We thank Drs Chakraborty and Morris for their interest in our study.
We acknowledge that the children without bleeding disorders were only
recruited in south Wales whilst those with bleeding disorders were
recruited in centres around the UK. Given the data available we are not
able to comment on whether children are likely to bruise differently
dependent on where they live.
We thank Drs Chakraborty and Morris for their interest in our study.
We acknowledge that the children without bleeding disorders were only
recruited in south Wales whilst those with bleeding disorders were
recruited in centres around the UK. Given the data available we are not
able to comment on whether children are likely to bruise differently
dependent on where they live.
We agree that it would have been useful to validate training of
carers of children with bleeding disorders, although the 100% concordance
between carer and trainer in the children without bleeding disorders is a
result that suggests that the data are valid.
Children with bleeding disorders are inevitably more likely to be
male than female. Previous work by ourselves and others has shown that
there is no detectable difference between bruising pattern in male and
females in this age group (1-4). Importantly, this is the case for the
control children in this study (5).
Yours sincerely
Peter W Collins, Melinda Hamilton, Frank D Dunstan, Sabine Maguire,
Diane E Nuttall, Ri Liesner, Angela E Thomas, John Hanley, Elizabeth
Chalmers, Victor Blanchette and Alison M Kemp
References
1. R F Carpenter. The prevalence and distribution of bruising in
babies Arch Dis Child 1999;80:363-366
2. Labb? J, Caouette G.Recent skin injuries in normal children.
Pediatrics. 2001 108:271-6.
3. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers:
those who don't cruise rarely bruise. Puget Sound Pediatric Research
Network. Arch Pediatr Adolesc Med. 1999 153:399-403.
4. S Maguire, M K Mann, J Sibert, A Kemp, Are there patterns of
bruising in childhood which are diagnostic or suggestive of abuse? A
systematic review
Arch Dis Child 2005;90:182-186
5. Kemp AH, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S.
Patterns of bruising in pre-school children - a longitudinal study.
Archives of Disease in Childhood 2015;100:426-431.
Two alternative explanations are given by Professor Taylor for the
global problem with ADHD diagnosis, but he overlooks one interesting
possibility- perhaps the reported prevalences are about right. That is,
perhaps the rates really do vary considerably between populations and are
rising in the USA and in other countries.
Professor Taylor recognises some obvious facts. Firstly, there is a
large unmet need. Seco...
Two alternative explanations are given by Professor Taylor for the
global problem with ADHD diagnosis, but he overlooks one interesting
possibility- perhaps the reported prevalences are about right. That is,
perhaps the rates really do vary considerably between populations and are
rising in the USA and in other countries.
Professor Taylor recognises some obvious facts. Firstly, there is a
large unmet need. Secondly the reported rates are very high in some places
and are changing quite rapidly. Thirdly, places where medical treatment is
well established have higher prevalence.
It can be pointed out that a large unmet need might be due to a
rising prevalence and that wealthy places with higher prevalence are
likely to have more established treatments. In short, we are offered no
good reason to disbelieve the data.
The unspoken reason why the prevalence data is questioned is that it
doesn't fit with our aetiological model. ADHD is supposedly genetic.
Professor Taylor, however, points out that the diagnosis for an individual
is not made based on aetiology and can't be disproved by aetiology. It is
made on well established behavioural diagnostic criteria.
Are we not left with the serious possibility that our aetiological
model is wrong. Genetics are involved with every condition. Might not twin
studies identify epigenetic as well as genomic processes? Epigenetics is
a science which is moving the ground beneath our feet. If we should not
dither in rigid constructions when the roof is falling in.
The team from Evelina are to be commended for questioning the current
direction of travel of acute hospital practice, seeking to find "policy-
based evidence" supporting the drive for increasingly consultant-delivered
healthcare and their detailed report should help inform wider discussions,
not just in paediatrics but across the entire spectrum of acute hospital
medicine.
The team from Evelina are to be commended for questioning the current
direction of travel of acute hospital practice, seeking to find "policy-
based evidence" supporting the drive for increasingly consultant-delivered
healthcare and their detailed report should help inform wider discussions,
not just in paediatrics but across the entire spectrum of acute hospital
medicine.
Apart from two specific instances (very short-stay admissions and
acute gastroenteritis (AGE) - conditions which of themselves are not
mutually exclusive), earlier consultant review does not appear to
significantly impact on hospital length of stays.
Whilst the authors describe AGE as "one of the commonest reasons for
an acute paediatric admission" and report that, following the introduction
of earlier consultant review, children presenting with (AGE) were
discharged sooner in 2014-'15 when compared to 2012-'14, they failed to
highlight the dramatic effect Rotavirus (Rotarix?) vaccination, introduced
into the United Kingdom's Immunisation Programme in July 2013 (roughly
midpoint in the study), has subsequently had on disease prevalence, which
goes some way towards negating this reported benefit from earlier AGE
discharge.
In 2012-'14, AGE made up 6.5% (291 admissions) of Evelina London
Children's Hospital (ELCH)'s unplanned admissions, whereas in 2014-'15
only 3.5% (70 admissions) of admissions were due to AGE, a fall of almost
50% (Table 2), an effect that must surely be attributed to vaccination and
reflects national trends where acute, unplanned admissions from rotavirus
have fallen dramatically [1].
Pre-2013, there were 13,000 hospital admissions for rotavirus in
England and Wales but since then rotavirus admissions have fallen
significantly with laboratory reported rotavirus infections in England
2013/14 falling 67% when compared to the previous 10-season averages from
2003-'13. Epidemiological reports have confirmed that this decline in
cases has continued and been sustained, suggesting that rotavirus
vaccination has been extremely successful in reducing the burden of
disease rotavirus placed on our acute paediatric units [2].
There can be no doubt that vaccination success has produced a
dramatic and sustained decrease in paediatric presentations/admissions
with acute gastroenteritis which, considered in the context of this
study's findings and conclusions, must further question the need for
increasingly earlier consultant review, the position endorsed by
politicians and royal colleges alike [3].
[1] Does increased duration of consultant presence affect length of
hospital stay for unplanned admissions in acute paediatrics?: an
observational before-and-after analysis using administrative healthcare
data. Cromb, D et al. Arch Dis Child Published Online
First:10.1136/archdischild-2016-311318
[2] PHE Monthly National Norovirus and Rotavirus Report Summary of
surveillance of norovirus and rotavirus 12 June 2015. Page 8.
www.gov.uk/government/uploads/system/uploads/attachment_data/file/434768/GEZIreportTableNew12062015.pdf
[3] RCPCH "Facing the Future: Standards for Acute General Paediatric
Services - 2015"
www.rcpch.ac.uk/sites/default/files/page/Facing%20the%20Future%20Standards%20web.pdf
I am grateful to Prof Weizman for his response to my Archivist
article. Like him, I was concerned that the saccharide content and high
osmolality of apple juice might make diarrhoea worse, not better. However,
the authors of this article did not find this. It is possible that their
surveillance for this adverse effect was inadequate but this cannot be
deduced from the article. Archivist can only convey what authors report...
I am grateful to Prof Weizman for his response to my Archivist
article. Like him, I was concerned that the saccharide content and high
osmolality of apple juice might make diarrhoea worse, not better. However,
the authors of this article did not find this. It is possible that their
surveillance for this adverse effect was inadequate but this cannot be
deduced from the article. Archivist can only convey what authors report:
readers must make up their own minds whether or not to act on any paper's
findings.
We thank Dr Kraemer for his constructive response and commend his
initiative to facilitate weekly staff meetings within neonatal intensive
care units. We concur that communication is an essential component of
addressing not only moral distress but improving workplace culture.
As Dr Kraemer notes, finding the best forum for such discussions
continues to be challenging. In our various institutions we continue to...
We thank Dr Kraemer for his constructive response and commend his
initiative to facilitate weekly staff meetings within neonatal intensive
care units. We concur that communication is an essential component of
addressing not only moral distress but improving workplace culture.
As Dr Kraemer notes, finding the best forum for such discussions
continues to be challenging. In our various institutions we continue to
struggle to address a range of questions about when and how to communicate
in ways that will be genuinely helpful. Some questions are about the
nature of the discussion, such as: Do such meetings only really cater for
those who are most vocal, or who have the ability to articulate their
concerns? (And if so, what approaches will help those who struggle to be
heard?) How do we bring the honesty and transparency of 'tea room'
discussions to these more formal clinical meetings?
Some questions are practical: How can such meetings meet the needs of
both day and night time healthcare professionals? When the facilitator is
the clinical lead, who will support and care for him/her as he/she seeks
to support and highlight all other voices in the matter?
Other questions are about attitudes and values: How do we turn the
attitude that such discussions "don't change anything", into positive
responses that both advance medicine and serve the patients and their
families? At times our efforts to build trust, communicate openly and to
walk a line of integrity still seem to fall short of what is needed or
expected to maintain morale and a safe workplace environment.
It is our hope that our current longitudinal study into moral
distress will highlight the key time points where further interventions
and debriefing meetings will be most effective in addressing healthcare
professionals' valid concerns while providing a unified team that is
equipped to care for the best interests of the patient and the family, no
matter how challenging that may be.
The purpose of our study was to document the prevalence of
hypercalcaemia in children and its possible associations and we agree
with the correspondent that it would be helpful to confirm these
associations, such as the one highlighted for sepsis, thorough more
detailed and rigorous studies.
I read with great interest the Archivist regarding Apple juice for
rehydration. It summarizes a recent study from Toronto, Canada set out to
see whether dilute apple juice was as good as standard electrolyte
maintenance solution for rehydration (Freedman S, et al. JAMA
2016;doi:10.1001/jama.2016.5352). They conclude that the use of half-
strength apple juice may be an appropriate alternative to electrolyte
maintenance fl...
I read with great interest the Archivist regarding Apple juice for
rehydration. It summarizes a recent study from Toronto, Canada set out to
see whether dilute apple juice was as good as standard electrolyte
maintenance solution for rehydration (Freedman S, et al. JAMA
2016;doi:10.1001/jama.2016.5352). They conclude that the use of half-
strength apple juice may be an appropriate alternative to electrolyte
maintenance fluids in children with mild gastroenteritis and minimal
dehydration. The Archivist recommends to use this mode of rehydration in
developed countries.
In my opinion the authors failed to fully delineate the dangers of
using fruit juice as rehydration fluid, even when diluted. Fruit juices,
such as apple juice, contain usually fructose, glucose, sucrose and
sometimes sorbitol, and their osmolality might reach occasionally a level
of 1,070 Osm/Kg H2O. Decreased carbohydrate absorption occurs more often
after ingestion of juices that contain more sorbitol, a non-absorbable
sugar, and higher concentrations of fructose over glucose than after
ingestion of juices which lack sorbitol and contain equal amounts of
glucose and fructose. Moreover, other factors in apple juice, probably
complex carbohydrates originating from the fruit skin, seem to be capable
of provoking osmotic diarrhea (Hyams JS, et al. Carbohydrate malabsorption
following fruit juice ingestion in young children. Pediatrics 1988;82:64-
8).
Therefore, suggestions to use fruit juices as an alternative to oral
rehydration solutions, even when diluted half-strength, as advised in the
present study, should be accompanied by additional warnings.
Recommendations to take precautions are especially relevant for very young
children and infants, as efficiency of these carbohydrates absorption
increases with age (Nobigrot T,et al. Carbohydrate absorption from one
serving of fruit juice in young children: age and carbohydrate composition
effects. J Am Coll Nutr 1997;16:152-8).
We would like to congratulate the authors of this excellent
observational study. For paediatricians, and for medico-legal
professionals, data from this study would be invaluable in their practice.
While the authors have discussed most of the limitations of their
study, we would like to point out a few more which have come to our
notice.
We would like to congratulate the authors of this excellent
observational study. For paediatricians, and for medico-legal
professionals, data from this study would be invaluable in their practice.
While the authors have discussed most of the limitations of their
study, we would like to point out a few more which have come to our
notice.
1) Controls were recruited only from South Wales, while cases were
multi-centre. This could give rise to inter-centre variability, which
needs to be looked at and accounted for.
2) Validation of training of carers was done on children with non-
bleeding disorders only. This should have been attempted on children with
bleeding disorders as well, as their reporting form the basis of this
study.
3) While sexes were balanced in children with non-bleeding disorders,
children with bleeding disorders were dominated by males. Differences in
type or duration of activity could be a confounding factor in comparing
these groups. While this is difficult to correct without introducing
further bias, this needs to be considered as a factor for adjustment in
models, if possible.
The findings of this important paper should be used to promote
regular staff development meetings in neonatal intensive care units. In my
experience the reason these are not more widespread is lack of
availability of suitably qualified staff to facilitate such groups.
Clinicians may ask for support then find the meetings disappointing.
Over many years in a district general hospital neonatal unit a
colleague and...
The findings of this important paper should be used to promote
regular staff development meetings in neonatal intensive care units. In my
experience the reason these are not more widespread is lack of
availability of suitably qualified staff to facilitate such groups.
Clinicians may ask for support then find the meetings disappointing.
Over many years in a district general hospital neonatal unit a
colleague and I found that staff would attend our weekly work discussions
because they knew and worked with us at other times; we were their
colleagues. This reduced quite understandable resistance to 'mental
health' that can put people off an invitation to reflect on ethical,
emotional and practical aspects of their daily work. Caring for tiny, sick
and helpless human beings and their shell-shocked parents is stressful
(Fischer et al 2000) and disturbing (Cohen 2003). Like soldiers at the
front line, staff often manage these strains heroically - not necessarily
good for morale (Braithwaite 2008). Where senior managers can support work
discussion by themselves attending and expecting staff to join them, a
change of culture is possible in which thinking about difficult and
apparently unresolvable questions is worthwhile. Though not widely used in
medical settings staff groups are a part of the weekly timetable in many
helping professions and follow a flexible tradition of curiosity and
reflection (Hartley & Kennard 2009). There are of course fundamental
ethical questions about the consequences of ever-progressing technical
advances in neonatal medicine, but also expectable tensions between staff
and parents and between staff themselves, aggravated by the harsh
political climate that so often prevails in expensive health services. It
is not all deeply serious. Provided there is good enough basic trust in
the unit, clinicians who work closely together can laugh at the irony of
it all, often leading to important points that might otherwise have been
missed. And there are satisfactions as well as gripes to be aired.
Work discussion goes against the grain of protocol-driven health
services. It is potentially subversive in that staff may become more aware
of how undermining their working environment is. Besides the more familiar
"we are far too busy for that sort of thing" and "it doesn't change
anything anyway" there are many seemingly good reasons for not having
meetings with no agenda or agreed outcome (Kraemer 2015), yet with
courage, foresight and skill there are even better ones for doing so.
Fischer JE, Calame A, Dettling AC, Zeier H, Fanconi S. (2000)
Experience and endocrine stress responses in neonatal and pediatric
critical care nurses and physicians. Crit Care Med. 28(9):3281-8.
Cohen, M. (2003) Sent Before My Time: A Child Psychotherapist's View
of Life on a Neonatal Intensive Care Unit. London: Karnac.
Braithwaite M.(2008) Nurse burnout and stress in the NICU. Adv
Neonatal Care. 8(6):343-7.
Hartley, P. & Kennard, D. (2009). Staff Support Groups in the
Helping Professions. London: Routledge
Kraemer, S. (2015) Anxiety at the front line. In D. Armstrong &
M. Rustin (Eds.) Social Defences against Anxiety: Explorations in a
Paradigm. London: Karnac http://bit.ly/29FH7zg
We thank Dr Williams and Mrs Scudamore for their letter. We entirely
agree with the comments made and congratulate them on giving a voice to
Rosie and other children and their families.
We endorse the approach taken that makes children and young people central
to any advocacy efforts. As we describe, and is mentioned in article 12 of
the UNCRC, the first step is to listen to and engage with the children and
young people th...
We thank Dr Williams and Mrs Scudamore for their letter. We entirely
agree with the comments made and congratulate them on giving a voice to
Rosie and other children and their families.
We endorse the approach taken that makes children and young people central
to any advocacy efforts. As we describe, and is mentioned in article 12 of
the UNCRC, the first step is to listen to and engage with the children and
young people themselves and developing stories, such as 'Fowl language',
is a wonderful example of this.
One of us (TW) has a particular interest in giving a voice to children and
young people and we offer two further examples to add to the superb
writing of Rosie. The first is, we believe, the first article to appear in
the Archives of Disease in Childhood on child rights practice in which a
young person added a commentary (Waterston T, Mann N. Child rights. Arch
Dis Child 2005; 90: 171 http://adc.bmj.com/content/90/2/178.full.pdf). The
second example is a publication by a group of young people in Newcastle in
1997 who carried out qualitative research among school children on health
in the school setting, looking both at problems and solutions. The work
was published locally under the title 'School can seriously damage your
health' and was presented at an educational conference.
Many other examples can be found around the country and we encourage
readers both to listen to their child patients and to work with young
people on making our health services more child focused.
Dear Editors
We thank Drs Chakraborty and Morris for their interest in our study. We acknowledge that the children without bleeding disorders were only recruited in south Wales whilst those with bleeding disorders were recruited in centres around the UK. Given the data available we are not able to comment on whether children are likely to bruise differently dependent on where they live.
We agree that...
Two alternative explanations are given by Professor Taylor for the global problem with ADHD diagnosis, but he overlooks one interesting possibility- perhaps the reported prevalences are about right. That is, perhaps the rates really do vary considerably between populations and are rising in the USA and in other countries.
Professor Taylor recognises some obvious facts. Firstly, there is a large unmet need. Seco...
The team from Evelina are to be commended for questioning the current direction of travel of acute hospital practice, seeking to find "policy- based evidence" supporting the drive for increasingly consultant-delivered healthcare and their detailed report should help inform wider discussions, not just in paediatrics but across the entire spectrum of acute hospital medicine.
Apart from two specific instances (very sh...
I am grateful to Prof Weizman for his response to my Archivist article. Like him, I was concerned that the saccharide content and high osmolality of apple juice might make diarrhoea worse, not better. However, the authors of this article did not find this. It is possible that their surveillance for this adverse effect was inadequate but this cannot be deduced from the article. Archivist can only convey what authors report...
We thank Dr Kraemer for his constructive response and commend his initiative to facilitate weekly staff meetings within neonatal intensive care units. We concur that communication is an essential component of addressing not only moral distress but improving workplace culture.
As Dr Kraemer notes, finding the best forum for such discussions continues to be challenging. In our various institutions we continue to...
The purpose of our study was to document the prevalence of hypercalcaemia in children and its possible associations and we agree with the correspondent that it would be helpful to confirm these associations, such as the one highlighted for sepsis, thorough more detailed and rigorous studies.
Conflict of Interest:
None declared
I read with great interest the Archivist regarding Apple juice for rehydration. It summarizes a recent study from Toronto, Canada set out to see whether dilute apple juice was as good as standard electrolyte maintenance solution for rehydration (Freedman S, et al. JAMA 2016;doi:10.1001/jama.2016.5352). They conclude that the use of half- strength apple juice may be an appropriate alternative to electrolyte maintenance fl...
Dear Sir,
We would like to congratulate the authors of this excellent observational study. For paediatricians, and for medico-legal professionals, data from this study would be invaluable in their practice.
While the authors have discussed most of the limitations of their study, we would like to point out a few more which have come to our notice.
1) Controls were recruited only from South Wal...
The findings of this important paper should be used to promote regular staff development meetings in neonatal intensive care units. In my experience the reason these are not more widespread is lack of availability of suitably qualified staff to facilitate such groups. Clinicians may ask for support then find the meetings disappointing.
Over many years in a district general hospital neonatal unit a colleague and...
We thank Dr Williams and Mrs Scudamore for their letter. We entirely agree with the comments made and congratulate them on giving a voice to Rosie and other children and their families. We endorse the approach taken that makes children and young people central to any advocacy efforts. As we describe, and is mentioned in article 12 of the UNCRC, the first step is to listen to and engage with the children and young people th...
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