At the risk of being accused of raising a trivial issue, I would
simply like to ask authors to quote accurately from references within
their articles. I am concerned in particular about the study of the
respiratory outcome of children of very low birthweight reported recently
by Anand and colleagues.[1] They quote the results of a similar study of
younger children, which we reported some years ago in...
At the risk of being accused of raising a trivial issue, I would
simply like to ask authors to quote accurately from references within
their articles. I am concerned in particular about the study of the
respiratory outcome of children of very low birthweight reported recently
by Anand and colleagues.[1] They quote the results of a similar study of
younger children, which we reported some years ago in this journal.[2]
Interestingly, the results were similar, suggesting that the functional
outcome for low birth weight children was independent of respiratory
support in the neonatal period, and independent of IUGR (“small for dates”
in our rather old fashioned terminology). We found a highly significant
linear relationship between the FEV 0.75 at the age of 7, and birthweight.
Anand and colleagues quote our study as showing “significant
differences between those who received ventilatory support and those who
did not”. This contradicts even a selected reading of the final line of
our abstract, which stated that “the absence of an association between
neonatal oxygen score or mechanical ventilation and childhood lung
function suggests that the long term effect of neonatal respiratory
treatment is small compared with that of low birth weight…..”. It is
gratifying that the two studies come to similar conclusions, but
disappointing to be utterly misquoted.
References
(1) D Anand, C J Stevenson, C R West, P O D. Pharoah. Lung function and
respiratory health in adolescents of very low birth weight. Arch Dis Child
2003;88:135-138.
(2) K N Chan, C M Noble-Jamieson, A Elliman, E M Bryan, M Silverman. Lung
function in children of low birth weight. Arch Dis Child 1989; 64:1284-1293.
Fulton et al. might also have included obstetricians and midwives in
their reminder to health professionals about the importance of vitamin D
supplementation. For many years a Reference Nutrient Intake of 10
micrograms per day has been set for pregnancy.[1] This will not be met by
diet yet the proportion of pregnant women nationally taking vitamin D
supplements is negligible, even amongst women...
Fulton et al. might also have included obstetricians and midwives in
their reminder to health professionals about the importance of vitamin D
supplementation. For many years a Reference Nutrient Intake of 10
micrograms per day has been set for pregnancy.[1] This will not be met by
diet yet the proportion of pregnant women nationally taking vitamin D
supplements is negligible, even amongst women who could be considered at
risk by virtue of culture or ethnic group. In consequence a recent study
in South Wales, for example, showed that over 50% of women in some ethnic
groups (particularly African and South Asian) had plasma 25-
hydroxycholeciferol concentrations consistent with deficiency.[2]
It is particularly disappointing that the recent NICE guideline on
antenatal care [3]concluded on the basis of a Cochrane review of only two
randomized trials involving 232 women: [4] “There is insufficient evidence to
evaluate the effectiveness of vitamin D in pregnancy”. The more so since
one of these studies indicated both a significant reduction in the
proportion of babies with neonatal hypocalcaemia and fewer of low weight
for gestation. These observations suggest that one should not fall into
the prevalent trap of construing the absence of level 1 evidence as
absence of effect. The overall case for vitamin D supplementation in
pregnancy as a public health measure remains compelling5.
References
1. Committee on Medical Aspects of Food Policy (COMA), Panel on
Dietary Reference Values. Dietary reference values for food energy and
nutrients for the United Kingdom. Report on Health and Social Subjects
(41). 1991. London, Her Majesty's Stationery Office.
2. Datta S, Alfaham M, Davies DP, Dunstan F, Woodhead S, Evans J et
al. Vitamin D deficiency in pregnant women from a non-European ethnic
minority population--an interventional study. BJOG: an International
Journal of Obstetrics & Gynaecology 2002;109:905-8.
3. NICE. Antenatal care: routine care for the healthy pregnant
woman. Compilation: Summary of Guidance issued to the NHS in England and
Wales. 2003, Issue 7, 127-160.
4. Mahomed K,.Gulmezoglu AM. Vitamin D supplementation in pregnancy
(Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester,
UK: John Wiley and Sons Ltd.
5. Wharton, B. and Bishop, N. Rickets. Lancet 362(October 25), 1389-
1400. 2003.
We thank Tullus and Brennan for their acknowledgement of the value of
our recently published Blood Pressure Centiles for Great Britain.
They have compared our centiles with those published in the USA [1],
and make a number of comments based on these observations, which we seek
to address below. However, we would like to preface our responses with a
comment. Few, if any, would feel it appropriate to use US refer...
We thank Tullus and Brennan for their acknowledgement of the value of
our recently published Blood Pressure Centiles for Great Britain.
They have compared our centiles with those published in the USA [1],
and make a number of comments based on these observations, which we seek
to address below. However, we would like to preface our responses with a
comment. Few, if any, would feel it appropriate to use US references for
height and weight, or other anthropometric measures in British children.
Inevitably, our centiles, even if presented in the same way as the US
data, would differ significantly. In marked contrast to the US data, the
blood pressure measurements in the subjects included in our analysis were
based on nationally representative samples of British children, obtained
using the same type of blood pressure monitor throughout (Dinamap 8100,
Critikon, Tampa, Florida, USA), to a very rigorous protocol. As such, we
believe these centiles are the most accurate characterisation of normal
blood pressure in children and young adults in any country yet published.
Tullus and Brennan ask why our centiles are based on age, rather than
height. We examined this relationship in detail in our paper. Current US
centiles are height- rather than age-based. However, it should be borne
in mind that the studies from which the US centiles were derived were non-
representative studies, using a range of methodologies. In contrast to
what was observed in the US data, we found a negative effect of height on
blood pressure after adjusting for weight. In other words, at any given
weight, a taller child would have lower blood pressure. This effect was
most pronounced for systolic blood pressure, but was also seen, albeit
weakly, in diastolic blood pressure. We have reanalysed our data to
clarify the relative importance of height and weight. For systolic blood
pressure the percentage variation explained by weight and height together
was 8.1%, while with weight alone (ignoring height) it was 7.9%, i.e.
almost the same. Conversely, controlling for height (and ignoring weight)
explained only 2.4% of the variation, so by far the largest effect on
blood pressure comes from weight not height. It would be possible in
principle to construct centiles adjusted both for age and weight, but we
are unclear how useful they would be. We would very much welcome a debate
on how to depict the data to best clinical advantage. Either way we are
clear that, based on the British data, it would be quite inappropriate to
express centiles by height.
Tullus and Brennan ask whether methodological flaws or rising obesity
rates might contribute to the observed strong positive association between
weight and blood pressure. The effect of weight on blood pressure applies
across the weight spectrum, not just in the small proportion of obese
subjects. The mean BMI SDS of the sample was +0.3 to +0.4 with an SD of
1.1, confirming a wide range of values. It is unlikely that obesity has
contributed more than a small amount to the strong weight-blood pressure
relationship.
The methodology used in the health surveys was rigorous and
consistent, with arm circumference being measured to determine the
appropriate cuff-size. Accordingly we do not accept that incorrect cuff
size played any significant part in determining the observed relationship
between weight and blood pressure.
Secondly, Tullus and Brennan criticise our adoption of the 98th
centile to define high blood pressure for age. US blood pressure centiles
define those above the 95th centile for blood pressure as having
hypertension. Other US centile charts also use the 5th and 95th centiles
to define normality. We do not feel that an arbitrary centile-based
definition of hypertension in childhood is appropriate. Such a definition
would inevitably define significant numbers of normal healthy children as
having hypertension. We note that Tullus and Brennan are themselves
unsure as to the appropriateness of using the 95th centile as the upper
limit of normality. We prefer the terms high and high-normal blood
pressure for age. We additionally suggest that the term hypertension be
reserved for children with high blood pressure and evidence of
pathological cause or effect.
Ultimately, a centile chart is a tool to inform clinical assessment
and decision-making. In keeping with other centile charts in use in Great
Britain, we chose to adopt the same standard nine-centile format ranging
from the 0.4th to 99.6th centiles [2]. In clinical practice, the
difference between the 95th and 98th centiles is of little practical
consequence. However, as requested by Tullus and Brennan, and
acknowledging the potential clinical value to clinicians following
internationally accepted treatment protocols, we here include charts
amended to include the 95th centile for systolic and diastolic blood
pressure.
On the third point raised by Tullus and Brennan, we concur that blood
pressure measurements using automated oscillometric devices are commonly a
little higher [3] than those seen using manual techniques, and this may
account for some of the differences between the US and British centiles.
For this reason we enjoin caution when referencing blood pressures derived
manually, to the published centiles. Nevertheless, we strongly believe
that our centiles are much more relevant for use in Great Britain,
particularly when automated oscillometric blood pressure measurements are
increasingly the norm [4].
1. National Blood Pressure Education Working Group on High
Blood Pressure in Children and Adolescents. Fourth report on the
diagnosis, evaluation and treatment of high blood pressure in children and
adolescents: a working group report from the National High Blood Pressure
Education Program. Pediatrics 2004;114:555-76.
2. Freeman JV, Cole TJ, Chinn S, et al. Cross sectional stature
and weight reference curves for the UK, 1990. Arch Dis Child 1995;73:17-
24.
3. O'Brien E, Petrie J, Littler W, et al. The British
Hypertension Society protocol for the evaluation of automated and semi-
automated blood pressure measuring devices with special reference to
ambulatory systems. J Hypertens 1990;8:607-19
4. O'Brien E. Demise of the mercury sphygmomanometer and the
dawning of a new era in blood pressure measurement. Blood Press Monit
2003;8:19-21.
Text to accompany modiefied Blood Pressure figures:
Fig.1a-d Centiles for systolic and diastolic blood pressure in
children and young adults 4-24y of age, modified to include 95th centile.
The potential for furosemide to exacerbate the maladaptive processes
involved in the worsening of heart failure(1) can, at least in theory, be
mitigated by the use of torasemide in preference to furosemide, given the
fact that the former agent is characterised by antialdosterone as well as
by antifibrotic properties(2)(3), which, in combination, have the
potential to enhance the process of reverse remo...
The potential for furosemide to exacerbate the maladaptive processes
involved in the worsening of heart failure(1) can, at least in theory, be
mitigated by the use of torasemide in preference to furosemide, given the
fact that the former agent is characterised by antialdosterone as well as
by antifibrotic properties(2)(3), which, in combination, have the
potential to enhance the process of reverse remodeling. Whereas,
presently, vasodilatation and afterload reduction are the guiding
principles of heart failure management(1), the new frontier ought now to
be the optimisation of opportunities to enhance reverse remodeling, the
latter exemplified by the significant(p < 0.01) improvement in left
ventricular ejection fraction following the combined use of spironolactone
and angiotensin receptor blockade(4). The combined use of spironolactone and components of the renin-angiotensin system has also been documented to reduce loop diuretic rquiremnents (as shown by the occurence of uraemia following addition of spironolactone to combined angiotensin converting enzyme(ACE) inhibitor and loop diuretic therapy)(5), thereby potentially leading to de-activation of the maladaptive cascade. The
reduction in loop diuretic requirements is attributable to the fact that
the natriuresis resulting from the combined use of spironolactone and ACE
inhibition is greater than the natriuresis attributable to the use of
either agent on its own(6). The processes outlined above(5)(6) might be
the ones at work in those heart failure patients(some of whom were on loop
diuretics) who experienced an increase in serum creatinine by a mean value
of 24 mcmol/l(p < .05) during combined treatment with spironolactone
and angiotensin receptor blockade(4). What these outcomes(4)(5)(6) mean,
in practical terms, is that the combined use of spironolactone and
blockade of the renin-angiotensin system(either at ACE level or at the
level of the angiotensin receptor) should be attended by vigilant
monitoring of blood volume status so as to pre-empt pre-renal uraemia by
appropriate titration of loop diuretic dose(7).
Opportunities for optimisation of reverse remodeling exist , not only in
the context of left ventricular systolic failure(4), but also in patients
such as those with hypertension, who are at risk of left ventricular
diastolic failure. In the hypertensive category, which is acknowledged to
be in need of increasing recognition in the young(8), the use of
angiotensin receptor blockade not only enhances reverse remodeling(by
reversing left ventricular hypertrophy)(9), but also reduces new-onset
atrial fibrillation(AF)(10), thereby delaying the onset of AF-related
heart failure and tachycardia-related cardiomyopathy. In conclusion, the
natural history of heart failure can be favourably modified by enhancing
reverse remodeling,not only in the context of clinically overt left
ventricular systolic failure but also in potential candidates for left
ventricular diastolic failure.
References:
(1) Fenton M., Burch M
Understanding chronic heart failure
Archives of Disease in Childhood 2007:92:812-16.
(2)Uchida T., Yamanage K., Nishikawa M et al
Anti-aldosterone effect of torasemide
European Journal of Pharmacology 1991:205:145-50.
(3) Lopez B., Querejata R., Gonzalez A et al
Effect of loop diuretics on myocardial fibrosis and collagen type 1
turnover in chronic heart failure
Journal of the American College of Cardiology 2004:43:2028-35.
(4) Chan KY., Sanderson JE., Wang T et al
Aldosterone receptor antagonism induces reverse remodeling when added to
angiotensin receptor blockade in chronic heart failure
Journal of the American College of Cradiology 2007:50:591-6.
(5) Ikram H., Webster MWI., Nicholls MG et al
Combined spironolactone and converting enzyme inhibitor therapy for
refractory heart failure
Australian and New Zealand Journal of Medicine 1986:16:61-3.
(6) Bauersachs J., Fraccarollo D., Ertl G et al
Striking increase in natriuresis by low-dose spironolactone in congestive
heart failure only in combination with ACE inhibition. Mechanistic
evidence in support of RALES
Circulation 2000:102:2325-8.
(7) Jolobe,O
Drug therapy in chronic heart failure(letter)
Postgraduate Medical Journal 2004:80:247.
(8) Hansen ML.,Gunn PW., Kaelber DC
Underdiagnosis of hypertension in children and adolescents
Journal of the American Medical Association 2007:298:847-9.
(9) Okin PM., Wachtell K., Devereux RB et al
Regression of electrocardiographic left ventricular hypertrophy and
decreased incidence of new-onset atrial fibrillation in patients with
hypertension
Journal of the American Medical Association 2006:296:1242-8.
(10) Wachtell K., Lehto M., Gerdts E et al
Angiotensin II receptor blockade reduces new-onset atrial fibrillation and
subsequent stroke compared to atenolol
Journal of the American College of Cardiology 2005:45:712-9.
Smith’s letter responding to our paper (1) examining the issues
around service improvement for children with epilepsies is very welcome.
His letter and paper (2) provide useful data and insight which is helpful
when considering how national recommendations could or should translate
into the ‘real world’.
Many long-term paediatric conditions benefit from designated services
with defined p...
Smith’s letter responding to our paper (1) examining the issues
around service improvement for children with epilepsies is very welcome.
His letter and paper (2) provide useful data and insight which is helpful
when considering how national recommendations could or should translate
into the ‘real world’.
Many long-term paediatric conditions benefit from designated services
with defined paediatricians and specialist nurses. One difficulty
providing such a service for children with epilepsies is not just the
need, but the greater number of children involved. The reality is that
unlike diabetes and cystic fibrosis there are often too many children for
a single paediatrician.
Smith therefore rightly emphasises one possibility of establishing a
lead paediatrician for epilepsy, who would see a proportion of such
children, as well as a Specialist Epilepsy Nurse, who would see all
children with epilepsy. This would seem a vital first step in the
evolution of services.
However it remains important, that if this model is followed
initially, that other paediatricians diagnosing and managing epilepsy are
appropriately supported in that role. We would challenge any concept of
“easy epilepsy” which sometimes arises when discussions occur on how
children might be shared across secondary level services. There is no
reason to suspect that the rates and consequences of misdiagnosis of
epilepsy are less in children with infrequent or transient seizures
compared to those with ‘intractable’ seizures referred to tertiary
services. Although it is true that in some children the diagnosis of
epilepsy is clear, there is often nothing easy about interpreting EEG
reports, refining the diagnosis to an appropriate epilepsy syndrome,
communicating risks and then enabling tailored treatment and
communication. If children with epilepsies are to be ‘shared’ much
attention should be given to how they can effectively access the necessary
Specialist Epilepsy Nurse support and how their care can be audited.
The practical calculations regarding an epilepsy service for an
‘averaged-sized’ population outlined by Smith demonstrate that it could be
feasible for all children with epilepsy to have their diagnosis confirmed
and managed by two ‘specialist paediatricians’ and one Specialist Epilepsy
Nurse. In one model, one of those paediatricians could also have
expertise in neurodisability and may choose to concentrate on children
with ‘epilepsy plus’. Designated epilepsy clinics including satellite
tertiary clinics and teenage/transitional clinics could see those children
whose needs are best met in that type of service.
All paediatricians diagnosing and managing children with epilepsies
should have appropriate expertise. All children with epilepsy need access
to a Paediatric Epilepsy Nurse Specialist.
References:
1. Dunkley C, Cross JH. NICE guidelines and the epilepsies: how
should practice change? Arch Dis Child 2006;91:525-8.
2. Smith RA, Philips R. How can epilepsy services best be delivered
in
secondary care? Seizure 2004;13:308-16.
Imaging has been a topic of discussion in all patients with head
injuries. Authors conducted a cross county retrospective audit in Royal
Shrewsbury and Princess Royal Hospitals in 2004 over a period of 6 months.
Our audit findings are very similar to findings of Reed et al1. We looked
at the implication of NICE Guidelines on the present protocol.2 NICE
Guidelines emphasise on the CT scan as the main cho...
Imaging has been a topic of discussion in all patients with head
injuries. Authors conducted a cross county retrospective audit in Royal
Shrewsbury and Princess Royal Hospitals in 2004 over a period of 6 months.
Our audit findings are very similar to findings of Reed et al1. We looked
at the implication of NICE Guidelines on the present protocol.2 NICE
Guidelines emphasise on the CT scan as the main choice of investigation
for head injury. We have ward guidelines based on Royal College of
Surgeons of England and Scottish Intercollegiate Network Guidelines [SIGN]
3. At the current moment we selectively CT children depending on their
neurological status and GCS.
Ninety children admitted were included in this study over a period of 6
months. Only 6 out of these 90 children had significant head injuries
[GCS<13].
A total of 9 children required a CT scan of their head [10%].2 children
had intracranial abnormalities. 45 more would have required a CT scan if
NICE guidelines were strictly adhered to. NICE would result in 5.2 times
more radiation and 2.7 times increase in the cost logistics. 71% children
had skull X-ray performed. Only 10% of these showed evidence of a skull
fracture. 2 of these also had a CT scan which gave the same findings.
Variables, which resulted in increased use of CT, were dangerous mechanism
of injury, amnesia and low GCS. Majority of children presented within 6
hours of injury. Most of the injuries were due to slips and trips.
We concluded that children presenting with head injury had a minor
injury in majority of cases. We do far too many X-Rays. Picking up a skull
fracture by itself does not predict internal injuries in children. We need
to device a system modifying our current one to optimise the use of scans
and reduce skull X-Rays.
References:
1. Reed MJ,BrowningJG,WilkinsonAG,BeattieT Can we abolish skull X
Rays from head injury? Arch Dis child 2005;90: 859-864
2.National institute for clinical excellence [NICE] Clinical Guidance
number 4Head injury, triage, assessment, investigation and early
management of head injury in infants, children and adults. June 2003
3. Royal College of Surgeons of England Report of the working party
on the management of patients of head injuryLondon: Royal College of
Surgeons of England, 1999
We read with great interest the article by SE Jones et al.
highlighting the worrying trend of increasing obesity detected by use of
routinely collected data. In 2002-2003 we carried out a prospective
observational study aimed at estimating the problem of obesity in children
presenting to the outpatient department of Royal Glamorgan Hospital. The
hospital caters to the population of Rhondda, Cynon and...
We read with great interest the article by SE Jones et al.
highlighting the worrying trend of increasing obesity detected by use of
routinely collected data. In 2002-2003 we carried out a prospective
observational study aimed at estimating the problem of obesity in children
presenting to the outpatient department of Royal Glamorgan Hospital. The
hospital caters to the population of Rhondda, Cynon and Taff Ely which are
amongst the most deprived areas in Europe.
We used Weight and height
measurements (which are routinely done for all children visiting the
outpatients), to calculate the Body Mass Index (BMI). These were then
plotted on standard BMI centile charts. Using the guidelines published by
the Child Growth Foundation those above the 98th centile were considered
obese while those between the 91st and 98th centile were classed as
overweight.
Of the 1184 children attending the outpatients, 992 satisfied the
study criteria: those excluded were infants less than 6 months and others
where it was difficult to accurately make these measurements. 133 (13.4%)
were obese and 132 (13.3%) were overweight. Although there was no
difference in the proportion of overweight girls (13.7%)and overweight
boys (13.2%), a higher percentage of girls (15.2%) was significantly obese
compared to boys (11.6%). The percentage of overweight or obese children
from the three valleys was comparable - Rhondda (27%), Taff Ely (27.5%)
and Cynon (29.4%). Only 18.4% of the children coming from outside these
areas were either obese or overweight. Analysis of the various age groups
showed only 13.6% of the infants>6 months and 15.5% of the 1 to 3 year
olds to be obese or overweight. The proportion of overweight or obese
children increased with age to reach 39.5% in 11 to 15 year olds.
The problem of obesity is on the increase and perhaps
disproportionately so in the more deprived areas. Inclusion of a BMI
calculation for all children presenting at any point of healthcare can
help highlighting the problem. This may be specially important in deprived
areas where a chubby child is presumed to be the healthy one.
The hazards of computed tomography (CT), in terms of radiation, are
being increasingly recognized. CT scanning, despite representing less than
5% of the total number of X-ray procedures performed, contributes
approximately 40% of the total collective radiation dose to the UK
population from all medical X-ray examinations.[1] It is well known that
children are more radiosensitive than adults e.g. a 1-yea...
The hazards of computed tomography (CT), in terms of radiation, are
being increasingly recognized. CT scanning, despite representing less than
5% of the total number of X-ray procedures performed, contributes
approximately 40% of the total collective radiation dose to the UK
population from all medical X-ray examinations.[1] It is well known that
children are more radiosensitive than adults e.g. a 1-year-old infant is
10-15 times more likely than a 50-year-old adult to develop a malignancy
from the same dose of radiation.[2] In addition, for a given procedure,
the effective (radiation) dose is larger in a small infant than in an
adult i.e. the effective dose increases as age decreases.[2] It has been
alleged that, “the lifetime mortality risk attributable to the radiation
exposure from a single abdominal CT in a 1-year-old child is in the order
of one in a thousand”.[2] CT scanning, therefore, is a potentially
dangerous modality, and when used in children in particular, the dose
should be kept as low as reasonably achievable (the so-called ALARA
principle).
A recent ‘Images in Paediatrics’ case contained one important piece
of CT information in an otherwise excellent CT image of a lipoblastoma
(admittedly far more immediately dangerous than a CT study).[3] The CT
examination of the lower chest was done in a 6-month-old baby using 250mA
(mA = milliamperage, which is the main determinant of CT dose). Unless
the authors have an extremely old scanner, this is an adult setting and is
much too high for a child. A perfectly good diagnostic study can be done
in an infant of this age with an mA of 50, which is one fifth of the dose.
In fact, an adequate study might even be achievable with an even lower mA,
but the CT scanner manufacturers have been slow to facilitate such low
dose techniques, ignoring the needs of children. Using excessive adult CT
doses in children is, in my experience, an unfortunately common error in
the UK. This has also been noted in the USA.[4] The message is slowing
filtering through to the Radiology community but Paediatricians should be
aware as well. CT is a high dose radiation technique - if a CT study is
truly justified in a child then weight (not age) adapted paediatric
parameters should be used, which can give adequate diagnostic information
with minimized radiation risk.
The recent review of suppression of menstruation by Albanese and
Hopper1 in adolescents with severe learning difficulties is the first
review of its type published in the UK. We have recently looked at the
issues surrounding puberty and management of menstruation in a group of
young women with severe learning difficulties and epilepsy who are living
at a residential school in Cheshire.
The recent review of suppression of menstruation by Albanese and
Hopper1 in adolescents with severe learning difficulties is the first
review of its type published in the UK. We have recently looked at the
issues surrounding puberty and management of menstruation in a group of
young women with severe learning difficulties and epilepsy who are living
at a residential school in Cheshire.
In our cohort there were 21 young women whose ages ranged from 12-20
years. Their age equivalent functional level on Vineland Adaptive and
Behavioural Scales was 1-2 years indicating a high level of supportive
care. Most of the individuals followed a normal pubertal developmental
path. Two had worsening of their seizure frequency around the time of
menstruation.
One third of the young women had no reported problems with menstruation
and did not require any medical management of their periods. In seven
girls dysmenorrhoea and other menstrual disturbances such as menorrhagia
were well managed with combinations of paracetamol and mefenamic acid.
Eight of the young women had taken hormonal treatments for menstruation at
some point. The combined oral contraceptive pill (OCP) was used cyclically
in seven of the young women. This allowed regulation of their menstrual
cycles and often reduction in menstrual flow and associated dysmenorrhoea.
There were no obvious associated benefits surrounding seizure frequency.
Only three of the young women remained on the oral contraceptive pill. It
was stopped in the remainder for reasons including excessive weight gain,
concerns regarding osteoporosis and other unrelated medical problems. One
of the young women still taking the OCP required further treatment with
paracetamol and mefenamic acid around the time of menstruation to further
modify symptoms. Those in whom the OCP was stopped now have their symptoms
managed by combinations of paracetamol and mefenamic acid.
In our practice Depo-Provera is not currently used in these adolescents
because of the concern over decreased acquisition of bone mineral density
in conjunction with the use of anticonvulsants. Norethisterone is
sometimes used to postpone menstruation if requested by the families or
carers.
Most of the carers and families did not have specific concerns relating to
menstrual management documented in the medical notes however it is well
recognised that many families and particularly mothers worry how their
daughters with severe learning difficulties will manage menstruation.
With appropriate support and advice concerns appear to dissipate through
time. The centre is devising an advice leaflet for families’ entitled
‘Practical management of periods’.
Two of the families had considered more definitive surgical management
options in the past however they are not currently pursuing this line of
treatment
We agree there is little evidence to guide clinicians practice in
this area and welcome your review in the first instance to stimulate
debate and encourage further studies.
Mel McMahon, Neurodisability SpR
Margaret Huyton, Associate Specialist
Dan Hindley, Consultant Paediatrician
David Lewis Centre
Mill Lane Warford Alderley Edge Cheshire SK9 7UD
Reference:
1. Albanese A, Hopper NW. Suppression of menstruation in adolescents
with severe learning difficulties. Arch Dis Child 2007;92:629-632.
I read with great interest the recent article by Gupta et al.[1]
Based on a systematic literature review, they conclude that
corticosteroids cannot be recommended in cases of suspected meningococcal
meningitis. However, I would like to make some comments.
In a recent study, the relationship of hypothalamic-pituitary-adrenal
axis to disease severity in children with meningococcal disease w...
I read with great interest the recent article by Gupta et al.[1]
Based on a systematic literature review, they conclude that
corticosteroids cannot be recommended in cases of suspected meningococcal
meningitis. However, I would like to make some comments.
In a recent study, the relationship of hypothalamic-pituitary-adrenal
axis to disease severity in children with meningococcal disease was
assessed.[2] Levels of adrenocorticotropic hormone and cortisol were found
to be low in children with fulminant meningococcal septicaemia (FMS).
These results suggest that the adrenal reserve in children is insufficient
to handle the extreme conditions and stress associated with severe
meningococcal disease. Moreover, usefulness of maintenance doses of
corticosteroid was shown in a child with adrenocortical insufficiency in
FMS.[3]
However, concerns have been raised that administration of
corticosteroids may contribute to recrudescence and relapse of
meningococcal meningitis and septicaemia.[4]
References
1. Gupta S, Tuladhar AB. Does early administration of dexamethasone
improve neurological outcome in children with meningococcal meningitis?
Arch Dis Child. 2004; 89: 82-3.
2. van Woensel JB, Biezeveld MH, Alders AM, et al. Adrenocorticotropic
hormone and cortisol levels in relation to inflammatory response and
disease severity in children with meningococcal disease. J Infect Dis.
2001; 184: 1532-7.
Dear Editor
At the risk of being accused of raising a trivial issue, I would simply like to ask authors to quote accurately from references within their articles. I am concerned in particular about the study of the respiratory outcome of children of very low birthweight reported recently by Anand and colleagues.[1] They quote the results of a similar study of younger children, which we reported some years ago in...
Dear Editor
Fulton et al. might also have included obstetricians and midwives in their reminder to health professionals about the importance of vitamin D supplementation. For many years a Reference Nutrient Intake of 10 micrograms per day has been set for pregnancy.[1] This will not be met by diet yet the proportion of pregnant women nationally taking vitamin D supplements is negligible, even amongst women...
We thank Tullus and Brennan for their acknowledgement of the value of our recently published Blood Pressure Centiles for Great Britain.
They have compared our centiles with those published in the USA [1], and make a number of comments based on these observations, which we seek to address below. However, we would like to preface our responses with a comment. Few, if any, would feel it appropriate to use US refer...
Dear Editor,
The potential for furosemide to exacerbate the maladaptive processes involved in the worsening of heart failure(1) can, at least in theory, be mitigated by the use of torasemide in preference to furosemide, given the fact that the former agent is characterised by antialdosterone as well as by antifibrotic properties(2)(3), which, in combination, have the potential to enhance the process of reverse remo...
Dear Editor,
Smith’s letter responding to our paper (1) examining the issues around service improvement for children with epilepsies is very welcome. His letter and paper (2) provide useful data and insight which is helpful when considering how national recommendations could or should translate into the ‘real world’.
Many long-term paediatric conditions benefit from designated services with defined p...
Dear Editor,
Imaging has been a topic of discussion in all patients with head injuries. Authors conducted a cross county retrospective audit in Royal Shrewsbury and Princess Royal Hospitals in 2004 over a period of 6 months. Our audit findings are very similar to findings of Reed et al1. We looked at the implication of NICE Guidelines on the present protocol.2 NICE Guidelines emphasise on the CT scan as the main cho...
Dear Editor,
We read with great interest the article by SE Jones et al. highlighting the worrying trend of increasing obesity detected by use of routinely collected data. In 2002-2003 we carried out a prospective observational study aimed at estimating the problem of obesity in children presenting to the outpatient department of Royal Glamorgan Hospital. The hospital caters to the population of Rhondda, Cynon and...
Dear Editor
The hazards of computed tomography (CT), in terms of radiation, are being increasingly recognized. CT scanning, despite representing less than 5% of the total number of X-ray procedures performed, contributes approximately 40% of the total collective radiation dose to the UK population from all medical X-ray examinations.[1] It is well known that children are more radiosensitive than adults e.g. a 1-yea...
Dear Editor,
The recent review of suppression of menstruation by Albanese and Hopper1 in adolescents with severe learning difficulties is the first review of its type published in the UK. We have recently looked at the issues surrounding puberty and management of menstruation in a group of young women with severe learning difficulties and epilepsy who are living at a residential school in Cheshire.
In our...
Dear Editor
I read with great interest the recent article by Gupta et al.[1] Based on a systematic literature review, they conclude that corticosteroids cannot be recommended in cases of suspected meningococcal meningitis. However, I would like to make some comments.
In a recent study, the relationship of hypothalamic-pituitary-adrenal axis to disease severity in children with meningococcal disease w...
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