McNeilly et al. (1) recently reported the results of their 5 year
retrospective study detailing frequency and aetiology of hypercalcaemia in
children (defined as total calcium >2.90mmol/l). Of those with
sustained hypercalcaemia (elevated levels for >2 consecutive days),
neonates were over-represented (42%), and suspected sepsis was the single
most common cause (24%). The authors hypothesis regar...
McNeilly et al. (1) recently reported the results of their 5 year
retrospective study detailing frequency and aetiology of hypercalcaemia in
children (defined as total calcium >2.90mmol/l). Of those with
sustained hypercalcaemia (elevated levels for >2 consecutive days),
neonates were over-represented (42%), and suspected sepsis was the single
most common cause (24%). The authors hypothesis regarding possible
mechanisms for this phenomenon included extrarenal production of
1,25(OH)2D by infiltrating macrophages (2), and release of cytokines such
as interleukin 6 increasing osteoclastic activity, thus bone resorption
and calcium release (3).
It is unfortunate the authors did not clarify how many of the
suspected sepsis cases were confirmed (4), if indeed this data was
available to them. This is because neonatal hypercalcaemia can produce
signs which mimic the stereotypical behaviour of a septic infant (5). Lack
of this data limits the utility of this finding in clinical practice - if
a neonate is incidentally found to be hypercalcaemic should the clinician
be vigilant regarding sepsis, or even commence antibiotics? Conversely, if
a neonate presents in a septic fashion, but is found to be hypercalcaemic
with normal inflammatory markers, should the clinician be reassured?
Given the difficulty in differentiating sepsis from non-infective
causes of poor handling in neonates; these findings suggest hypercalcaemia
may have potential as another biochemical tool to be used in conjunction
with clinical judgment (6).
References
1. McNeilly JD, Boal R, Shaikh MG, Ahmed SF. Frequency and aetiology
of hypercalcaemia. Arch Dis Child. 2016;101:344-7 doi:
10.1136/archdischild-2015-309029
archdischild-2015-309029 [pii] [published Online First: 2016/02/24].
2. Lietman SA, Germain-Lee EL, Levine MA. Hypercalcemia in children and
adolescents. Curr Opin Pediatr. 2010;22:508-15 doi:
10.1097/MOP.0b013e32833b7c23 [published Online First: 2010/07/06].
3. Davies JH, Shaw NJ. Investigation and management of hypercalcaemia in
children. Arch Dis Child. 2012;97:533-8 doi: 10.1136/archdischild-2011-
301284
archdischild-2011-301284 [pii] [published Online First: 2012/03/27].
4. Wynn JL, Wong HR, Shanley TP, Bizzarro MJ, Saiman L, Polin RA. Time for
a neonatal-specific consensus definition for sepsis. Pediatr Crit Care
Med. 2014;15:523-8 doi: 10.1097/PCC.0000000000000157 [published Online
First: 2014/04/23].
5. Rodd C, Goodyer P. Hypercalcemia of the newborn: etiology, evaluation,
and management. Pediatr Nephrol. 1999;13:542-7 doi: 10.1007/s004670050654
[published Online First: 1999/08/19].
6. Ismail AQ, Gandhi A. Using CRP in neonatal practice. J Matern Fetal
Neonatal Med. 2015;28:3-6 doi: 10.3109/14767058.2014.885499 [published
Online First: 2014/01/21].
Any paediatrician would welcome this necessary article, which should
already be a benchmark of our routine daily practice. However I wondered
if it missed an opportunity on advocacy having a role in making the
childrens' own voices being heard.
One such example is the recently published RCPCH Research Charter [1].
We as paediatricians can bring influence to create opportunities for your
patients and their siblings and the...
Any paediatrician would welcome this necessary article, which should
already be a benchmark of our routine daily practice. However I wondered
if it missed an opportunity on advocacy having a role in making the
childrens' own voices being heard.
One such example is the recently published RCPCH Research Charter [1].
We as paediatricians can bring influence to create opportunities for your
patients and their siblings and thereby give children a voice.
Another such example is creation of films, such as 'The First Day' which
give credited roles for children with specials needs both in front of and
behind the camera [2].
Another means is the creation of stories for individual children and
I give one such example.
Rosie has Goldenhaar's syndrome, and is deaf, mute, has a tracheostomy and
gastrostomy. Yet in spite of this she is beautiful, bright, kind and
fearless. 'Fowl Language the adventures of Rosie and her 3 Legged Chicken
Friend' is the first of a series of short stories about Rosie and a
signing 3 legged chicken who communicate through 'Fowl Language' a version
of British Sign Language.. The stories thus become a shared journey
between a child and an animal, both of whom have complex disabilities and
special needs. They take wing in hand and together, learn about
friendship, problem solving and understanding the world [3].
These are thus other important means by and through which we as
paediatricians can advocate for children not only in the UK but abroad.
References
1) http://www.rcpch.ac.uk/cyp-research-charter accessed July 15th
2016
2) https://www.youtube.com/watch?v=sZ0dWFcGONU accessed July 15th
2016
3) http://kidshealth.wix.com/rosieandchicken accessed July 15th 2016
We thank Dr Di Mascio and his colleagues for their interest in our
study. In response we would like to point out that only a very small
proportion (5.8%) of the children admitted with NSAP were subsequently
hospitalised with bowel pathology (1). The increased relative risk of
being diagnosed with appendicitis in the first year following a diagnosis
of NSAP is clearly notable.
We thank Dr Di Mascio and his colleagues for their interest in our
study. In response we would like to point out that only a very small
proportion (5.8%) of the children admitted with NSAP were subsequently
hospitalised with bowel pathology (1). The increased relative risk of
being diagnosed with appendicitis in the first year following a diagnosis
of NSAP is clearly notable.
Further analysis of the data shows that, considering "acute and
unspecified appendicitis" (ICD10 K35 & K37) and "other appendicitis"
(K36) together, of the 268 623 NSAP cohort 6274 (2%) children were
admitted with appendicitis within the first year after their NSAP
admission. We excluded cases where appendicitis occurred on the same
admission record as the code for NSAP because this was a follow-up study
based on person-days at risk. Of the 6274 children who were admitted with
appendicitis within the first year following an admission with NSAP, 1926
(31% of the 6274) experienced the appendicitis admission within 1-3 days
and 2505 (40%) experienced the appendicitis admission within 1-7 days of
the admission with NSAP. This leaves an excess number of children who do
get admitted with appendicitis some considerable time after the initial
admission with NSAP, as the rate ratio remained significantly high even
after 10 years (1). The small single centre study, described by Dr Di
Mascio and colleagues, with just a short period of time studied between
NSAP and appendicitis, is not comparable with our huge cohort constructed
from linked English national hospital episode statistics with substantial
follow-up.
It is not known what pre-disposes individuals and protects others
from developing acute appendicitis. One can perhaps hypothesise that a
number of these children who were unwell enough to be admitted with NSAP
have appendicular colic as the cause of their pain and may have some
predisposition such as the luminal size or anatomical site of of their
appendicular orifice which may subsequently lead to clinical appendicitis.
Kind regards
1- Diagnostic outcomes following childhood non-specific abdominal
pain: a record-linkage study G C D Thornton, M J Goldacre, R Goldacre, L J
Howarth Arch. Dis. Child. 2016 101:305-309
We support any idea or initiative to try to better understand the
covariates of paracetamol PK in neonates, including the potential impact
of excipients (propylene glycol, mannitol or none) on paracetamol
clearance.
We have carefully read the e-letter of Pisapia et al., and support
the potential impact of mannitol co-administration on paracetamol
clearance, however, we do have some relevant additional comments...
We support any idea or initiative to try to better understand the
covariates of paracetamol PK in neonates, including the potential impact
of excipients (propylene glycol, mannitol or none) on paracetamol
clearance.
We have carefully read the e-letter of Pisapia et al., and support
the potential impact of mannitol co-administration on paracetamol
clearance, however, we do have some relevant additional comments.
First, in the initial versions of the paper, we have explored the
potential impact of the different study as an indicator for potential
differences, including excipients, but this turned out to be negative.
This is a common practice for pooled datasets. This does not mean that
there is no impact, but it did not reach sufficient impact to be
quantified in this cohort of 150 neonates or has been superimposed by
other variables;
Second, if mannitol stimulates diuresis, it is not very likely to
affect paracetamol clearance since urinary elimination of paracetamol is a
very minor route of elimination in neonates, while sulphation and
glucuronidation are the most important contributors (1,2). For drugs
eliminated by renal route, the impact may be more relevant.
Finally, and in order to correct the suggestions made, the estimates
should correct for the 'real doses' administered, commonly below 60
mg/kg/24h while the impact of paracetamol administration on hemodynamics
in both neonates and healthy adult volunteers have been quantified (3,4).
References
1) Allegaert K, de Hoon J, Verbesselt R, Vanhole C, Devlieger H,
Tibboel D. Intra- and interindividual variability of glucuronidation of
paracetamol during repeated administration of propacetamol in neonates.
Acta Paediatr 2005;94:1273-9.
2) Krekels EH, van Ham S, Allegaert K, et al. Developmental changes rather
than repeated administration drive paracetamol glucuronidation in neonates
and infants. Eur J Clin Pharmacol 2015;71:1075-82.
3) Allegaert K, Naulaers G. Haemodynamics of intravenous paracetamol in
neonates. Eur J Clin Pharmacol 2010;66:855-8.
4) Chiam E, Weinberg L, Bailey M, McNicol L, Bellomo R. The haemodynamic
effects of intravenous paracetamol (acetaminophen) in healthy volunteers:
a double-blind, randomized, triple crossover trial. Br J Clin Pharmacol
2016;81:605-12.
Dear editor,
In their study G C D Thornton and al (1) found a diagnosis of appendicitis
in 6065 children out of 268623, previously diagnosed as non specific
abdominal pain (NSAP) at the first access, who returned within one year.
According to their data, the RR to develop appendicitis in the first year
after discharge with a diagnosis of NSAP is 15.04 times higher than the
risk in the control cohort. Appendicitis is an a...
Dear editor,
In their study G C D Thornton and al (1) found a diagnosis of appendicitis
in 6065 children out of 268623, previously diagnosed as non specific
abdominal pain (NSAP) at the first access, who returned within one year.
According to their data, the RR to develop appendicitis in the first year
after discharge with a diagnosis of NSAP is 15.04 times higher than the
risk in the control cohort. Appendicitis is an acute disease with a rapid
development (2) and, as expected for an acute condition, the RR gets down
considerably after the first year (RR 3.26 at 1-4 years; 2.13 at 5-9
years).
We recently evaluated patients readmitted to our emergency department,
from March 2015 to September 2015, with a previous diagnosis of abdominal
pain without a defined cause: we had 37 patients hospitalized for
appendicitis, 23 of them were diagnosed at the first access, 6 returned
within 72 hours, other 7 cases were readmitted within 7 days, and only one
returned in more than a week.
It could be interesting to know how many patients with appendicitis in the
Thornton's series were readmitted in an acute setting (defined as
readmission within 72 hours) or in the first week after discharge. A high
number of early readmissions would strongly clarify this otherwise very
puzzling connection.
Bibliography
1- Diagnostic outcomes following childhood non-specific abdominal
pain: a record-linkage study G C D Thornton, M J Goldacre, R Goldacre, L J
Howarth Arch. Dis. Child. 2016 101:305-309
2- Appendicitis. Lewis SR, Mahony PJ, Simpson J. BMJ. 2011 Oct
6;343:d5976
Thyroid hormone is critical for normal growth and brain development,
and hypothyroidism in infancy is the leading cause of intellectual
impairment worldwide.
Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones
at birth.
Congenital hypothyroidism is very important clinically since severe cases
will lead to irreversible mental handicap without prompt treatment.
Thyroid hormone is critical for normal growth and brain development,
and hypothyroidism in infancy is the leading cause of intellectual
impairment worldwide.
Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones
at birth.
Congenital hypothyroidism is very important clinically since severe cases
will lead to irreversible mental handicap without prompt treatment.
The essential role of thyroid hormones in brain development during
the first 24-36 months of age is well established; thus prompt
normalization of thyroid hormone levels is essential .
The incidence of CH diagnosed by neonatal screening varies per population,
ranging from 1 in 2000 to 1 in 3000 births and is comparatively higher
than the reported incidence prior to the era of screening.
Following clinical assessment, a good venous blood sample for
measurement of free thyroxine (fT4) and TSH is mandatory, since the result
reflects the presence and severity of congenital hypothyroidism.
Compared to venous serum, the concentrations in skin puncture serum
were higher for thyroid stimulating hormone (TSH) (86.7%). Capillary TSH
dried blood spot testing on the 3rd-5th day is the most sensitive method.
In our setup we could use only venous blood TSH levels rather than
capillary blood samples reason may be having expert nursing care to
collect the blood samples but not having sufficient infrastructure and
personnel to implement the same.
In our experience 4 babies out of 1500 had transient elevated TSH
levels which on follow up normalized within 3 weeks after birth without
treatment. There was no proved case of congenital hypothyroidism was seen
probable reasons may be use of common salt fortified with iodine for
cooking and staple diet being mainly fish.
In countries that can afford newborn screening, treatment within the
first 28 days of life - so-called 'early treatment' - has transformed the
outlook for children with CH so that severe growth retardation with mental
handicap(congenital hypothyroidism) is no longer seen.
It is described as primary when the gland itself is affected and
central when the defect lies in the hypothalamo-pituitary axis;
compensated when the hypothalamo-pituitary-thyroid axis is jeopardised but
still manages to maintain normal thyroxine (T4) levels and decompensated
when normal thyroid hormone levels cannot be maintained.
Van der Sluijs Veer et al. studied 95 toddlers with CH in whom L-
thyroxine treatment had been started at a median age of 9 days, with
normalization of the serum free T4 concentration within 2.1 days and of
the serum TSH level within 18.6 days.
Cord FT4 identifies only infants with severe CH. Cord TSH is more
sensitive than cord FT4 screening. Capillary TSH dried blood spot testing
on the 3rd-5th day is the most sensitive method.
In our experience it was found that serum thyrotropin values at 2nd and
3rd day were useful in screening and early treatment of congenital
hypothyroidism.
References :
Nikolina Zdraveska, Violeta Anastasovska and Mirjana Kocova.
Frequency of thyroid status monitoring in the first year of life and
predictors for more frequent monitoring in infants with congenital
hypothyroidism. J Pediatr Endocrinol Metab 2016; aop
Ari J. Wassner and Rosalind S. Brown. Hypothyroidism in the Newborn
Period. Curr Opin Endocrinol Diabetes Obes. 2013 Oct; 20(5): 449-454. doi:
10.1097/01.med.0000433063.78799.c2
Deladoey J, Ruel J, Gigu?re Y, et al. Is the incidence of congenital
hypothyroidism really increasing? A 20-year retrospective population-based
study in Quebec. J Clin Endocrinol Metab 2011;96:2422-9.
Grosse SD, Van Vliet G. Prevention of intellectual disability through
screening for congenital hypothyroidism: how much and at what level? Arch
Dis Child 2011;96:374-9.
Corbetta C, Weber G, Cortinovis F, Calebiro D, Passoni A, Vigone MC
et al. A 7-year experience with low blood TSH cutoff levels for neonatal
screening reveals an unsuspected frequency of congenital hypothyroidism
(CH). Clin Endocrinol (Oxf). 2009 Nov;71(5):739-45. doi: 10.1111/j.1365-
2265.2009.03568.x. Epub 2009 Mar 28.
Hardy JD, Zayed R, Doss I, Dhatt GS. Cord blood thyroxine and thyroid
stimulating hormone screening for congenital hypothyroidism: how useful
are they? J Pediatr Endocrinol Metab. 2008 Mar;21(3):245-9.
Hardy JD1, Zayed R, Doss I, Dhatt GS. Cord blood thyroxine and
thyroid stimulating hormone screening for congenital hypothyroidism: how
useful are they? J Pediatr Endocrinol Metab. 2008 Mar;21(3):245-9.
Heyerdahl S. Long-term outcome in children with congenital
hypothyroidism. Acta Paediatr 2001;90:1220-2.
Falch DK. Clinical chemical analyses of serum obtained from capillary
versus venous blood, using Microtainers and Vacutainers. Scand J Clin Lab
Invest. 1981 Feb;41(1):59-62.
We have found very interesting the paper by Dr Allegaert et al. about
iv paracetamol pharmacokinetics (1) in which they referred that between-
subject variability (BSV) is explained by covariates such as size, weight,
disease characteristics or co-administration of drugs. They mentioned that
they found an unexplained variance in paracetamol clearance, and that it
remained high (39,1 per cent) even a...
We have found very interesting the paper by Dr Allegaert et al. about
iv paracetamol pharmacokinetics (1) in which they referred that between-
subject variability (BSV) is explained by covariates such as size, weight,
disease characteristics or co-administration of drugs. They mentioned that
they found an unexplained variance in paracetamol clearance, and that it
remained high (39,1 per cent) even after taking size, age and bilirubin
into account.
Regarding the co-administration of drugs as a covariate, an issue
that was not addressed in the paper, we would like to note that the
neonates included in the pooled analysis (n: 158) were from different
studies and had been administered three different iv paracetamol
formulations; one of them (Perfalgan) with a considerable amount of
mannitol (3,85g/100ml) as excipient. Thus, the
neonates in study 3 (n: 50) were administered every 6 hours a concomitant
mannitol dose of 58 mg/Kg with each paracetamol dose of 15 mg/Kg; they
received 232 mg/Kg/day of mannitol during 2 to 7 days.
The amount of mannitol included as excipient in pharmaceutical
products licensed for adults and children is considered a non-active
ingredient because it is far below the pharmacologically significant dose
for them. However, it could be enough to show an osmotic diuretic effect
in neonates, especially in low weight preterm infants. This enhanced
osmotic effect would be greater in the most immature neonates and would
decline logarithmically during the first few weeks of life(2). The osmotic
diuretic effect of the same dose of mannitol could be considerably
different in accordance with the maturation of the renal function.
In Argentina iv paracetamol is available only since last year, with
mannitol as excipient.
In 2006 we had seen that a low amount of mannitol could have some
influence on the less oliguria observed with ibuprofen compared to
indomethacin for PDA closure.(3)
Last year, a new investigation by Chiam et al. showed that the majority of
the formulations with 1g iv paracetamol also contain near 4g of mannitol
(38-39mg/ml). They explained that this low amount of mannitol was a
clinically relevant dose which might cause hypotension in critically ill
adults due to its diuretic nature even in low doses.(4)
The fact that only 1/3 of neonates (50/158) in Allegaert et als study
were co-administered a concomitant diuretic dose of mannitol should be
considered, as it could have contributed to the extensive variability and
the unexplained high variance they found in iv paracetamol clearance.
Further research is necessary to evaluate the effects of low doses of
mannitol in neonates, especially in low birth weight infants, and to
determine how iv paracetamol pharmacodynamics and pharmacokinetics are
influenced, if so, by the mannitol content of the medication.
Jorge Pisapia. Matias Lucero. Leonardo Giunta.
Clinica y Maternidad Suizo Argentina. Department of Pharmacy. SWISS
MEDICAL GROUP. Buenos Aires. Argentina.
REFERENCES
1- Allegaert K, Palmer GM, Anderson BJ. The pharmacokinetics of
intravenous paracetamol in neonates: size matters most. Arch Dis Child
2011; 96:575???580.
2- Kleinman LI, Disney TA. Renal osmotic in the neonatal and adult
dog. Am J Physiol Renal Physiol 1984; 247 Issue 3 F396-F402.
3- Pisapia J, Giunta L, Alonso MR. Mannitol influence on the less
renal side effects of ibuprofen vs indomethacin for PDA closure. Arch Dis
Child
2003;88:1135.adc.bmj.com/content/88/12/1134.full/reply#archdischild_el_1881
Jan 2006
4- Chiam E, Weinberg L, Bellomo R. Paracetamol: a review with
specific focus on the haemodynamic effects of intravenous administration.
Heart Lung Vessel 2015; 7(2):121-32.
The MCS research by Massion and colleagues on childhood obesity
should be read in the light of other recent cohort studies exploring the
impact of early life factors in the UK and the USA (1). Kimbro and
Augustine found that US children living in married two biological parent
households had a lower risk of obesity than those living in other family
types. In the presence of other controls, poverty was not a significant
r...
The MCS research by Massion and colleagues on childhood obesity
should be read in the light of other recent cohort studies exploring the
impact of early life factors in the UK and the USA (1). Kimbro and
Augustine found that US children living in married two biological parent
households had a lower risk of obesity than those living in other family
types. In the presence of other controls, poverty was not a significant
risk factor for childhood obesity (2).
The reported associations of childhood obesity with parents'
educational attainment and smoking status are certainly important. Goodman
and Greaves, using the MCS, found that the educational attainment of
mothers was the strongest predictor of cognitive and social development in
children born in two parent households. This attenuated a significant
effect of parental marriage. Early parental separation had a major impact
on cognitive and social development, and this was much more common among
unmarried couples (3). Also, unmarried adults are more likely to smoke
(4).
Conclusions about the impact of early life factors on health
inequalities for children cannot be made without controlling for family
structure. Some of the reported findings of this research might be
confounded by the marital status of parents and parental separation.
1. Massion S, Wickham S, Pearce A, Barr B, Law C, Taylor-Robinson D.
Exploring the impact of early life factors on inequalities in risk of
overweight in UK children: findings from the UK Millenium Cohort Study.
Arch Dis Child 2016
2. Augustine J, Kimbro R. Family Structure and Obesity among US
Children. Journal of Applied Research on Children 2013
3. Goodman A, Greaves E. Cohabitation, marriage and child outcomes.
IFS Commentary C114 2010
4. Adult Smoking Habits in Great Britain: 2014. ONS 2016
In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety
netting advice and its documentation...
In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety
netting advice and its documentation in the medical notes, the authors
propose the introduction of a checklist. However, at this moment the
effective components or the best way to perform this safety netting
management still remains unknown.
A systematic review of Neill et al. states that incomplete
information on the illness of their child leaves parents still in need for
help.(1) Moreover, irrelevant information reduces parents' trust in the
intervention.(1) We know that parental knowledge and satisfaction improved
more after video discharge instructions than after written discharge
instructions alone.(2) So to proceed we think the next step is to focus on
the parental role in the decision making process. One could think of
parental monitoring of alarming signs and symptoms of their febrile child.
A study on self-referred children with fever emphasized that many parents
properly judged and acted on their febrile child's severity of illness.(3)
In England every parent is trained to recognise petechial rash,(4) we
might enlarge this knowledge to other alarming or reassuring signs and
symptoms. This could be initiated for example for respiratory rate, a
useful marker of pneumonia, one of the most frequent serious illness at
the ED.(5) We are aware of current projects on this topic. A next step is
evaluating the impact of such strategies providing improved information on
patient (re)consultation.
In addition to the recognition of deterioration, an important gap in
safety netting literature is its time frame strategy. The development of
optimal safety netting management should include clinical signs and
symptoms, but also a disease specific time frame to inform parents when
they should seek help again. This combination of safety netting
determinants may establish new starting points for improvement of care.
References:
1. Neill S, Roland D, Jones CH, Thompson M, Lakhanpaul M, group ASs.
Information resources to aid parental decision-making on when to seek
medical care for their acutely sick child: a narrative systematic review.
BMJ Open. 2015;5:e008280 doi: 10.1136/bmjopen-2015-008280 [published
Online.
2. Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to
standard written instructions improved caregivers' understanding of their
child's emergency department visit, plan, and follow-up: a randomized
controlled trial. Pediatr Emerg Care. 2013;29:699-704 doi:
10.1097/PEC.0b013e3182955480 [published Online.
3. van Ierland Y, Seiger N, van Veen M, et al. Self-referral and serious
illness in children with fever. Pediatrics. 2012;129:e643-51 doi:
10.1542/peds.2011-1952 [published Online.
4. Acutely sick kid safety netting interventions for families.
http://asksniff.org.uk/
5. Taylor JA, Del Beccaro M, Done S, Winters W. Establishing clinically
relevant standards for tachypnea in febrile children younger than 2 years.
Arch Pediatr Adolesc Med. 1995;149:283-7 Online.
Bronchiolitis is on rise, both in prevalence and severity in our
country due to many social and life style factors. in our hospital we
adopted a protocol named: SuProNO INCLUDE:-
- PROVIDE VITAL SIGN ASSESSMENT and close monitoring
- PROVIDE O2 AS NEEDED
- Provide IV fluid/ NGT Feeds as appropriate
-provide Hypertonic (3%) saline nebulization
-provide nasal decongestant drops/ spray and suctioning as needed
- provide anti...
Bronchiolitis is on rise, both in prevalence and severity in our
country due to many social and life style factors. in our hospital we
adopted a protocol named: SuProNO INCLUDE:-
- PROVIDE VITAL SIGN ASSESSMENT and close monitoring
- PROVIDE O2 AS NEEDED
- Provide IV fluid/ NGT Feeds as appropriate
-provide Hypertonic (3%) saline nebulization
-provide nasal decongestant drops/ spray and suctioning as needed
- provide antipyretics if needed
-NO NO NO antibiotics
NO NO NO steroids.
with this protocol, the out come is excellent even for severe cases,
with short hospitalization, and no need for high facility respiratory
support like CPAP or ventilator.
Dear Sir,
McNeilly et al. (1) recently reported the results of their 5 year retrospective study detailing frequency and aetiology of hypercalcaemia in children (defined as total calcium >2.90mmol/l). Of those with sustained hypercalcaemia (elevated levels for >2 consecutive days), neonates were over-represented (42%), and suspected sepsis was the single most common cause (24%). The authors hypothesis regar...
Any paediatrician would welcome this necessary article, which should already be a benchmark of our routine daily practice. However I wondered if it missed an opportunity on advocacy having a role in making the childrens' own voices being heard. One such example is the recently published RCPCH Research Charter [1]. We as paediatricians can bring influence to create opportunities for your patients and their siblings and the...
Dear Editor,
We thank Dr Di Mascio and his colleagues for their interest in our study. In response we would like to point out that only a very small proportion (5.8%) of the children admitted with NSAP were subsequently hospitalised with bowel pathology (1). The increased relative risk of being diagnosed with appendicitis in the first year following a diagnosis of NSAP is clearly notable.
Further anal...
We support any idea or initiative to try to better understand the covariates of paracetamol PK in neonates, including the potential impact of excipients (propylene glycol, mannitol or none) on paracetamol clearance.
We have carefully read the e-letter of Pisapia et al., and support the potential impact of mannitol co-administration on paracetamol clearance, however, we do have some relevant additional comments...
Dear editor, In their study G C D Thornton and al (1) found a diagnosis of appendicitis in 6065 children out of 268623, previously diagnosed as non specific abdominal pain (NSAP) at the first access, who returned within one year. According to their data, the RR to develop appendicitis in the first year after discharge with a diagnosis of NSAP is 15.04 times higher than the risk in the control cohort. Appendicitis is an a...
Thyroid hormone is critical for normal growth and brain development, and hypothyroidism in infancy is the leading cause of intellectual impairment worldwide. Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones at birth. Congenital hypothyroidism is very important clinically since severe cases will lead to irreversible mental handicap without prompt treatment.
The essential role of thyroid...
To the editor:
We have found very interesting the paper by Dr Allegaert et al. about iv paracetamol pharmacokinetics (1) in which they referred that between- subject variability (BSV) is explained by covariates such as size, weight, disease characteristics or co-administration of drugs. They mentioned that they found an unexplained variance in paracetamol clearance, and that it remained high (39,1 per cent) even a...
The MCS research by Massion and colleagues on childhood obesity should be read in the light of other recent cohort studies exploring the impact of early life factors in the UK and the USA (1). Kimbro and Augustine found that US children living in married two biological parent households had a lower risk of obesity than those living in other family types. In the presence of other controls, poverty was not a significant r...
Dear editor,
In their letter, colleagues Jacob et al. raised further evidence of the lack of standardised safety netting. We thank them for their comments emphasizing the disparity between paediatric trainees' perception of their safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety netting advice and its documentation...
Bronchiolitis is on rise, both in prevalence and severity in our country due to many social and life style factors. in our hospital we adopted a protocol named: SuProNO INCLUDE:- - PROVIDE VITAL SIGN ASSESSMENT and close monitoring - PROVIDE O2 AS NEEDED - Provide IV fluid/ NGT Feeds as appropriate -provide Hypertonic (3%) saline nebulization -provide nasal decongestant drops/ spray and suctioning as needed - provide anti...
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