children will -
- in general -- eat more or less of that which was prescribed. Moreover
offering solid foods to a child who is not interested at all to them, one
is just looking for feeding problems. Man proposes, Child disposes.
It is about eight years since a considerable group of family
paediatricians, throughout Italy, started practicing what we today define
“Demand Complementary Feeding”, i.e. “Baby led introduction of
complementary foods in the context of family meals whenever and wherever
they take place.” The proposal was first published in 2002 (1), and then
reaffirmed in 2006 (2).
The point is that the change in WHO recommendations about the most
appropriate age of introducing solid foods, gradually sliding towards more
mature stages of child development, allowed us to catch those cues you
talked about, without the confusing confounding factors arising from the
practice of an imposed weaning. So, today, we can not say any more that
babies on an exclusive milk-diet show interest in table-food because they
are hungry or antsy for something different. They do not know yet that
such thing is food. They are, as every baby between five to six month old,
interested in table-food as well as in every other thing parents, or other
trusty caregivers, are doing all day long. Only after parents yield to
their irresistible staring, flustering and reaching, babies taste, often
recognize, appreciate and finally accept happily “that thing”,-- which
they did not know what it was -- as food.
In a cohort study (personal data) in which mothers were followed during
pregnancy, they were instructed through specific courses and interviewed
in the second half of the first year. Nearly all of them had recognised
timely their children's "interest cues" and most of them had carried on
meeting their increasing requests of any food on the table, at the
children’s pace. Obviously, they did not show problems of refusal or of
selected diet, and their mother never worried about insufficient intake or
fights for the last crumb. And, on the other hand, there is a decrease in
useless work for the paediatrician. Sooner or later all children,
gradually, within the end of the first year substituted their midday and
evening milk-meals with solid food.
At last, but not least, all that, obviously and inevitably, entails an
elementary and simple parent’s education about the optimal diet (from now
on) for the whole family, that does not necessarily means a tasteless
diet. Weaning, as well breast feeding, is primarily a family task.
1) Lucio Piermarini. Autosvezzamento. Medico e Bambino 2002;21:468-
471
2) Lucio Piermarini. Complementary feeding at request. Medico e Bambino
2006;25:439-442
We fully agree with Dr Miller, who draw attention to the fact that
statistical significance is not always equal to clinical significance. We
also agree that the effect size is the appropriate measure for clinical
relevance. For the difference in mean total problems scores on the Child
Behavior Checklist (CBCL) between moderately preterm and term-born
children the effect size is 0.22 in our study, being a small (but not...
We fully agree with Dr Miller, who draw attention to the fact that
statistical significance is not always equal to clinical significance. We
also agree that the effect size is the appropriate measure for clinical
relevance. For the difference in mean total problems scores on the Child
Behavior Checklist (CBCL) between moderately preterm and term-born
children the effect size is 0.22 in our study, being a small (but not
negligible) effect. However, clinicians in particular take care for those
children that have elevated (clinical) CBCL scores, which have been
presented in Table 4. In this Table, the effect sizes for total,
externalizing, and internalizing problems are 0.34, 0.27, and 0.50,
meaning small (0.34 and 0.27) to moderate effects (0.50). An effect size
of 0.5 is often the value to be detected in clinical trials. However, we
think that the effects are clinically relevant indeed because of the high
prevalence of moderate preterm birth, which implies rather large effects
on child public health. We thank Dr Miller for giving us the opportunity
to provide this additional information on the relevance of our findings.
Editor, I read the recent publication by Ghaleb et al with a great
interest. Ghaleb et al concluded that prescribing
and medication administration errors are not uncommon in paediatrics,
partly as a result of the extra challenges in prescribing and
administering medication to this patient group [1].
Indeed, the prescription error is a common problem in pediatrics. Luckily,
in a recent systematic review, the rate of error w...
Editor, I read the recent publication by Ghaleb et al with a great
interest. Ghaleb et al concluded that prescribing
and medication administration errors are not uncommon in paediatrics,
partly as a result of the extra challenges in prescribing and
administering medication to this patient group [1].
Indeed, the prescription error is a common problem in pediatrics. Luckily,
in a recent systematic review, the rate of error was more common in adults
than children (about 4.5 times) [2]. "How to manage" is a big question. It
is needed to set a system to check for the prescription error as well as
promoting the awareness of practitioner before prescription. In addition,
the reformatting of the present medical curriculum to improve the quality
of prescription practice is also recommended [3]. Starting at medical
students might result in an improvement in the future life as
practitioner.
References
1. Ghaleb MA, Barber N, Franklin BD, Wong IC. The incidence and nature of
prescribing and medication administration errors in paediatric inpatients.
Arch Dis Child. 2010 Feb;95(2):113-8.
2. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM.
Prevalence, incidence and nature of prescribing errors in hospital
inpatients: a systematic review. Drug Saf. 2009;32(5):379-89.
3. Wangsaturaka D. Wiwanitkit V. An evaluation of prescription writing and
rational prescribing in Third-Year Medical Students, Faculty of Medicine,
Chulalongkorn University. Thai J Pharmacol 2000 May-Aug; 22(2): 115-20.
We read with great interest the recent review article by Creswell,
Waite and Cooper on 'Assessment and management of anxiety disorders in
children and adolescents'. The article brought to the forefront the
importance of accurately identifying and treating anxiety disorders during
development, with an encouraging discussion of new treatment strategies
and delivery approaches to increase access to psychological therapies fo...
We read with great interest the recent review article by Creswell,
Waite and Cooper on 'Assessment and management of anxiety disorders in
children and adolescents'. The article brought to the forefront the
importance of accurately identifying and treating anxiety disorders during
development, with an encouraging discussion of new treatment strategies
and delivery approaches to increase access to psychological therapies for
children with anxiety disorders. We are keen to add to these discussions
by raising awareness of the common co-occurrence and interaction between
anxiety symptomatology and tics for children with Tourette syndrome or
other chronic tic disorders (CTD). Psychiatric diagnoses are commonly
reported for children with CTD , with approximately 50% of children
meeting criteria for at least one anxiety disorder.[1] Obsessive
compulsive disorder (OCD), social phobia and generalised anxiety disorder
are most commonly reported, though separation anxiety may also co-
occur.[1] Interestingly, for children with CTD, behavioural difficulties
(e.g. Attention Deficit Hyperactivity Disorder) are most commonly reported
during the primary school years whilst anxiety disorders are more
prevalent during the teenage years, thus a reduction in externalising
behaviours are associated with an increase in internalising behaviours.[2]
Findings from our own clinical population support this trajectory and
indicate that for children with CTD quality of life is more closely
related to anxiety symptomatology than tic severity.[3] In addition, in
our clinical experience, the effective management of anxiety disorders
with evidence based cognitive-behavioural strategies (as advocated by
Creswell and colleagues) often results in improved in tic control and
reduced interference from tics on day to day life. Thus, there is a
complex interaction between anxiety and tics during development. This
highlights the need for the careful evaluation of anxiety disorders in
children with CTD to ensure that their broader mental health needs are not
overlooked, as for many children often it is not the tics that need
managing but the co-morbid psychiatric conditions.
References:
1. Specht, M. W., Woods, D. W., Piacentini, J., Scahill, L., Wilhelm,
S., Peterson, A. L., ... & Walkup, J. T. Clinical characteristics of
children and adolescents with a primary tic disorder. Journal of
Developmental and Physical Disabilities 2011;23(1):15-31.
2. Rizzo, R., Gulisano, M., Cal?, P. V., & Curatolo, P. (2012).
Long term clinical course of Tourette syndrome. Brain and Development
2012;34(8):667-673.
3. Woods, M., Robinson, S., Brennan, H, Bunton, P., & Hedderly,
T. A Comparison of Clinician and Self-Report Measures of Tics, Co-morbid
Difficulties and Quality of Life [abstract p48]. European Society Study of
Tourette Syndrome, 25-26 April 2014, Pitie-Salpetriere Hospital, Paris
Subhi et al have asked when oxygen should be given to children at
high altitude observing that hypoxaemia is the most common fatal
complication in deaths occurring from pneumonia in children in developing
countries (1). Might the answer be never?
Supplementary oxygen appears to be harmful in climbers on Everest
possibly because it eliminates the up-regulation of oxidative
phosphorylation by mass action by hypoc...
Subhi et al have asked when oxygen should be given to children at
high altitude observing that hypoxaemia is the most common fatal
complication in deaths occurring from pneumonia in children in developing
countries (1). Might the answer be never?
Supplementary oxygen appears to be harmful in climbers on Everest
possibly because it eliminates the up-regulation of oxidative
phosphorylation by mass action by hypocarbia (2) but the benefical effects
of this up-regulation could be concealed by the adverse effects of
hypothermia at this altitude. A more relevant question might be should
supplementary oxygen be given to children with pneumonia or even asthma at
low altitude for in these circumstances hypothermia is unlikely to be a
confounding factor.
Supplementary oxygen was not a significant factor in the non-
traumatic deaths that occurred in descent from the summit of Everest.
Nevertheless the putative beneficial effects of hypocarbia on oxidative
phosphorylation can be expected to be far greater at sea level, than on
Everest, for they will not be concealed by the adverse effects of
hypothermia. Asthmatics, for example, might be better off not receiving
oxygen. The same applies to patients with sepsis. In the latter
progressive adjustments to the ventilator settings designed to achieve as
low PaCO2 as safely possible might not only up-regulate oxidative
phosphorylation but also limit the severity of the metabolic acidosis that
can develop in these patients. In so doing the associated development of
cellular apoptosis and necrosis, the local inflammatory response induced
by cellular necrosis, and organ dysfunctions and deaths might also be
prevented.
Two variables would seem to be particular important in the regulation
of oxidative phosphorylation: the PaCO2 and the pH, the protonmotive force
increasing as the extracellular, or more specifically the
extramitochondrial, pH falls. The effects appear to be independent of one
another. In the first place "the mammalian central chemoreceptor for
respiratory control is responsive independently to H+ and CO2 and that H+
and CO2 exert differential effects on the respiratory centre in terms of
frequency and magnitude" (3). Secondly lactate is a linear function of
tissue PCO2 in rats (4). Thirdly in patients with sepsis those with a high
lactate paradoxically appear to have a higher tissue pH than those with a
low lactate (5) presumably because up-regulation of oxidative
phosphorylation decreases the likelihood of developing a "lactic
acidosis".
Hypoxia exerts its effects upon respiration through peripheral
chemoreceptors. In our study of ventilated dogs progressive decreases in
FiO2 failed to induce oxygen supply-dependency before death from cardiac
arrest (6). In retrospect this demonstrated the remarkable capacity to
deliver adequate amounts of oxygen to tissues in the face of hypoxic
stress, a finding confirmed by the studies on Everest. There was another
study, conducted by Canadian investigators, that followed DO2 and VO2 in
dying patients and found that oxygen supply-dependency failed to develop
until the DO2 was so abnormally low that the findings were difficult to
believe at the time. Regretably I have been unable to locate the
reference. If, however, my recollection is accurate these studies add to
the weight of evidence demonstrating that DO2 may not be the limiting
factor in the acutely ill. More importantly, perhaps, is the hypothetical
risk of ischaemia/ reperfusion or hyopoxia/reoxygenation injury if acute
hypoxia is reversed with oxygen.
To prevent reprfusion/reoxygenation injury, which must be a primary
objective during resuscitation, it would seem desirable to withold
supplementary oxygen in all circumstances and possibly even to reduce FiO2
to abnormally low levels or give supplementary carbon monoxide during the
initial phases of resuscitation. To optimize ATP resynthesis in a child
who is critically ill it might be best to reduce the PaCO2 as low as
possible, and that might be as low as 10 mmHg, and/or to reduce the
arterial bicarbonate concentration so that the pH is clamped at normal or
slightly lower (7,8). Clamping of the pH at the derisred level could in
theory be achieved using the pH-stat technique using two auto-burettes,
one filled with a suitable acid and the other a suitable alkali (9).
Giving supplementary oxygen to children with acute respiratory
infections and even asthma might never be advisable. If oxygen is to be
given it might be better to give it intraperitoneally for giving it into
the lumen of the gut appears to be cardioprotective in hypoxaemia. There
are good grounds for doing so (10, 11,12). The risk/benefit of such an
approach has, however, not been established except in the case of ECMO.
1. Rami Subhi, Katherine Smith, Trevor Duke When should oxygen be
given to children at high altitude? A systematic review to define altitude
-specific hypoxaemia. Archives of Disease in Childhood 2009;94:6-10
2. Dexamethasone and hepatic energetics in climbers attempting
Everest. Richard G Fiddian-Green (17 January 2009). eLetter re: Matiram
Pun. Important points in analysing deaths on Mount Everest
BMJ 2009; 338: b41.
3. Y Harada, M Kuno, and Y Z Wang. Differential effects of carbon
dioxide and pH on central chemoreceptors in the rat in vitro. J Physiol.
1985 November; 368: 679–693
4. Nakagawa Y, Weil MH, Tang W, Sun S, Yamaguchi H, Jin X, Bisera J.
Sublingual capnometry for diagnosis and quantitation of circulatory shock.
Am J Respir Crit Care Med. 1998 Jun;157(6 Pt 1):1838-43.
5. Effect of dobutamine on oxygen consumption and gastric mucosal pH
in septic patients. Gutierrez G, Clark C, Brown SD, Price K, Ortiz L,
Nelson C. Am J Respir Crit Care Med. 1994 Aug;150(2):324-9.
6. Grum CM, Fiddian-Green RG, Pittenger GL, Grant BJ, Rothman ED,
Dantzker DR. Adequacy of tissue oxygenation in intact dog intestine. J
Appl Physiol. 1984 Apr;56(4):1065-9.
8. Monitoring of tissue pH: the critical measurement. Fiddian-Green
RG. Chest. 1999 Dec;116(6):1839-41.
9. Mechanisms of disposal of acid and alkali in rabbit duodenum.
Fiddian-Green RG, Silen W.
Am J Physiol. 1975 Dec;229(6):1641-8.
10. The intestinal factor in irreversible hemorrhagic shock. LILLEHEI
RC. Surgery. 1957 Dec;42(6):1043-54.
11. The intestinal factor in irreversible endotoxin shock.
LILLEHEI RC, MACLEAN LD. Ann Surg. 1958 Oct;148(4):513-24
12. Supplemental systemic oxygen support using an intestinal
intraluminal membrane oxygenator.
Gross BD, Sacristán E, Peura RA, Shahnarian A, Devereaux D, Wang HL,
Fiddian-Green R. Artif Organs. 2000 Nov;24(11):864-9.
Every GP acknowledges the difficulties of differentiating between
severe and non-severe respiratory tract infections in children.
Diagnostic value of signs and symptoms are known to be low and additional
investigations in all symptomatic children is neither efficient nor
feasible. Nevertheless GPs manage to diagnose and treat over 95% of
children with a respiratory infections without referral to secondary
care. Doing...
Every GP acknowledges the difficulties of differentiating between
severe and non-severe respiratory tract infections in children.
Diagnostic value of signs and symptoms are known to be low and additional
investigations in all symptomatic children is neither efficient nor
feasible. Nevertheless GPs manage to diagnose and treat over 95% of
children with a respiratory infections without referral to secondary
care. Doing so they of course both under- and overdiagnose certain disease
entities such as pneumonia. Drawing conclusions about primary care
management of children with a respiratory tract infection from the very
small minority of those children that end up in hospital with a pneumonia
is hazardous. The conclusion of the authors that disease severity is still
not well assessed cannot be drawn from only looking at the very few
treatment/diagnostic failures. However, we agree with the authors that
point-of care-tests that could support GPs to diagnose pneumonia in
children would be very helpful. Certainly such a test would help us to
reduce underdiagnosis and undertreatment even further, but more
importantly to reduce overuse of antimicrobials at the same time.
As your study states, little systematic research has been done on the effects of cranio-sacral therapy in crying infants. I would like to call your attention to serious side-effects to this form of therapy. Two well-proven cases of healthy infants that died during the therapy have been described, one in the Netherlands and one in Germany. It is important to tell parents about this potential side-effect.
As your study states, little systematic research has been done on the effects of cranio-sacral therapy in crying infants. I would like to call your attention to serious side-effects to this form of therapy. Two well-proven cases of healthy infants that died during the therapy have been described, one in the Netherlands and one in Germany. It is important to tell parents about this potential side-effect.
I am not surprised you were not able to find the Dutch article (to be found on PubMed): the title of the Dutch article has been translated incorrectly: diseased, rather than deceased!
References
Jacobi G, Riepert Th , Kieslich M, Bohl J. Uber einen Todesfall wahrend der Physiotherapie nach Vojta bei einem drei Monate alten Saugling. Klin Padiatr. 2001;213:76-8.
Holla M, Ijland MM, van der Vliet AM, Edwards M, Verlaat CW Ned Tijdschr Geneeskd. Diseased infant after 'craniosacral' manipulation of the neck and spine 2009 Apr 25;153(17):828-31.
I read with great interest, Dr Rosenbloom's recent article. He
discusses how difficult issues are raised involving blame when a medical
error is discovered but the process may offer families restitution and
compensation. 'Parental responsibility' is a term used to describe the
legal duty that a parent has to their child (1). Parents act, therefore,
as surrogate decision makers on the basis of what they believe to be in...
I read with great interest, Dr Rosenbloom's recent article. He
discusses how difficult issues are raised involving blame when a medical
error is discovered but the process may offer families restitution and
compensation. 'Parental responsibility' is a term used to describe the
legal duty that a parent has to their child (1). Parents act, therefore,
as surrogate decision makers on the basis of what they believe to be in
the child's best interests. This responsibility includes making decisions
to pursue litigation that may have an effect on their child's future and
weighing up the harms and benefits of pursuing litigation.
Existing regulations and legislation are designed to afford
protection to children receiving medical care. However, in today's
climate, litigation can be viewed as an indispensable form of protection
or compensation against medical carelessness or error. Almost every
hospital and clinician have full insurance coverage which are skyrocketing
annually. Yet, there is no evidence that medical litigation has resulted
in improved healthcare.(2) Studdert et al found that claims which found
no evidence of medical error were often denied compensation but
substantial expenditures go toward litigation over errors and payment of
them. The overhead costs of medical litigation is spiralling (3).
Wood states that 'the law confuses error with negligence and error
should not be the basis for litigation'(4). Litigation based on error is
therefore counter-productive to improving quality of care. Surely, the
ultimate aim of our healthcare system is to enhance safety and quality,
not reduce insurance premiums
1.Children's Act 1989, section 3(1).
2. Morris JA Jr, Carrillo Y, Jenkins JM, Smith PW, Bledsoe S, Pichert J,
White A. Surgical adverse events, risk management, and malpractice
outcome: morbidity and mortality review is not enough. Ann Surg. 2003
Jun;237(6):844-51
3. Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and
compensation payments in medical malpractice litigation. N Engl J Med
2006;354:2024-33.
4. Wood C.The misplace of litigation in medical practice. Aust N Z J
Obstet Gynaecol. 1998 Nov;38(4):365-76.
The study by Kirk et al (1) highlights important issues regarding the crucial role of the paediatric medical examination in cases of alleged or suspected maltreatment. The authors rightly note that a comprehensive medical assessment is integral to the child protection process and should additionally aim to serve as a tool for health surveillance in this at- risk group.
Our own 10-year retrospective case-note an...
We appreciate the response from Murch(1) and colleagues as it highlights the dramatic difference in firearm injury rates between the United Kingdom and the United States. Great Britain's firearm regulation is among the strictest in the world while there is significant state to state variability in the United States (2, 3). A study by Fleegler (3), et al. demonstrated that greater statewide firearm regulations are asso...
Dear Sir I absolutely agree with your conclusions about demand feeding being something “we might all be able to live with”, but we should really respect the children’s “demand”. I also agree that there is no strong evidence to support exclusive breast feeding for six months, but there is neither strong evidence about the optimal complementary diet and there is not any certainty that the child introduced to solid foods wi...
We fully agree with Dr Miller, who draw attention to the fact that statistical significance is not always equal to clinical significance. We also agree that the effect size is the appropriate measure for clinical relevance. For the difference in mean total problems scores on the Child Behavior Checklist (CBCL) between moderately preterm and term-born children the effect size is 0.22 in our study, being a small (but not...
Editor, I read the recent publication by Ghaleb et al with a great interest. Ghaleb et al concluded that prescribing and medication administration errors are not uncommon in paediatrics, partly as a result of the extra challenges in prescribing and administering medication to this patient group [1]. Indeed, the prescription error is a common problem in pediatrics. Luckily, in a recent systematic review, the rate of error w...
We read with great interest the recent review article by Creswell, Waite and Cooper on 'Assessment and management of anxiety disorders in children and adolescents'. The article brought to the forefront the importance of accurately identifying and treating anxiety disorders during development, with an encouraging discussion of new treatment strategies and delivery approaches to increase access to psychological therapies fo...
Subhi et al have asked when oxygen should be given to children at high altitude observing that hypoxaemia is the most common fatal complication in deaths occurring from pneumonia in children in developing countries (1). Might the answer be never?
Supplementary oxygen appears to be harmful in climbers on Everest possibly because it eliminates the up-regulation of oxidative phosphorylation by mass action by hypoc...
Every GP acknowledges the difficulties of differentiating between severe and non-severe respiratory tract infections in children. Diagnostic value of signs and symptoms are known to be low and additional investigations in all symptomatic children is neither efficient nor feasible. Nevertheless GPs manage to diagnose and treat over 95% of children with a respiratory infections without referral to secondary care. Doing...
I am not surprised you...
I read with great interest, Dr Rosenbloom's recent article. He discusses how difficult issues are raised involving blame when a medical error is discovered but the process may offer families restitution and compensation. 'Parental responsibility' is a term used to describe the legal duty that a parent has to their child (1). Parents act, therefore, as surrogate decision makers on the basis of what they believe to be in...
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