Thanks to Dr Colvin for his interest. I should like to clarify that
an "unspoken assumption" of genetic determinism did not underlie my
review. I agree with his points on the aetiology: the balance of genetic
and environmental influences and their interaction deserve much more
study. The aetiology, however, is an issue rather separate from
prevalence. Even if countries did differ in their actual rates (rather
than just...
Thanks to Dr Colvin for his interest. I should like to clarify that
an "unspoken assumption" of genetic determinism did not underlie my
review. I agree with his points on the aetiology: the balance of genetic
and environmental influences and their interaction deserve much more
study. The aetiology, however, is an issue rather separate from
prevalence. Even if countries did differ in their actual rates (rather
than just the rates of diagnosis in practice), the explanation could
equally be in genetic or environmental diversity. The suggestion, that
the actual rate of ADHD is broadly similar across countries, did not
derive from theories of cause, but from the cited metaanalyses of
epidemiological research. Those meta-analyses conclude that geographical
location plays only a small and limited role in the variability of
prevalence (eg as between estimates from North America on one hand and
Africa and the Middle East on the other). That conclusion is provisional
in the presence of uncertainties about case identification and the strong
influences of methodology on prevalence results.
I hope the questions raised will not distract readers from the key
argument that there is substantial and avoidable under-recognition and
under-treatment of ADHD in the UK. I am glad that Dr Colvin agrees and
indeed regards it as obvious. I hope other readers will do the same and
convey their concern to commissioners and providers of services in health
and education.
It is encouraging to see a clinical service making an effort to examine the patterns of growth found in their condition. However the conclusions drawn from their data seem greatly overstated. They describe a pattern of 'progressive growth failure' in nearly a quarter of children with ataxia telangiectasia (AT), yet there is an average decline across all children of less than half a centile space over 3 years. These children are...
It is encouraging to see a clinical service making an effort to examine the patterns of growth found in their condition. However the conclusions drawn from their data seem greatly overstated. They describe a pattern of 'progressive growth failure' in nearly a quarter of children with ataxia telangiectasia (AT), yet there is an average decline across all children of less than half a centile space over 3 years. These children are as a group very short, with a majority being below the 2nd centile, but far fewer are thin, making a nutritional origin for this short stature unlikely. Even those children who are thin are not necessarily malnourished. Our experience in a specialist feeding clinic is that children with neurodisability and chronic disorders often have low lean mass due to low muscle mass, which may actually coexist with normal or even high fat levels (1).
It is clear from the figure that three of the 12 children who received PEG feeding showed marked weight and some height gain, but others showed no weight acceleration or even a decline, with an overall median annualised gain of less than a third of a centile space. PEG feeding is an invasive, expensive, life changing treatment and to be justified there must be the substantial objective evidence of benefit. It thus seems unreasonable to infer from these findings that more children with AT should be PEG fed at an earlier stage. This should be reserved for individual children where there are clearcut problems with swallowing, or objective evidence of low fat reserves measured using skinfolds or other methods.
1.Wright CM, Smith K, Morrison j. Withdrawing feeds from children on long term enteral feeding: factors associated with success and failure. Arch-Dis-Child 2011 96(5):433-9.
Conflict of Interest:
I work in a clinic that specialises in helping children withdraw form or avoid tube feeding
This article helps us think about how we would like to provide
services to infants, children and young people (ICYP) in response to
changing needs, financial constraints and a push for multi-agency
integrated working.
We propose that paediatric services should have integrated mental health
expertise in primary care, community and hospital based services. This
would allow for prevention and early intervention, development...
This article helps us think about how we would like to provide
services to infants, children and young people (ICYP) in response to
changing needs, financial constraints and a push for multi-agency
integrated working.
We propose that paediatric services should have integrated mental health
expertise in primary care, community and hospital based services. This
would allow for prevention and early intervention, development of staff
confidence and expertise when confronted with mental health difficulties
as part of the paediatric presentations, as well as timely assessments,
formulation and treatment of mental health disorders.
Such integrated working would facilitate the early detection of mental
health difficulties which may be the primary difficulty and improve the
quality of paediatric treatment and attendant outcomes. This relates not
only to ICYP with chronic illness and complex disability, but also to
those who present at general paediatric clinics. Much time is spent by
paediatric colleagues without the relevant training and expertise in
addressing psychological difficulties which are regularly part of the
clinical presentation and separate services prevent development of skills
in managing these where appropriate, as well as causing delay to ICYP who
need to be referred elsewhere.
An integrated health response facilitates working across social services,
education and other agencies which is seen as the most helpful response to
supporting children's well-being as well as in the domain of child
protection and disability.
Anyone considering the commissioning, continuation or development of
paediatric services should be thinking of ICYP holistically and
remembering that "there is no health without mental health".
Wright and Wales highlight the issues of childhood obesity but there
is a lack of clear guidance on who should deal with it. The suggestion to
" opportunistically discuss a childs weight" is easier said than done.
Whose responsibility is it ? There is little immediate consequence if it
is not done.
Obesity is rarely the presenting complaint to a doctor. So tackling
obesity, in addition to the primary complaint is two co...
Wright and Wales highlight the issues of childhood obesity but there
is a lack of clear guidance on who should deal with it. The suggestion to
" opportunistically discuss a childs weight" is easier said than done.
Whose responsibility is it ? There is little immediate consequence if it
is not done.
Obesity is rarely the presenting complaint to a doctor. So tackling
obesity, in addition to the primary complaint is two consultations. With
time pressures in healthcare this is challenging.
The obesity diagnosis, for a child , and sometimes the parents is
breaking bad news, it is traumatic and difficult, and often avoided for
that reason. The family doctor hopes the Paediatrician will do it and
vice versa.
The Paediatrician rarely sees the long term consequences of obesity -
hypertension, Type 2 diabetes, cardiovascular disease and arthritis and
does not own these problems. By the time we see these patients it is often
too late.
The obese child is often from an obese family which requires the doctor to
address the parents obesity as well, something that Paediatricians cannot
do.
They recommend walking ( may require a supervisor, some children
dislike it and not easy in winter) cycling ( see walking) and use of
sports centres ( requires transport and organization)
"Encouraging" a child to play less video games is like asking an addict
to use less drugs. Prescribe the following: unplug the television, turn
off the wifi and put the kids out the door to the garden or street. If
these fail refer to the enforcer for radical phonectomy!. This can
result in hours of activity.
The authors don't emphasize the difficulties of getting obese children
active. In calorie burning sports the obese child is often the goalie (
with little calorie burning) or the substitute , or cannot compete e.g.
running - where weight is a major disadvantage. The child often
leaves the team after a time having had no matches and a feeling of
inferiority.
The indignity of always being last in the race will put any child off
running. Coaches who focus on the elite and have a win at all cost
mentality give little time , or worse , to the weaker children.
Could I suggest that any sporting organization, club or school that
receives government or municipal funding, is obliged to play every child
on the team in every match for at least half an hour. They should allow
every child to play on at least one team regardless of ability. Failure to
comply should result in reduction of funds.
There are too many lost kids. They are lost between the specialties
and they are lost between the schools and clubs. Time to find them again.
Brian McNicholl FRCEM FRCS FRCPI FFSEM MCh
Consultant Emergency Medicine and amateur sports coach
University College Hospital
Galway
Ireland
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.
Thanks to Dr Colvin for his interest. I should like to clarify that an "unspoken assumption" of genetic determinism did not underlie my review. I agree with his points on the aetiology: the balance of genetic and environmental influences and their interaction deserve much more study. The aetiology, however, is an issue rather separate from prevalence. Even if countries did differ in their actual rates (rather than just...
This article helps us think about how we would like to provide services to infants, children and young people (ICYP) in response to changing needs, financial constraints and a push for multi-agency integrated working. We propose that paediatric services should have integrated mental health expertise in primary care, community and hospital based services. This would allow for prevention and early intervention, development...
Wright and Wales highlight the issues of childhood obesity but there is a lack of clear guidance on who should deal with it. The suggestion to " opportunistically discuss a childs weight" is easier said than done. Whose responsibility is it ? There is little immediate consequence if it is not done. Obesity is rarely the presenting complaint to a doctor. So tackling obesity, in addition to the primary complaint is two co...
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
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