I read with interest the article by Raynor and Rudolf[1] comparing
the anthropometric indices of failure to thrive. In the same context, I
would like to share the findings of our study which was done to compare
the indices used for assessing nutritional status at birth.
The indices used were the birth weight, Ponderal index and the CANSCORE
(Clinical assessment of nutritional score).
I read with interest the article by Raynor and Rudolf[1] comparing
the anthropometric indices of failure to thrive. In the same context, I
would like to share the findings of our study which was done to compare
the indices used for assessing nutritional status at birth.
The indices used were the birth weight, Ponderal index and the CANSCORE
(Clinical assessment of nutritional score).
A 20 consecutive newborn infants admitted
to the postnatal unit of Sultan Qaboos University Hospital (SQUH), Oman
were recruited. The measurements including the birth weight, length, and
head circumference,
were noted down. Ponderal index was calculated by the formula: Weight (g)/Length (cm)3 and the CANSCORE from the nine signs shown in the table.
Score
4
3
2
1
Hair
Large, smooth
Thin
Thinner
Depigmented
Cheeks
Full
Reduced
Narrowed
Flat
Neck and chin
2-3 folds on chin
Neck not seen
Neck seen easily
Neck with wrinkled skin
Arms
Full
Wrinkels
wrinkles
Loose skin over
Back
Grasping of skin difficult
grasping
grasping
Loose skin
Buttocks
Full
Gluteal fat
Wrinkles
wrinkles
Legs
Full
Wrinkles
- wrinkles
Loose skin over
Chest
Full, invisible ribs
Ribs obvious
More obvious ribs
Loss of intercostal tissue
Abdomen
Full, round
Loose skin
Very loose skin
Wrinkled
Score rated from 4 (best) to 1 (worst). See Reference 4 for details.
Under nutrition was
defined accordingly[2-5] that for CANSCORE (<_24 birth="birth" weight="weight" _="_" _3="_3" and="and" ponderal="ponderal" index="index" _2.="_2." p="p"/> Out of 20 neonates, 15 (75%) were noted to have
adequate nutritional status, while 5 neonates (25%) were noted to be
undernourished, basing on the birth weight, ponderal index and CANSORE.
Significant correlation was noted between all the parameters, birth weight
with CANSORE, r = 0.76, P = 0.0001, birth weight with ponderal index, r = 0.51, P = 0.013 and ponderal index with CANSORE, r = 0.46, P = 0.031,respectively.
We were able to demonstrate a unique combination of birth weight,
ponderal index and canscore in the assessment of nutritional status at
birth. We concluded that as good
correlation existed between the birth weight, ponderal index and CANSORE,
they could be equally used individually to assess the newborn's
nutritional status. However, birth
weight is the simplest, most objective and least tedious of them.
Dr Shabih Manzar, MRCPCH (Associate), FAAP Assistant Professor, Department of Pediatrics
King Fahd University Hospital
PO Box 40211
Al-Khobar 31952, Saudi Arabia
Fax & telephone + 966 3 897 6941
References
1. Raynor P, Rudolf MCJ. Anthropometric indices of failure to thrive. Arch Dis Child 2000;82:364-365
2. Roberton NRC. Textbook of Neonatology. 2nd ed. Longman Group UK
Limited, Churchill Livingstone, Edinburgh. 1992; p 320
3. Avery GB, Fletcher MA, MacDonald MG . Neonatology:
pathophysiology and management of the newborn.4th ed, J.B.Lippincott
Company, Philadelphia 1994; 369-398
4. Metcoff J. Clinical assessment of nutritional status at birth.
Fetal malnutrition and SGA are not synonymous. Pediatric Clinic North
America 1994;41(5):875-891
Dr Marcovitch's comments about Heather Zar's article (Arch Dis Child 2000;82:495-8), championing the use of home made spacers and in
particular the coffee cup, do not stand up to a closer examination. In a
recent randomised study of the bronchodilator effects of different spacers
from the same authors as the ADC article, in 44 children with
moderate...
Dr Marcovitch's comments about Heather Zar's article (Arch Dis Child 2000;82:495-8), championing the use of home made spacers and in
particular the coffee cup, do not stand up to a closer examination. In a
recent randomised study of the bronchodilator effects of different spacers
from the same authors as the ADC article, in 44 children with
moderate to severe airways obstruction, a coffee cup gave significantly
less bronchodilation (median increase in FEV1 0%; PEF 12%) compared with a
'conventional' spacer (FEV1 37%; PEF 59%)(Lancet 1999;89:979-82). So a
coffee cup, which I used as well, 10 to 15 years ago, really cannot
be recommended except for drinking coffee.
What of other home made devices? Anaesthetic bags (Woodcock, Postgrad Med J 1984;60:37-39), Paper bags (El Kassimi, Eur J Resp Dis 1987;70:234-8), freezer bags (Lee, Pediatrics 1984;73:230-2) and even a chocolate
Easter egg (Hayden, Med J Aus 1995;163:587-8) have all been evaluated and
found to perform as well as 'conventional' spacers, at least at points
high on the dose response curve or in relatively healthy subjects. They
may be satisfactory, especially in the absence of evidence that more
expensive devices are more efficacious in every day use. Zar's conclusions
that choice of spacer should be based on factors such as patient
preference echo previous advice on choice of delivery device.
There are however methodological and ethical problems with Zar's
study. The aerosol used (a nebulised solution) is completely different from
the aerosol emitted from a pressurised metered dose inhaler, and is likely
to have a very different interaction with the spacer. Zar asserts that a
valid comparison may be made between spacers as the delivery system is
kept constant. This is hardly credible given other studies which have
demonstrated that different formulations of aerosols behave differently
with spacers. Furthermore, subjects with clinical signs or recent symptoms
of bronchoconstriction were excluded from Zar's study, the very children
that you would want to treat!
I'm not disdainful of attempts to provide a cheap, effective
alternative, and have even presented data on the use of a 1 litre milk
carton (great in an emergency, but avoid milk protein sensitive patients!)
but Zar's study uses the wrong aerosol in the wrong patients and compares
the coke bottle with the wrong 'conventional' spacers. It hardly justifies
raising the hopes of those searching for the final word.
Did Raynor and Rudolf[1] look at height or head circumference as
anthropometric predictors of developmental, dietary and eating problems?
They measured height in order to calculate the Waterlow method of
classifying wasting, and head circumference is easier to measure
accurately in the field. Waterlow’s 1973 contribution[2] was to divide
the weight-for-age deficits classified by Gomez et al in 1956...
Did Raynor and Rudolf[1] look at height or head circumference as
anthropometric predictors of developmental, dietary and eating problems?
They measured height in order to calculate the Waterlow method of
classifying wasting, and head circumference is easier to measure
accurately in the field. Waterlow’s 1973 contribution[2] was to divide
the weight-for-age deficits classified by Gomez et al in 1956[3] into two
components, stunting (low height for median at that age) and wasting (low
weight for median weight at that height). It is the former that is a
closer equivalent to the Raynor and Rudolf concept of failure to thrive.
Pure stunting represented chronic undernutrition and was of low priority
for a centre’s acute intervention which was unlikely to succeed. Stunting
has, however, been shown to be strongly associated with developmental
delay.[4] Waterlow saw pure wasting, on the other hand, as
characteristic of the child who had NOT been failing to thrive, but had
suddenly run into an acute shortage of nutrient substrate remediable by
acute therapy. Wasting and stunting together obviously make for a yet
more severe problem, but using the wasting component only and then showing
that it is not a measure of failure to thrive is no achievement. It is
depressing when work done on the huge, international, largely tropical,
problem of childhood malnutrition is at last imported into western Europe
and then so misunderstood.
I also find it strange to assess anthropometric variables as
independent in a regression to predict the dependent “problem” of low
dietary intake. I see children as having a dietary intake in order to
attain stature and mass rather than the other way round.
Finally, “parameters measured” in Table 1 is a contradiction in
terms, parameter being a combination of para, not and meter, measure. In
parametric statistics parameters are virtual population constants
estimated from measurements on samples and in deterministic equations they
are also constants. They are confused with variables so often that it is
pedantic to complain, but growth is one subject where their meaning needs
protection, because if Child 1 grows along the curve W = a1 f(t) + ... and
Child 2 grows along the curve W = a2 f(t) + ..., weight (W) and age (t) are
variables, measured, and a1 and a2 are parameters characteristic of each
child but constant during their growth and calculated, not measured.
I believe Raynor and Rudolf have a valuable data-set and the muddle
in the analysis reflects on the editorial process. When the subject is so
central to paediatrics and it is published in ADC this matters.
E S COOPER
Department of Paediatrics
Newham General Hospital
Glen Road
London E13, UK
REFERENCES
1. Raynor P, Rudolf MCJ. Anthropometric indices of failure to thrive. Arch Dis Child 2000;82:364-365.
2. Waterlow JC. Note on the assessment and classification
of protein-energy malnutrition in children. Lancet 1973;ii:1176-1178.
3. Gomez F, Ramos-Galvon R, Frenk S, et al. Mortality in second and third degree malnutrition. Journal of Tropical Pediatrics. 1956;2:77-83.
4. Grantham-Mcgregor SM, Powell CA, Walker SP, Himes JH. Nutritional supplementation, psychosocial stimulation and
mental development of stunted children. Lancet 1991;338:1-5.
In a not cited paper published by Pediatric Allergy Immunology I have
detailed everything about soy formulas (SFs). Children with atopic
dermatitis fare well on SFs, those with colitis/enterocolitis have
reactions to soy, but Burks demonstrated that these are not IgE-mediated,
therefore it is improper to classify such reactions as allergenic.
In
Table 4, 19.8% of children (mean) reacted to SFs, but...
In a not cited paper published by Pediatric Allergy Immunology I have
detailed everything about soy formulas (SFs). Children with atopic
dermatitis fare well on SFs, those with colitis/enterocolitis have
reactions to soy, but Burks demonstrated that these are not IgE-mediated,
therefore it is improper to classify such reactions as allergenic.
In
Table 4, 19.8% of children (mean) reacted to SFs, but in the only DBPCFC
study the prevalence was 0%, therefore 80-100% of such babies tolerate
SFs. In all other seven studies no food challenge was attempted. Burks has
also shown that children reacted to liquid SF, but not to powdered ones,
thus indicating that epitopes could be present in one formula, but not in
the other.
The American Academy of Pediatrics "recognized that soy protein is anti-genic does not
mean that soy protein is highly allergenic" and that "most infants with
documented IgE-mediated allergy to CM protein will do well on isolated
SPFs". Høst et al also suggest to feed atopic infants with hydrolysate
formulas (HFs). We have documented 202 reactions to HFs in a
paper, and 41 case-reports in another. In total 17 cases of shock-
anaphylaxis (one every 3.3 years) versus one case of anaphylaxis/22.3
years provoked by SPFs, with a difference of 676%.
Arnaldo Cantani, MD, PhD
Monica Micera, MD
Professor of Pediatric Allergy and Immunology
Rome University "La Sapienza"
The recent article by Christian et al (1) highlights the
value of clinical features in assessing the risk of renal
scarring and therefore the need for DMSA scan after urinary
tract infection (UTI). We recently performed a case note
study to assess the recording of fever, malaise, recurrent
UTI and urine culture results in children investigated with
DMSA scan after UTI. Between April 1996 and October 199...
The recent article by Christian et al (1) highlights the
value of clinical features in assessing the risk of renal
scarring and therefore the need for DMSA scan after urinary
tract infection (UTI). We recently performed a case note
study to assess the recording of fever, malaise, recurrent
UTI and urine culture results in children investigated with
DMSA scan after UTI. Between April 1996 and October 1997
there were 171 DMSA scans in our hospital that fitted these
criteria; 30 case notes could not be traced. There were 105
girls (74%) and 36 boys. Age when UTI was diagnosed ranged
from 9 days to 15.3 years, mean 4.2 years (SD 3.2).
There were 17 (12%) cases of definite or probable
renal scar none of which followed a sterile or
contaminated urine culture. Of the 141 case notes, there was
no mention of fever in 48 (34%), and no mention of malaise
in 76 (54%). In 69 case notes reviewed there was no mention
of previous history of UTI in 14 (20%) cases. Of those with
a history of fever 19% (10/53) had an abnormal DMSA scan
compared to 10% (4/40) in those without fever. 18% (9/50)
of those unwell at the time of UTI had an abnormal scan
compared to 13% (2/13) of those not ill.
These data suggest that in a substantial proportion of cases
the decision to request a DMSA scan is apparently not
influenced by salient clinical features and urine culture
results. In this series, it would appear that those children
with sterile or contaminated urine cultures should not have
had a DMSA scan. This would have saved the cost and burden
of 48 scans, 34% of this series, over an 18 month period.
It is unlikely that these findings are peculiar to our
district.
1. Christian MT, McColl JH, MacKenzie JR, Beattie TJ. Risk
assessment of renal cortical scarring with urinary tract
infection by clinical features and ultrasonography. Arch Dis Child 2000;82:376-380.
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!
Dear Editor:
I read with interest the article by Raynor and Rudolf[1] comparing the anthropometric indices of failure to thrive. In the same context, I would like to share the findings of our study which was done to compare the indices used for assessing nutritional status at birth. The indices used were the birth weight, Ponderal index and the CANSCORE (Clinical assessment of nutritional score).
A 20 co...
Dr Marcovitch's comments about Heather Zar's article (Arch Dis Child 2000;82:495-8), championing the use of home made spacers and in particular the coffee cup, do not stand up to a closer examination. In a recent randomised study of the bronchodilator effects of different spacers from the same authors as the ADC article, in 44 children with moderate...
Dear Editor:
Did Raynor and Rudolf[1] look at height or head circumference as anthropometric predictors of developmental, dietary and eating problems? They measured height in order to calculate the Waterlow method of classifying wasting, and head circumference is easier to measure accurately in the field. Waterlow’s 1973 contribution[2] was to divide the weight-for-age deficits classified by Gomez et al in 1956...
In a not cited paper published by Pediatric Allergy Immunology I have detailed everything about soy formulas (SFs). Children with atopic dermatitis fare well on SFs, those with colitis/enterocolitis have reactions to soy, but Burks demonstrated that these are not IgE-mediated, therefore it is improper to classify such reactions as allergenic.
In Table 4, 19.8% of children (mean) reacted to SFs, but...
The recent article by Christian et al (1) highlights the value of clinical features in assessing the risk of renal scarring and therefore the need for DMSA scan after urinary tract infection (UTI). We recently performed a case note study to assess the recording of fever, malaise, recurrent UTI and urine culture results in children investigated with DMSA scan after UTI. Between April 1996 and October 199...
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...
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