In their observational study Sammons et al. showed that general
anaesthesia (GA) is more convenient and better tolerated than procedural
sedation (PS) for paediatric neuroimaging.1 These findings are fully
consistent with what can be obviously concluded from recent literature: in
paediatric neuroimaging, and especially in magnetic resonance imaging,
standard sedatives lack optimal effectiveness. The obvious explanation is...
In their observational study Sammons et al. showed that general
anaesthesia (GA) is more convenient and better tolerated than procedural
sedation (PS) for paediatric neuroimaging.1 These findings are fully
consistent with what can be obviously concluded from recent literature: in
paediatric neuroimaging, and especially in magnetic resonance imaging,
standard sedatives lack optimal effectiveness. The obvious explanation is
the unpredictability of onset, depth and duration of sedation. Although
the incidence of sedation failure is usually below 10%, delay, motion
artefacts, interruption of procedure for supplementary sedation and
interference with scanning schedule occur frequently. In addition, the
long half-life makes an extensive monitored recovery period imperative,
generating an extra burden for health care. Finally, these drugs may cause
unexpectedly deep sedation that might interfere with respiratory
reflexes.2 Their use must therefore be restricted to settings with high
safety standards for monitoring, professional competences and rescue
facilities. From a cost-benefit point-of-view one may question the
justifiability of implying these standards in a sedation practice that
applies suboptimal sedatives. Simply replacing PS by GA is not a
reasonable alternative, given the generally limited anaesthesia services
for neuroimaging.
Recent literature yields interesting new concepts. The anaesthetic
propofol is an excellent sedative for PS in spontaneously breathing
children. Its short induction and recovery times and optimal titratability
make propofol a suitable alternative for GA in neuroimaging.3 Furthermore,
there is good evidence that well-trained non-anaesthesiologists may
provide propofol sedation safely.4 Appropriate safety precautions,
monitoring and professional skills, rather than professional title, are
determinants for its safe and effective use. 5 Time has come to further
explore these concepts and to move to practical implementation. Optimally
safe and effective PS in paediatric neuroimaging needs competent sedation
providers who are specifically trained in deep sedation using highly
effective drugs within a context of transparency and ongoing quality
control.
Piet LJM Leroy1, Hans (J) TA Knape2
1Paediatric Sedation Unit, Department of Paediatrics, Maastricht
University Medical Centre, P.O. Box 5800,
6202 AZ Maastricht, The Netherlands
2Department of Anaesthesiology, University Medical Centre, P.O. Box 85500,
3508 GA Utrecht, The Netherlands
References
1. Sammons HM, Edwards J, Rushby R, et al. General anaesthesia or sedation
for paediatric neuroimaging: current practice in a teaching hospital.
Archives of disease in childhood;96(1):114.
2. Motas D, McDermott NB, VanSickle T, et al. Depth of consciousness and
deep sedation attained in children as administered by
nonanaesthesiologists in a children's hospital. Paediatric anaesthesia
2004;14(3):256-60.
3. Mallory MD, Baxter AL, Kost SI. Propofol vs pentobarbital for sedation
of children undergoing magnetic resonance imaging: results from the
Pediatric Sedation Research Consortium. Paediatric anaesthesia
2009;19(6):601-11.
4. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of
adverse events during pediatric sedation/anesthesia with propofol for
procedures outside the operating room: a report from the Pediatric
Sedation Research Consortium. Anesthesia and analgesia 2009;108(3):795-
804.
5. Green SM, Krauss B. Barriers to propofol use in emergency medicine.
Annals of emergency medicine 2008;52(4):392-8.
I agree with the editorialists that bed sharing is a decision that
each parent must make based on their own risk profile and the benefits
that they receive. A dogmatic single message approach is not appropriate
for this widespread practice when it has such a small affect on absolute
risk of SIDS in many families. I would like to bring to their attention a
very useful app (available for android and apple devices) from the...
I agree with the editorialists that bed sharing is a decision that
each parent must make based on their own risk profile and the benefits
that they receive. A dogmatic single message approach is not appropriate
for this widespread practice when it has such a small affect on absolute
risk of SIDS in many families. I would like to bring to their attention a
very useful app (available for android and apple devices) from the infant
sleep lab at Durham University, called Infant Sleeplab. It includes a risk
stratification tool for parents on bed-sharing as well as other evidence-
based information on infant sleep. https://www.isisonline.org.uk/app/
Conflict of Interest:
I have used the Infant Sleeplab app and associated website to inform my own parenting decisions. I have shared a bed with my second child since she was a few weeks of age.
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful
editorial that accompanied the publication of our paper [2]. We would
agree that, despite discrepant observational data in the UK regarding the
waning of antibody titres [2, 3], there is now a large body of evidence
[4] demonstrating that, even where antibody titres have waned, booster
doses are not required if an adequate primary schedule has been comp...
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful
editorial that accompanied the publication of our paper [2]. We would
agree that, despite discrepant observational data in the UK regarding the
waning of antibody titres [2, 3], there is now a large body of evidence
[4] demonstrating that, even where antibody titres have waned, booster
doses are not required if an adequate primary schedule has been completed.
As discussed in the editorial, the pragmatic priority is to ensure
that all children complete the course and receive at least one further
dose after their initial (accelerated) schedule at 0, 1, 2 months.
Routine immunisation visits are a convenient time to do this, and the
pre-school booster presents one such opportunity. However, as Dr Ladhani
and Dr Ramsay have noted elsewhere, almost all UK children diagnosed with
chronic hepatitis B infection acquire this through vertical transmission
[5]. Having a named clinician responsible for delivery of the 0, 1, 2
month schedule can improve its delivery , and the 12 month routine vaccine
visit is more timely than the pre-school booster for ensuring its
completion.
1. Ladhani SN, Ramsay ME. The importance of a preschool booster for
children born to hepatitis B-positive mothers. Arch Dis Child. 2013; 98:
395-396.
2. Yates TA, Paranthaman K, Yu LM, et al. UK vaccination schedule:
persistence of immunity to hepatitis B in children vaccinated after
perinatal exposure. Arch Dis Child. 2013; 98: 429-433.
3. Boxall EH, A Sira J, El-Shuhkri N, et al. Long-term persistence of
immunity to hepatitis B after vaccination during infancy in a country
where endemicity is low. J Infect Dis. 2004; 190(7): 1264-9.
4. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose.
Clin Infect Dis. 2011; 53(1): 68-75.
5. Flood J, Amirthalingam G, Ramsay ME, et al. The diagnosis of chronic
Hepatitis B infection among children born in England after introduction of
universal antenatal HBV screening programme. Poster presented at the
European Society of Paediatric Infectious Disease Meeting, The Hague, June
2011. http://www.kenes.com/ espid2011/cd/pdf/P774.pdf.
Conflict of Interest:
Our study was supported by the NIHR Oxford Biomedical Research Centre and GlaxoSmithKline Biologicals. SL has undertaken paid work for vaccine manufacturers for provision of travel health training and attendance at advisory group meetings. AJP and MDS have conducted clinical trials on behalf of Oxford University sponsored by manufacturers of vaccines. AJP and MDS do not accept any personal payments from vaccine manufacturers: grants for support of educational activities are paid to an educational/administrative fund held by the Department of Paediatrics, Oxford University. MDS has received support from vaccine manufacturers to attend academic conferences. ED, SBW, SJH, KP and TAY declare no conflicts of interest besides funding received for the study.
The authors of this study are to be congratulated on a unique and useful collection of data which, in the present climate, is increasingly difficult to achieve. Unfortunately the title is somewhat misleading and the abstract potentially open to mis-interpretation. Although parents collected diary data on their children during concurrent weeks, this is presented by the authors in a cross sectional, not longitudinal manner. Thus, wh...
The authors of this study are to be congratulated on a unique and useful collection of data which, in the present climate, is increasingly difficult to achieve. Unfortunately the title is somewhat misleading and the abstract potentially open to mis-interpretation. Although parents collected diary data on their children during concurrent weeks, this is presented by the authors in a cross sectional, not longitudinal manner. Thus, when the authors report just 6.7% of "collections" among premobile infants had at least one bruise, this refers to a single week of observation. Lost in the text of the results section is the information that 27% had a bruise over all weeks surveyed. The true proportion of infants with a bruise over the whole of the 0-11 month period must be significantly higher than this as parents did not necessarily provide data for the whole period. Equally although a bruise was recorded in just 2.2% of one week "collections" among infants unable to roll over, it seems likely that the true figure over the 17 weeks or so at that developmental stage is likely to be very much higher - perhaps as high as 10%!
Although we should continue to ensure that health and care services maintain a high level of vigilance, it is important for paediatricians to assess each case on its merits looking for features such as clusters of bruises and bruises in areas typical of child abuse rather than responding to these and other data with a "one rule fits all" response thereby subjecting large numbers of infants to unnecessary and harmful investigation and parents to huge anxiety and intrusion. A further concern, and from my own experience from attempting to design a similar longitudinal approach, is that ethics committees and safeguarding boards are increasingly likely to make it very difficult to collect this type of essential longitudinal data without unacceptable intrusion.
Harvey Marcovitch suggests that it is "good news" that only 4% of
cases are settled in court. Nearly half (43%) are settled out of court.
Is this because in these cases it is not clear to either party whether
there has been negligence or not; or is it because medical attendants have
simply performed below average? At any one time half of us, by
definition, will perform below average. A settlement out of court, to many
p...
Harvey Marcovitch suggests that it is "good news" that only 4% of
cases are settled in court. Nearly half (43%) are settled out of court.
Is this because in these cases it is not clear to either party whether
there has been negligence or not; or is it because medical attendants have
simply performed below average? At any one time half of us, by
definition, will perform below average. A settlement out of court, to many
people, equates with negligence. So could it be that in 43% of cases,
paediatricians have been deemed negligent when they have simply been
performing below average?
It used to be thought that in half of all cot deaths the cause was medical
negligence. A change in sleeping position brought dramatic improvement,
to show that many paediatricians had suffered false condemnation. Are
paediatricians still being falsely condemned by rushing into out of court
settlements?
Thank you for your response to our research 'The agreement of
fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue
perfusion in a simple and timely manner and continue to extrapolate that
in shock, blood is usually diverted from the skin in an attempt to perfuse
vital organs. Current practice and guidance assumes that CRT is a
reflecti...
Thank you for your response to our research 'The agreement of
fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue
perfusion in a simple and timely manner and continue to extrapolate that
in shock, blood is usually diverted from the skin in an attempt to perfuse
vital organs. Current practice and guidance assumes that CRT is a
reflection of this (1-7).
We were not expecting to find fingertip CRT to be faster than sternum CRT,
although we did not find it strange. We agree and also suspect that
different sites have different refill times because of the complex and
intricate relationships involved, which are not practical or possible to
record prior to carrying out the CRT (such as arteriolar resistance,
venular resistance etc. as discussed in Carcillo (1)). There is a
substantial amount of research in CRT in vascular medicine which we
decided not to include in our literature review prior to this study,
although our findings might indicate it would be more appropriate to
examine this area in more detail. We do know that the fingertip pulp is
rich in arterio-venous anastomoses which may explain why it had the
quickest CRT and that vascular resistance is increased in peripheral beds
and this may explain why it also had the slowest CRT.
We agree that there needs to be standardisation of the technique,
greater awareness of CRT limitations and it should be analysed in
conjunction with other haemodynamic markers. We suggested that guidance
provided by the Resuscitation Council (RC) (2-4), amongst others, be
reviewed for exactly these reasons. The RC highlight CRT as one of the
five parameters to observe when examining circulation, giving it equal
weighting to heart rate, pulse volume, blood pressure and end organ
perfusion status. The RC guidance does advise to consider CRT with other
cardiovascular signs but importantly does not consider the fingertip site
or variables such as inter and intra observer reliability and skin colour.
Carcillo's editorial is interesting; however this purposive review is
not balanced or systematic and does not provide a comprehensive overview
of the literature relating to CRT. Interestingly although Carcillo is
discussing sick children we are informed that CRT is age dependant and
rightly references the study that discovered this in 1988, there is no
evidence that tells us otherwise, yet we can find no guidance by the RC or
other group that utilises an age dependant model, why is that?
Our study did not set out to examine the usefulness of the test, but
led us to question the way CRT is conducted in current clinical practice.
In an era where we try to practice evidence based medicine, if this test
is recommended for use in practice (something our research cannot answer)
then we have a duty to generate the evidence to support the way in which
it is conduced.
1. Carcillo JA. Capillary refill time is a very useful clinical
signin early recognition and treatment of very sick children. Editorial on
Pediatr Crit Care Med 2012; 13:136 -140
2. Resuscitation Council. Medical Emergencies and Resucitation--
Standards for clinical
practice and training for dental practitioners and dental care
professionals in
general dental practice. http://www.resus.org.uk/pages/MEdental.pdf
(accessed May
2013):24.
3. Resuscitation Council. European paediatric life support (EPLS).
3rd edn. London:
4. Resuscitation Council 2011:12. Resuscitation Council. A systematic
approach to the acutely ill patient, adapted from the ALERTTM.
http://www.resus.org.uk/pages/alsABCDE.htm (accessed May 2013).
5. Jevon P. Measuring capillary refill time. Nurs Times 2007;103:26-
7.
6. Lima A, Jansen TC, Van Bommel J, et al. The prognostic value of
the subjective assessment of peripheral perfusion in critically ill
patients. Crit Care Med 2009;37:934-8.
7. Graham C, Parke T. Critical care in the emergency department:
shock and circulatory support. Emerg Med J 2005;22:17-21.
We support the call for action by Wolfe et al. to address UK's high
child mortality rates relative to some other European countries (e.g.
Sweden) and we agree that preventive public health strategies are crucial
for reducing child mortality in the UK. To put these aspirations into
practice policy makers need to know which populations to target. In
particular, whether the priority should be to focus on the health of women...
We support the call for action by Wolfe et al. to address UK's high
child mortality rates relative to some other European countries (e.g.
Sweden) and we agree that preventive public health strategies are crucial
for reducing child mortality in the UK. To put these aspirations into
practice policy makers need to know which populations to target. In
particular, whether the priority should be to focus on the health of women
and girls, especially during pregnancy, or on the care of children and
families after birth. We do not suggest either or, but our basic
comparison of England & Wales and Sweden, using publicly available
tabulated data, adds information about where the priorities might lie.
We compared mortality rates per 1000 live births by birth weight and
age-at-death categories in England & Wales and Sweden for singleton
pregnancies in 2006. We restrict these analyses to infants, because most
deaths occur in the first year of life.
First, when we applied the Swedish infant mortality rate to the
number of live births in England and Wales, and compared the result with
the actual number of deaths that occurred in 2006, we obtained a
difference of 1238 excess deaths. This result is consistent with the
numbers cited in the paper (2000 excess deaths under the age of 14). We
then applied Swedish birth weight specific infant mortality rates to the
number of live births in England and Wales in each birth weight category
and calculated the differences with the observed number of deaths. When we
summed excess deaths over all categories, we obtained only 559 excess
deaths. This substantial drop implies that the majority of excess deaths
in 2006 were driven by the differences in the distribution of birth
weights between England & Wales and Sweden. Field et al. (2009) show
consistent results for gestational age - a higher proportion of children
in the UK are born preterm compared to other European countries and this
accounts for a substantial amount of the mortality difference. These
results suggest that preventive strategies should focus on reducing
prenatal risk factors and improving maternal health before and during
pregnancy.
Amongst the remaining excess deaths our research has identified two
groups most at risk. The greatest disparities were observed for extremely
low birth weight babies (<1000g) dying in the first week of life, with
440 excess deaths. Differences in resuscitation policies, practices for
the recording of live births and/or obstetric practices could explain
disparities in the early deaths among these babies. Babies with normal
birth weights (2500-3499g) had the second highest number of excess deaths
(219), with the majority occurring in the post-neonatal period. Further
investigation into causes of death and the impact of socio-economic
factors is required to fully understand the mechanisms driving mortality
in this group. Numbers of excess deaths in these two groups sum to more
than 559 as some birth weight groups had lower rates in England &
Wales than in Sweden.
These calculations are based on tabulations, but illustrate that if
we take into account differences in characteristics of babies at birth,
then the outlook for England and Wales is better than previously assumed.
Comparability of the datasets to explore country differences related to
reporting of live- and stillbirths, birth weight, and gestational age
distributions, and timing of death registrations could be maximised by the
use of individual-level data for such cross-country comparisons. Such
analyses would enable better understanding of where the disparities
originate from and more specifically what preventive strategies in the UK
may have the greatest impact.
Field D, Draper ES, Fenton A, et al. Rates of very preterm birth in
Europe and neonatal mortality rates. Arch Dis Child Fetal Neonatal Ed
2009;94:F253-6.
Modi and McIntosh [1] discuss over-regulation of clinical trials and
the small number of large neonatal multicentre trials carried out in the
UK in 2006.
As there is no single and exhaustive repository of data about UK
trials, it is difficult to determine exactly the level of trial activity
at that time. We can provide data which include 2006 from a survey of
level 2 and 3 neonatal units which identified ran...
Modi and McIntosh [1] discuss over-regulation of clinical trials and
the small number of large neonatal multicentre trials carried out in the
UK in 2006.
As there is no single and exhaustive repository of data about UK
trials, it is difficult to determine exactly the level of trial activity
at that time. We can provide data which include 2006 from a survey of
level 2 and 3 neonatal units which identified randomised trials conducted
in the UK in 2002-06. As part of the BRACELET (Bereavement and Randomised
Controlled Trials) Study questionnaires were sent to 220 neonatal units;
191(86.8%) responded, of which 149 were eligible (82 Level 2, 67 Level 3).
Seventy-six units enrolled 3137 neonates in one or more of 36 identified
trials in 2002-06 (10 international, 14 UK multicentre, 12 single centre);
85% (N=2657) were enrolled into multicentre trials [2]. Our parallel
paediatric survey showed a much smaller proportion (55% N=116) enrolled
into multicentre trials in this setting.
We categorised interventions as drugs and foods (including blood
products, anaesthesia, oxygen, food supplements) (n=19); physical
therapies (including cooling, heating, mechanical ventilation, surgery)
(n=15); other (including monitoring, parenting support (n=2)).
We are unable to disaggregate individual years within 2002-06 so
cannot show trends but it is clear that, in addition to INIS, NIRTURE and
PROGRAMS, there were other albeit smaller trials assessing medicinal and
other interventions in the UK.
These figures provide a recruitment baseline for neonatal trials
around the time of the regulatory and structural changes to the UK
research environment considered by Modi and McIntosh. Future studies may
be able to determine empirically whether the number of research-active
units and participants recruited increases, decreases or remains stable in
the aftermath.
[1]Neena Modi, Neil McIntosh. The effect of the neonatal Continuous
Negative Extrathoracic Pressure (CNEP) trial enquiries on research in the
UK. Arch Dis Child published 25 January 2011, 10.1136/adc.2010.188243
[2] Snowdon C, Harvey SE, Brocklehurst P, Tasker RC, Ward Platt MP, Allen
E, Elbourne D. BRACELET Study: surveys of mortality in UK neonatal and
paediatric intensive care trials. Trials 2010,11:65 (26 May 2010).
We read Ladhani and Ramsay's editorial with great interest. Whilst we
agree on the need for the delivery of a completed course of Hepatitis B
vaccinations in infants of high-risk mothers where the fourth vaccination
is administration by their first birthday, in order to improve uptake of
vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in an...
We read Ladhani and Ramsay's editorial with great interest. Whilst we
agree on the need for the delivery of a completed course of Hepatitis B
vaccinations in infants of high-risk mothers where the fourth vaccination
is administration by their first birthday, in order to improve uptake of
vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in antenatal services
may give birth in a labour unit outside of their local area due to bed
pressures and newborns may not receive their first vaccination. This
should, however, be limited by the use of patient-held maternity records.
The initial Hepatitis B vaccination is often administered by
maternity or neonatal paediatric staff under a hospital doctor
prescription. Subsequent vaccines are currently offered by a variety of
healthcare professionals such as general practitioners (GP) or community
paediatricians. Yates et al[1] showed a high level of participation at the
first vaccination but large numbers of infants did not have follow-up
vaccines. Reasons for this may include poor transfer of information and
clinical records between providers. Also, the administration of infant
Hepatitis B vaccinations does not result in item of service payments for
GPs and as such GP may be less likely to offer follow up vaccinations.
Similarly, acquisition of vaccines, blood test sampling, sample handling
practices and pathology systems may vary among GP practices, thus posing
additional barriers to the completion of vaccination schedules and
serological testing.
In the North London Borough of Enfield, a number of children under
the age of 2 years old move in and out of area making follow-up more
challenging. However, in 2004 in this borough, 80% of all high-risk
neonates of Hepatitis B positive mothers registered at Chase Farm Hospital
during antenatal testing received the full vaccination course and
serology[2]. This success has been attributed to the use of a named
clinical lead conducting an integrated immunisation clinic with a clinic
nurse. The team would recall and follow up patients to offer immunisation
and serological testing while considering migration, language and access
barriers. In a resource-limited health system such immunisation clinics
may not be feasible. Universal vaccination of children with Hepatitis B
vaccines is not practical or more effective than a targeted approach[3].
Therefore, we would recommend that follow-up Hepatitis B vaccinations and
serology are performed by incentivised GPs as a new 'item of service'
payment.
1. Yates TA, Paranthaman K, Yu L-M, et al. UK vaccination schedule:
persistence of immunity to hepatitis B in children vaccinated after
perinatal exposure. Arch Dis Child 2013;98:429-33.
2. Giroudon I. Immunization Coverage in Infants at Risk of Perinatal
Transmission of Hepatitis B: A London Study (LANSSG). HPA London Regional
Epidemiology Unit. 2008.
3. Balogum MA, Parry JV, Mutton K, et al. Hepatitis B virus transmission
in pre-adolescent schoolchildren in four multi-ethnic areas of England.
Epidemiol Infect 2013; 141(5):916-25
Wolfe et al heighten my anxiety about solution- focussed
epidemiological research with their recommendations for improving child
survival in the UK (1). The correlation of lower socio- economic
inequality with better child health outcomes in Sweden is clear enough but
correlation does not equal causation, as we never tire of hearing. The
assertion that "child survival in Britain would be improved through
macroeconomic po...
Wolfe et al heighten my anxiety about solution- focussed
epidemiological research with their recommendations for improving child
survival in the UK (1). The correlation of lower socio- economic
inequality with better child health outcomes in Sweden is clear enough but
correlation does not equal causation, as we never tire of hearing. The
assertion that "child survival in Britain would be improved through
macroeconomic policies to redistribute wealth and narrow the income gap
between rich and poor people" is barely plausible and not demonstrable.
The relevant papers in October's ADC demand a solution to fundamental
puzzles of pathophysiology- What causes intra-uterine growth restriction
and premature birth; and what part is played by their social determinants?
The association of preterm birth with poverty is modest (2). The
suggestion that a comparison of your income with your wealthy compatriots
can cause death goes too far.
One reason that Sweden has lower infant mortality rates is that they
have very few births to teenage women. This in turn is due to high
abortion ratios for teenagers, rather than having particularly low rates
of teenage pregnancy (3). Of course we can't rationally propose more
abortion as a solution to infant mortality when it is associated with
increased rates of premature birth in subsequent pregnancies (4).
Teenage maternity is a biological norm, and is not universally
associated with preterm birth. We must consider why preterm birth is
commoner in young mothers in the UK and many other countries. Pre-
conception stressful life events are associated with a four-fold increase
in preterm birth for teenage mothers in the USA (5). Pre-conception stress
provides us with a plausible pathophysiological model for causes of
prematurity and a potential focus for research. Its causes reach far
beyond family income and a protective effect against childhood stress of
certain family structures might explain their association with infant
survival and reduced risk of preterm birth(6).
Meanwhile, Sweden may be storing up its child mortality risk. Falling
educational attainment and rising rates of reported stress in young Swedes
should cause our Scandinavian colleagues some sleepless nights(3).
1 Wolfe I; ADC 2015
2 De Franco E; BMC Public Health 2008
3 Hjern A; Scand J Public Health 2012
4 Hardy G; J Obs Gynaecol Canada 2013
5 Witt W; AJPH 2014
6 Zeitlin JA; Paediatr Perinat Epidemiol 2002
In their observational study Sammons et al. showed that general anaesthesia (GA) is more convenient and better tolerated than procedural sedation (PS) for paediatric neuroimaging.1 These findings are fully consistent with what can be obviously concluded from recent literature: in paediatric neuroimaging, and especially in magnetic resonance imaging, standard sedatives lack optimal effectiveness. The obvious explanation is...
I agree with the editorialists that bed sharing is a decision that each parent must make based on their own risk profile and the benefits that they receive. A dogmatic single message approach is not appropriate for this widespread practice when it has such a small affect on absolute risk of SIDS in many families. I would like to bring to their attention a very useful app (available for android and apple devices) from the...
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful editorial that accompanied the publication of our paper [2]. We would agree that, despite discrepant observational data in the UK regarding the waning of antibody titres [2, 3], there is now a large body of evidence [4] demonstrating that, even where antibody titres have waned, booster doses are not required if an adequate primary schedule has been comp...
Harvey Marcovitch suggests that it is "good news" that only 4% of cases are settled in court. Nearly half (43%) are settled out of court. Is this because in these cases it is not clear to either party whether there has been negligence or not; or is it because medical attendants have simply performed below average? At any one time half of us, by definition, will perform below average. A settlement out of court, to many p...
Thank you for your response to our research 'The agreement of fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue perfusion in a simple and timely manner and continue to extrapolate that in shock, blood is usually diverted from the skin in an attempt to perfuse vital organs. Current practice and guidance assumes that CRT is a reflecti...
We support the call for action by Wolfe et al. to address UK's high child mortality rates relative to some other European countries (e.g. Sweden) and we agree that preventive public health strategies are crucial for reducing child mortality in the UK. To put these aspirations into practice policy makers need to know which populations to target. In particular, whether the priority should be to focus on the health of women...
Modi and McIntosh [1] discuss over-regulation of clinical trials and the small number of large neonatal multicentre trials carried out in the UK in 2006.
As there is no single and exhaustive repository of data about UK trials, it is difficult to determine exactly the level of trial activity at that time. We can provide data which include 2006 from a survey of level 2 and 3 neonatal units which identified ran...
We read Ladhani and Ramsay's editorial with great interest. Whilst we agree on the need for the delivery of a completed course of Hepatitis B vaccinations in infants of high-risk mothers where the fourth vaccination is administration by their first birthday, in order to improve uptake of vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in an...
Wolfe et al heighten my anxiety about solution- focussed epidemiological research with their recommendations for improving child survival in the UK (1). The correlation of lower socio- economic inequality with better child health outcomes in Sweden is clear enough but correlation does not equal causation, as we never tire of hearing. The assertion that "child survival in Britain would be improved through macroeconomic po...
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