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I fully agree with the authors of this letter and suggest that the paediatricians in the whole country should pressurise the health
secretary to bring out a bill to highlight this problem.
Many of my nights on call are now spent taking care of 15 and 16 year old
kids who have taken overdoses of paracetamol or aspirin. There seems to be
an especially large number of such cases in the Lincolnshire area as
compared to Yorksh...
I fully agree with the authors of this letter and suggest that the paediatricians in the whole country should pressurise the health
secretary to bring out a bill to highlight this problem.
Many of my nights on call are now spent taking care of 15 and 16 year old
kids who have taken overdoses of paracetamol or aspirin. There seems to be
an especially large number of such cases in the Lincolnshire area as
compared to Yorkshire or Lancashire where I worked earlier.
The policy makers in this area will do well to take up this matter before
more precious young lives are put in danger.
In addition to the age limit of people buying over the counter drugs,
there should be a limit on the number of tablets one can buy on any one
occasion.
Drs Lawson and Bray (1) have presented arguments for and against deep
sedation of children by non-anaesthetists. We would like to contribute to
the debate by expanding on issues which have influenced and encouraged the
development of a nurse led sedation service for MRI at our hospital.(2)
There continues to be a huge demand for MR imaging and as a result we
have had to meet the challenge of providing a sedation a...
Drs Lawson and Bray (1) have presented arguments for and against deep
sedation of children by non-anaesthetists. We would like to contribute to
the debate by expanding on issues which have influenced and encouraged the
development of a nurse led sedation service for MRI at our hospital.(2)
There continues to be a huge demand for MR imaging and as a result we
have had to meet the challenge of providing a sedation and anaesthesia
service with limited resources. With safety in mind, in 1996 we sought
funding for sufficient staffing to provide an anaesthesia only service for
one MR scanner, for 4 days a week. Funding was refused because of high
costs, and because the option of improved sedation by non-anaesthetists
had not been fully explored. Fortunately, we have been successful in
developing our nurse led sedation service and have needed only a modest
increase in anaesthesia sessions from 2 in 1996 to 3 currently. We now
have 2 MRI scanners providing a total of 8 days a week of clinical service
and we are able to look back and reflect that if we had held the
philosophy that only anaesthesia was safe enough this would have severely
limited any expansion and flexibility in the totality of the anaesthetic
service we provide to the hospital. We believe we have developed a
sedation service by non-anaesthetists that is safe and effective.
Everyone seems to agree that conscious sedation, where the patient
can be roused by verbal command, is safe for non-anaesthetists but is
impractical for imaging in small children because they must be "asleep" to
be still enough. We have always accepted the danger of deeply sedated
children becoming effectively anaesthetised during imaging. Indeed, one
of us (DH) was a member of the working party that developed the guidelines
for sedation in adults quoted by Lawson and Bray.(3) We have therefore
applied the following definition of sedation for MRI: a technique in which
the use of a drug or drugs produces a state of depression of the nervous
system such that the patient is not easily roused but which has a safety
margin wide enough to render the loss of airway and breathing reflexes
unlikely.
We accept that in an ideal world, anaesthetists are the best people
to manage deep sedation. However this statement is too broad and overlooks
the fact that sedation is specific to a particular procedure. Gastroscopy
for example, requires sedation to a degree which suppresses the gag reflex
and consequently airway reflexes are often reduced. Such a "depth" of
sedation is unnecessary for non-painful imaging and therefore mortality
data about sedation for endoscopy is not helpful in answering the question
"is deep sedation by non-anaesthetists of children for MRI safe?".
We believe that our nurse led sedation service is safe because we
have developed a protocol that makes any airway or breathing problem
extremely unlikely and, if it should occur, our nurses have sufficient
resuscitation skills to cope until help arrives. Reducing the risks to
acceptable levels depends on the strict adherence to exclusion criteria,
the characteristics of the drug regimen and finally, but most crucially,
the judgement, skills and experience of the nurses. Our nurses, are
carefully assessed after an initial training period, and those who are
accepted as sedationists receive regular retraining and reassessment. They
work to strict protocols devised by a multidisciplinary team consisting
of radiologists, anaesthetists, paediatricians, senior nurses and
radiographers. If such a strictly controlled system is not developed, or
suitable people cannot be found to implement it we have no doubt that an
anaesthesia service is safer. The references quoted by Dr Bray demonstrate
that accidents can happen if good practice is not followed.
Our latest figures are encouraging. We have sedated almost 3500
children according to our published sedation guidelines and so far no
child has required the use of any airway or breathing device. Oxygen
saturation has not dropped below 87%. Can anaesthesia, including
postoperative recovery by nurses, match these statistics?
It is fair to suggest that a sedation service might be made even
safer with anaesthetists present throughout the procedure. Nevertheless in
our hospital, we do not believe that such an expense could be justified.
Furthermore, if anaesthetists are available they are more cost-effective
when administering anaesthesia than supervising sedation.
References
(1) Lawson GR, Bray RJ. Sedation of children for magnetic resonance
imaging. Arch Dis Child 2000;82:150-4.
(2) Sury MRJ, Hatch DJ, Deeley T, Dicks-Mireaux C, Chong WK.
Development of a Nurse-led Sedation Service for Paediatric Magnetic
Resonance Imaging. Lancet 1999;353:1667-71.
(3) Royal College of Anaesthetists and Royal College of
Radiologists. Sedation and anaesthesia in radiology. Report of a joint
working party. London. 1992.
MRJ Sury, Consultant Paediatric Anaesthetist
Great Ormond Street Hospital
DJ Hatch, Portex Professor of Paediatric Anaesthesia
Institute of Child Health, London
W Millen, Senior Nurse
Department of Radiology, Great Ormond Street Hospital
K Chong, Consultant Radiologist
Department of Radiology, Great Ormond Street Hospital
We agree with Dr Deshpande that the sensitivity quoted for
dipstick
testing might not be the "true value" as a screening test for urinary
tract infection as urine culture was not done on all the children in the
study.
Our study was based on the current practice at our
hospital of
sending urine for culture if any dipstick (nitrites, protein, leucocyte
esterase or blood) was abnormal or if there was a clinical su...
We agree with Dr Deshpande that the sensitivity quoted for
dipstick
testing might not be the "true value" as a screening test for urinary
tract infection as urine culture was not done on all the children in the
study.
Our study was based on the current practice at our
hospital of
sending urine for culture if any dipstick (nitrites, protein, leucocyte
esterase or blood) was abnormal or if there was a clinical suspicion of
UTI, history of previous UTI or renal anomalies and also before starting
antibiotics. This practice resulted in more 60% of the children admitted
to the children's ward getting a urine culture done. We wanted to see if a
change in practice where urine culture is undertaken only if nitrites or
leucocyte esterase was positive would be effective in reducing the number
of urine cultures.
However, in our study it was seen that nitrites even when
combined
with leucocyte esterase have a very low sensitivity and UTI would be
missed if a negative nitrite and leucocyte esterase were used to exclude
UTI.
EDITOR, - The paper by Noble et al on capillary dried spot testing
for TSH measurement is a welcome advance for children with Down's syndrome
(DS).(1) In reducing the number of venepunctures this patient group needs,
we hope that those professionals caring for children with DS do not omit
screening for coeliac disease (CD). This condition is equally prevalent
and can be as difficult to diagnose as hypothyroidism in DS as i...
EDITOR, - The paper by Noble et al on capillary dried spot testing
for TSH measurement is a welcome advance for children with Down's syndrome
(DS).(1) In reducing the number of venepunctures this patient group needs,
we hope that those professionals caring for children with DS do not omit
screening for coeliac disease (CD). This condition is equally prevalent
and can be as difficult to diagnose as hypothyroidism in DS as it too is
often asymptomatic. Screening for CD should be done by the measurement of
anti-gliadin (AGA) and anti-endomysial (EmA) antibodies. Their use as a
screening tool is well described in DS with reported prevalence between
3.9 and 16.9 %.(2-4) Diagnosing CD has important consequences with regards
to preventing long-term complications and maximising growth potential.(4) We
would like to highlight that community-based testing is also feasible for
CD.
A study at our centre investigating the prevalence of coeliac disease
in Type I diabetics utilised patient self-sampling for screening
bloods.(5) Blood was drawn into a Lithium Heparin capillary tube
(Monovette, Sarsdedt Ltd, Germany) or onto filter paper. The in-house
assays used for AGA and EmA were performed on 10-20 microlitres of serum or plasma;
thus capillary samples were more than adequate. This method could easily
be incorporated into the "at-school" testing described by the authors.
Annual screening for hypothyroidism is recommended.(1) How often
screening should be performed for CD is still a matter of debate. With
their proposal to establish a Scottish register of school-aged children
with Down's syndrome Noble et al provide the opportunity to perform a
Scottish-wide population study for the prevalence of coeliac disease in
Down's syndrome and, more importantly, to identify those children who may
benefit from early detection. Community based screening with capillary
samples would make that a very realistic prospect.
R K RUSSELL
P M GILLETT
Department of Paediatric Gastroenterology,
Royal Hospital for Sick Children
9 Sciennes Road, Edinburgh EH9 1LF, UK
References
1. Noble SE, Leyland K, Findlay CA, Clark CE, Redfern J, Mackenzie
JM, Girdwood RWA, Donaldson MDC. School based screening for
hypothyroidism in Down's syndrome by dried blood spot TSH measurement.
Arch Dis Child 2000;82:27-31.
2. Gale L, Wimalaratna H, Brotodiharjo A, Duggan JM. Down's syndrome is
strongly associated with coeliac disease. Gut 1997;40:492-496.
3.Carlsson A, Axelsson I, Borulf S, bredberg A, Forslund M, Lindberg B,
Sjöberg K, Ivarsson SA. Prevalence of IgA-antigliadin antibodies and IgA-
antiendomysium antibodies related to celiac disease in children with Down
syndrome. Pediatrics 1998;101:272-275.
4. Jansson U, Johansson C. Down Syndrome and Celiac Disease. J Pediatr
Gastroenterol Nutr 1995;21:443-445.
5. Gillett HR, Kingstone K, Noyes K, Ferguson A. Screening for coeliac
disease in the paediatric insulin-dependent diabetic population of South-
East Scotland using fingerprick blood samples. Horm Res 1997;48 (Suppl
2):145.
While having some sympathy with Drs Wynne and Speight over the
despair that they feel about the containment of child neglect and abuse,
the answer surely cannot be the wholesale transfer of children from the
frying pan of their own homes (one notes that the West children remained
in a way fond of their father despite truly appalling treatment at his
hands) to the fire of local authority institutions staffed by paedophile...
While having some sympathy with Drs Wynne and Speight over the
despair that they feel about the containment of child neglect and abuse,
the answer surely cannot be the wholesale transfer of children from the
frying pan of their own homes (one notes that the West children remained
in a way fond of their father despite truly appalling treatment at his
hands) to the fire of local authority institutions staffed by paedophiles
or unsuitable and stop-gap fostering. The problem is perhaps essentially
insoluble, given its nature and the way in which our resources are made
available and deployed -as in the case of imprisonment for offenders; and
occasional exceptions merely prove statistical rules. But to reduce the
numbers of children in such straits may require changes in our whole
culture; which may not only be impossible to achieve but might do more
harm than good by rescuing the unlucky 10% at the cost of no longer taking
the well being of the 90% for granted, as one should be able to do. Nor
does the insinuation of best practice necessarily work since it so much
depends on the enthusiasm, dedication and idealism of those who have
developed it which is usually the kernel of their achievement while what
can be described and specified is only the husk.
It is surely unacceptable that in a grossly overpopulated world with
over exploited resources and with the availability of effective birth
control children are still being born whose parents don't want them, can't
provide for them or, instead of rearing them properly, abuse and exploit
them - while at the same time we spend a lot of public money on the
treatment of infertility. A pseudo Darwinian free for all mitigated by
charity is not the answer in that in a struggle for survival the survivors
are often damaged without necessarily any culling of the unfit in terms of
the qualities that are needed to promote the kind of world we want and
strive for; yet we rightly cannot bring ourselves to manage society like
an ant heap. It could be that make do and mend is the best way forward;
relying on those in the front line - like Drs Wynne and Speight - for
guidance on how best to use limited resources.
Currently two types of measurements are used to assess (chemical and
functional) vitamin B6 status, which measure directly B6 and its
metabolites and activation of vitamin B6 dependent enzymes and associated
aminoacids. The load tests are also used to reveal the subtle defects by
stressing the B6 metabolic pathway. None of them is ideal and a
combination of them is recommended. Additionally there is no concordance
betwe...
Currently two types of measurements are used to assess (chemical and
functional) vitamin B6 status, which measure directly B6 and its
metabolites and activation of vitamin B6 dependent enzymes and associated
aminoacids. The load tests are also used to reveal the subtle defects by
stressing the B6 metabolic pathway. None of them is ideal and a
combination of them is recommended. Additionally there is no concordance
between these indices. Transaminase activity in serum and red blood cell
(functional index) decreases along with plasma PLP (pyridoxal phosphate,
urine B6 and pyridoxic acid (direct chemical index)) within 1 week after
removal vitamin B6 from the diet. Electromyelographic abnormalities appear
within 3 weeks (1).
Some population groups in modern society have a
suboptimal intake with or without excess protein intake, although severe vitamin
B6 deficiency is uncommon in man (2). Epileptiform convulsions are a common
finding in young vitamin B6 deficient subjects (1). These (sub)clinical
deficiencies can be screened routinely by a clinical laboratory even in a
small remote village if a simple test like transaminases are used which is
easily available on (semi)automated chemistry analysers. Vitamin B6
deficiency in a well nourished child with an autosomal recessively
inherited pyrroline-5-carboxylate dehydrogenase deficiency led to
childhood fits, because of binding of the proline metabolite, pyrroline-5-carboxylate with vitamin B6 reported by Walker et al (3). It is very
interesting to know if the authors had measured the transaminases (and by
which method) as some method come with PLP supplement), if not it would
be interesting to know their view on this simplistic approach. Their
transaminase results if significant will emphasise their usefulness as a cost and
clinically effective screening test.
References:
1. Mccormick DB, Green HL. Vitamins. In: Burtis CA, Ashwood ER eds.
Tietz text book of clinical chemistry, 3rd ed. Pennsylvania: W.B.Saunders.
1999:1016-18.
Hodge et al(1) draw our attention to the possible association of
hypogammaglobulinemia and global lymphopenia with Proteus syndrome. They
suggest that this may be secondary to loss of immunoglobulins and
lymphocytes into lymphoedematous tissue. We have seen a similar phenomenon
in a child with massive cystic hygroma in the neck. Immunological
investigations showed persistent severe lymphopenia with low levels of
all lym...
Hodge et al(1) draw our attention to the possible association of
hypogammaglobulinemia and global lymphopenia with Proteus syndrome. They
suggest that this may be secondary to loss of immunoglobulins and
lymphocytes into lymphoedematous tissue. We have seen a similar phenomenon
in a child with massive cystic hygroma in the neck. Immunological
investigations showed persistent severe lymphopenia with low levels of
all lymphocyte subsets. Lymphocyte proliferative responses to PHA were
normal as were immunoglobulin levels and antibody responses to protein (diphtheria and tetanus toxoid) and polysaccharide (haemophilus b)
vaccines. He initially suffered recurrent chest and skin infections and
oral candidiasis but this responded well to treatment with prophylactic
cotrimoxazole and nystatin mouthwashes. As in their case, we feel we may
have been observing peripheral sequestration of circulating lymphocytes in
this case and that, as a consequence, the clinical phenotype was milder
than one would have expected in a child with similar results but caused by
failure of lymphocyte production. We would like to extend their suggestion
for immunological investigations in Proteus syndrome to other children
with large lymphatic malformations.
1. Hodge D, Misbah SA, Mueller RF, Glass EJ, Chetcuti PAJ. Proteus syndrome and immunodeficiency. Arch Dis Child 2000;82:234-235
Thayyil-Sudhan and Gupta suggest that urine culture needs to be
undertaken if any of the four indices of dipstick analysis (nitrates
(sic), blood, protein or leucocyte esterase) are abnormal (1) based
presumably on the high sensitivity and negative predictive value (NPV) of
this criterion. However, the design of their study wherein urine cultures
were not performed on the majority of samples where dips...
Thayyil-Sudhan and Gupta suggest that urine culture needs to be
undertaken if any of the four indices of dipstick analysis (nitrates
(sic), blood, protein or leucocyte esterase) are abnormal (1) based
presumably on the high sensitivity and negative predictive value (NPV) of
this criterion. However, the design of their study wherein urine cultures
were not performed on the majority of samples where dipstick testing was
normal may have falsely overestimated the sensitivity and NPV of this
criterion. From their study, we, therefore do not know the 'true' false
negative rate of urinary dipstick analysis as a screening test.
May I draw attention to a recent meta-analysis of screening tests for
urinary tract infection in children which showed that for predicting a
positive urine culture, presence of any bacteria on a Gram-stained urine
specimen followed closely by presence of nitrite or leucocyte esterase on
dipstick analysis, offer the best combination of sensitivity and
specificity (2).
Sanjeev Deshpande
Consultant Neonatologist
Royal Shrewsbury Hospital
Mytton Oak Road
SHREWSBURY SY3 9PU
1. Thayyil-Sudhan S, Gupta S. Dipstick examination for urinary tract
infections (letter). Arch Dis Child 2000;82:271.
2. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in
children: a meta-analysis. Pediatrics 1999;104 (5).URL:
http://www.pediatrics.org/cgi/content/full/104/5/e54
I recognise that Drs. Speight and Wynne, wrote an unbalanced article
(Is the Children Act failing severely abused and neglected children) to
encourage discussion but I expect more respect for evidence in Archives of
Disease in Childhood.
I could trade insults based on factual inaccuracies (the Children Act
was enacted in 1989 not 1990 and implemented in 1991), selective and
inaccurate references and many unsuppor...
I recognise that Drs. Speight and Wynne, wrote an unbalanced article
(Is the Children Act failing severely abused and neglected children) to
encourage discussion but I expect more respect for evidence in Archives of
Disease in Childhood.
I could trade insults based on factual inaccuracies (the Children Act
was enacted in 1989 not 1990 and implemented in 1991), selective and
inaccurate references and many unsupported statements that largely ignore
counter-indicators. But insults would obscure the important point.
The Children Act is framework legislation. It does not dictate
practice but sets a framework sufficiently flexible to adapt to new ideas.
If evidence shows that removing more children from their relatives will
result in greater child protection, the Act will permit such a change in
emphasis.
The child protection field lacks reliable evidence about what works,
for whom, when and why. Into this vacuum floods completely inconsistent
ideology and rhetoric. Practitioners are criticised one week for doing
too little, the next for being over reactive.
Would a greater willingness to prosecute parents, intervene in family
life and remove children lead to better outcomes for victims of
maltreatment? I do not know. I could produce a learned, properly
referenced article giving the pros and cons. Can the state parent better
than an errant parent? The answer is sometimes 'yes', sometimes 'no'.
Evidence from the United States, probably the most interventionist of
western developed countries and almost certainly the least effective in
protecting children urges caution.
We need less rhetoric and more evidence. The struggle is to find out
what works in the protection of children and to encourage the consistent
application and re-evaluation of that technology. Arguing whether to
remove more or fewer children is pointless. Thinking about what we do when
we are responsible for supporting these children is the key. The Children
Act encourages reflection and will allow implementation of results,
whether they be for or against the views of Drs Speight and Wynne.
Michael Little, Ph.D.
Co-director Dartington Social Research Unit,
Research Fellow, Chapin Hall Center for Children at
The University of Chicago
I read with interest the article by Chong et al, in which they
studied the variations in blood pressure, heart rate, shin and abdominal
wall skin temperature in 44 term infants during sleep, in 4 different
positions, prone and supine, horizontal and with a 600 head up tilt
respectively. They concluded that the variations observed in the 4
different positions, due to vasomotor tone, may have a role in su...
I read with interest the article by Chong et al, in which they
studied the variations in blood pressure, heart rate, shin and abdominal
wall skin temperature in 44 term infants during sleep, in 4 different
positions, prone and supine, horizontal and with a 600 head up tilt
respectively. They concluded that the variations observed in the 4
different positions, due to vasomotor tone, may have a role in sudden
infant death syndrome.(1) However, I feel that the statistical analysis
used is inappropriate and may not necessarily support their findings.
The authors used the Student t test to compare, in each of the 4 body
positions, the mean values of each measured parameter in the 44 infants.
If the measured values do not follow a Normal distribution (this is not
mentioned in the study), the use of the t test would be invalid.
Furthermore, the authors measured the unpaired t test when they
compared the mean values in all infants, in each body position
respectively. However, the samples were paired (not independent), with 4
body positions for each infant. The parameters of each infant should
therefore be compared in the 4 different body positions (each infant being
his own control), instead of comparing the mean values of all infants in
each body position. The unpaired t test they used cannot distinguish
variations for each subject from variations due to differences between
groups.
It is however still possible that the reported results are correct,
but to prove it, the authors need to use either the paired t test for
comparing means, if the measured values follow a Normal distribution, or
the paired Wilcoxon test if they do not.
References
1. Chong A, Murphy N, Matthews T. Effect of prone sleeping on
circulatory control in infants. Arch Dis Child 2000:82;253-256.
Hassib Narchi
Paediatric Department
Sandwell General Hospital
Lyndon, West Bromwich
West Midlands B 71 4HJ
E-mail: hassibnarchi@hotmail.com
I fully agree with the authors of this letter and suggest that the paediatricians in the whole country should pressurise the health secretary to bring out a bill to highlight this problem. Many of my nights on call are now spent taking care of 15 and 16 year old kids who have taken overdoses of paracetamol or aspirin. There seems to be an especially large number of such cases in the Lincolnshire area as compared to Yorksh...
Drs Lawson and Bray (1) have presented arguments for and against deep sedation of children by non-anaesthetists. We would like to contribute to the debate by expanding on issues which have influenced and encouraged the development of a nurse led sedation service for MRI at our hospital.(2)
There continues to be a huge demand for MR imaging and as a result we have had to meet the challenge of providing a sedation a...
We agree with Dr Deshpande that the sensitivity quoted for dipstick testing might not be the "true value" as a screening test for urinary tract infection as urine culture was not done on all the children in the study.
Our study was based on the current practice at our hospital of sending urine for culture if any dipstick (nitrites, protein, leucocyte esterase or blood) was abnormal or if there was a clinical su...
EDITOR, - The paper by Noble et al on capillary dried spot testing for TSH measurement is a welcome advance for children with Down's syndrome (DS).(1) In reducing the number of venepunctures this patient group needs, we hope that those professionals caring for children with DS do not omit screening for coeliac disease (CD). This condition is equally prevalent and can be as difficult to diagnose as hypothyroidism in DS as i...
While having some sympathy with Drs Wynne and Speight over the despair that they feel about the containment of child neglect and abuse, the answer surely cannot be the wholesale transfer of children from the frying pan of their own homes (one notes that the West children remained in a way fond of their father despite truly appalling treatment at his hands) to the fire of local authority institutions staffed by paedophile...
Currently two types of measurements are used to assess (chemical and functional) vitamin B6 status, which measure directly B6 and its metabolites and activation of vitamin B6 dependent enzymes and associated aminoacids. The load tests are also used to reveal the subtle defects by stressing the B6 metabolic pathway. None of them is ideal and a combination of them is recommended. Additionally there is no concordance betwe...
Hodge et al(1) draw our attention to the possible association of hypogammaglobulinemia and global lymphopenia with Proteus syndrome. They suggest that this may be secondary to loss of immunoglobulins and lymphocytes into lymphoedematous tissue. We have seen a similar phenomenon in a child with massive cystic hygroma in the neck. Immunological investigations showed persistent severe lymphopenia with low levels of all lym...
Editor,
Thayyil-Sudhan and Gupta suggest that urine culture needs to be undertaken if any of the four indices of dipstick analysis (nitrates (sic), blood, protein or leucocyte esterase) are abnormal (1) based presumably on the high sensitivity and negative predictive value (NPV) of this criterion. However, the design of their study wherein urine cultures were not performed on the majority of samples where dips...
I recognise that Drs. Speight and Wynne, wrote an unbalanced article (Is the Children Act failing severely abused and neglected children) to encourage discussion but I expect more respect for evidence in Archives of Disease in Childhood.
I could trade insults based on factual inaccuracies (the Children Act was enacted in 1989 not 1990 and implemented in 1991), selective and inaccurate references and many unsuppor...
Editor,
I read with interest the article by Chong et al, in which they studied the variations in blood pressure, heart rate, shin and abdominal wall skin temperature in 44 term infants during sleep, in 4 different positions, prone and supine, horizontal and with a 600 head up tilt respectively. They concluded that the variations observed in the 4 different positions, due to vasomotor tone, may have a role in su...
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