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While strongly supporting this document, I think that its
recommendation that research in children should not simply duplicate
earlier work is open to misinterpretation.
Many randomised studies in paediatrics are too small and under
powered to provide conclusive results. (1, 2) Meta analysis of multiple
similar studies provides a useful tool for overcoming the limitations of
inadequate...
While strongly supporting this document, I think that its
recommendation that research in children should not simply duplicate
earlier work is open to misinterpretation.
Many randomised studies in paediatrics are too small and under
powered to provide conclusive results. (1, 2) Meta analysis of multiple
similar studies provides a useful tool for overcoming the limitations of
inadequate sample size. Systematic reviews often fail to draw clear
conclusions because meta analysis is based on inadequate numbers of
patients. When this is so, the only way forward may be to randomise
further patients.
I would like to suggest that the recommendation be modified to read
that research in children should not simply duplicate earlier work which
is already conclusive.
References
1. Campbell H, Surry SAM, Royle EM, A review of randomised
controlled trials published in archives of disease in childhood from 1982-
96. Arch Dis Child 1998;79:192-7
2. Tarnow-Mordi, WO, Healy MJ. Distinguishing between "no evidence
of effect" and "evidence of no effect" in randomised controlled trials and
other comparisons. Arch Dis Child 1999;80:210-1.
William Tarnow-Mordi
Professor of Neonatal Medicine
Westmead and New Children's Hospitals
University of Sydney
Australia
With interest we read the study of Zar et al¹ on the
usefullness of sputum induction in infants and young children for the
diagnosis of pulmonary tuberculosis. Bacteriological confirmation of
pulmonary tuberculosis in infants and young children remains a problem
because it is difficult to obtain sputum. Therefore, in young children,
gastric lavage is the recommended method for the collection of res...
With interest we read the study of Zar et al¹ on the
usefullness of sputum induction in infants and young children for the
diagnosis of pulmonary tuberculosis. Bacteriological confirmation of
pulmonary tuberculosis in infants and young children remains a problem
because it is difficult to obtain sputum. Therefore, in young children,
gastric lavage is the recommended method for the collection of respiratory
secretions.² Since the number of tubercle bacilli and the frequency of
positive cultures in specimens recovered by gastric lavage are usually
small, gastric washings are ideally performed on three consecutive
mornings to maximize the yield.³
In this prospective study, children with acute pneumonia with a high risk
on pulmonary tuberculosis were included. On 142 children both gastric
lavage and sputum induction was performed. The yield of M tuberculosis in
sputum and gastric lavage was compared, as was the amount of positive
cultures in sputum and gastric lavage. The influence of HIV-status on the
yield was also determined.
The authors found more positive cultures in the induced sputa compared to
the gastric lavages. Therefore they conclude that sputum induction was a
more sensitive method than gastric lavage for culture of M tuberculosis.
However, in order to compare the sensitivity of two diagnostic tests, one
should perform both tests in all patients. In this study, 39 patients
underwent only one gastric lavage, 77 patients had lavages on two
consecutive mornings and only 26 patients underwent all 3 gastric lavages.
We therefore disagree with the authors on one of the conclusions, that
induced sputum is better than gastric lavage for the isolation of M tuberculosis in infants and children.
In our opinion, in order to answer the question whether sputum induction
is as good as or better than gastric lavage, only the results from the
patients who underwent gastric lavages on three consecutive days should be
used.
H E WIERSMA
W M C VAN AALDEREN
M O HOEKSTRA
Department of Pediatric Pulmonology
Emma Children's Hospital
Academic Medical Centre
PO BOX 22660
1100 DD Amsterdam
The Netherlands
1. Zar HJ, Tannebaum E, Apolles P, Roux P, Hanslo D, Hussey G. Sputum
induction fot the diagnosis of pulmonary tuberculosis in infants and young
children in an urban setting in South Africa. Arch Dis Child 2000;82:305-
308.
2. Abadco DL, Steiner P. Gastric lavage is better than bronchoalveolar
lavage for isolation of Mycobacterium tuberculosis in childhood pulmonary
tuberculosis. Pediatr Invect Dis J
1992;11:735-8.
3. Chernick V, Boat TF. Kendig's disorders of the respiratory tract in
children. W.B. Saunders Company 1998;893-894.
As someone who is in the throes of writing a chapter on growth
monitoring in primary care for the Royal College of General Practitioners
I read Garner et al's article(1) as well as their original Cochrane review
(2) with interest. Both Professor Davies commentary and Professor
Marcovitch’s precis in "Archives this month" discuss the findings in
relation to growth monitoring in the United Kingdom. Un...
As someone who is in the throes of writing a chapter on growth
monitoring in primary care for the Royal College of General Practitioners
I read Garner et al's article(1) as well as their original Cochrane review
(2) with interest. Both Professor Davies commentary and Professor
Marcovitch’s precis in "Archives this month" discuss the findings in
relation to growth monitoring in the United Kingdom. Unfortunately the
inclusion criteria used by Garner et al, charitably described as ‘strict’
by Davies, by their nature excluded anything that resembles what currently
takes place in general practice in the UK.
The ‘types of participants’ considered for inclusion in their review
were populations of children up to five years of age. The ‘selection
criteria’ compared ‘routine growth monitoring’ defined as at least three
monthly with no growth monitoring. In their Cochrane review (2) the
authors highlight the lack of national guidelines regarding the frequency
of growth monitoring but quote the Child Growth Foundation recommendations
of five routine measurements between birth and five years. Thus this
criteria by default excludes routine growth monitoring in the UK,
particularly in the over 2 year olds.
Garner et al excluded ‘single population measures, such as height at
one or more specific ages, which aim to screen for conditions such as
growth hormone deficiency’. However Hall in his recent article stated that
growth hormone deficiency was one of only two conditions that were the
‘primary justification for growth monitoring’ in under two year olds.(3)
Thus having read both articles,(1, 2) neither represent a systematic
review of growth surveillance as it takes place in the UK and I am left
none the wiser as to whether anyone has undertaken trials comparing growth
monitoring in this country with any alternative.
Yours sincerely
Michael Perkin
Wellcome Research Fellow in Clinical Epidemiology
1. Garner P, Panpanich R, Logan S. Is routine growth monitoring
effective? A systematic review of trials. Arch Dis Child 2000;82:197-201.
2. Panpanich R, Garner P. Growth monitoring in children. Cochrane
Review 1999:issue 2. (Oxford: Update software.)
3. Hall DMB. Growth monitoring. Arch Dis Child 2000;82:10-
15.
A six month old child is admitted with seizures as a result of the
deliberate administration of sulphonylurea.
Things have come to a pretty pass when the term "poisoning" does not
feature in the keywords of this paper.
The authors' use of the term "Munchausen syndrome by proxy" implies
that they have knowledge of the perpetrator's motivation. In our view,
they have not justified this conclusion. The on...
A six month old child is admitted with seizures as a result of the
deliberate administration of sulphonylurea.
Things have come to a pretty pass when the term "poisoning" does not
feature in the keywords of this paper.
The authors' use of the term "Munchausen syndrome by proxy" implies
that they have knowledge of the perpetrator's motivation. In our view,
they have not justified this conclusion. The only data they do offer is of
a strong background of violence. This is common in scenarios involving the
abuse of children.
As Paediatricians, we are safest addressing the absolute facts. When
we draw in spurious considerations we run the risk of undermining the
truth. In this case - the baby was the victim of the crime of deliberate
poisoning.
I write with reference to the article by "Archivist" on Sex
Preference in the April issue.
"Archivist" asks if the view that adolescent iconoclasm and tongue in
cheek humour could have an effect upon how they answer questionnaires, or
whether that is just too cynical. I am the father of two sons, both of
whom were often approached during their adolescent years to participate in
psychologic...
I write with reference to the article by "Archivist" on Sex
Preference in the April issue.
"Archivist" asks if the view that adolescent iconoclasm and tongue in
cheek humour could have an effect upon how they answer questionnaires, or
whether that is just too cynical. I am the father of two sons, both of
whom were often approached during their adolescent years to participate in
psychologically oriented research projects. They both told me that they
and their peer group had great fun in giving untruthful and occasionally
ridiculous answers to many of the questions on the questionnaire.
This n of 2 raises the question about the reliability of much
research done with adolescents!
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.
Dear Editor:
While strongly supporting this document, I think that its recommendation that research in children should not simply duplicate earlier work is open to misinterpretation.
Many randomised studies in paediatrics are too small and under powered to provide conclusive results. (1, 2) Meta analysis of multiple similar studies provides a useful tool for overcoming the limitations of inadequate...
Dear editor:
With interest we read the study of Zar et al¹ on the usefullness of sputum induction in infants and young children for the diagnosis of pulmonary tuberculosis. Bacteriological confirmation of pulmonary tuberculosis in infants and young children remains a problem because it is difficult to obtain sputum. Therefore, in young children, gastric lavage is the recommended method for the collection of res...
Dear Editor
As someone who is in the throes of writing a chapter on growth monitoring in primary care for the Royal College of General Practitioners I read Garner et al's article(1) as well as their original Cochrane review (2) with interest. Both Professor Davies commentary and Professor Marcovitch’s precis in "Archives this month" discuss the findings in relation to growth monitoring in the United Kingdom. Un...
A six month old child is admitted with seizures as a result of the deliberate administration of sulphonylurea.
Things have come to a pretty pass when the term "poisoning" does not feature in the keywords of this paper.
The authors' use of the term "Munchausen syndrome by proxy" implies that they have knowledge of the perpetrator's motivation. In our view, they have not justified this conclusion. The on...
Dear Editor
I write with reference to the article by "Archivist" on Sex Preference in the April issue.
"Archivist" asks if the view that adolescent iconoclasm and tongue in cheek humour could have an effect upon how they answer questionnaires, or whether that is just too cynical. I am the father of two sons, both of whom were often approached during their adolescent years to participate in psychologic...
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...
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