We read with interest the suggestion that dosing charts may reduce
gentamicin prescribing errors.(1)
We fully support the concept but raise question with some of the
detail.
BNFc advises against use of unecessary decimal points.(2) They may be
misinterpreted or misread and result in 10-fold overdose.(3) Doses in the
neonatal table include trailing zero’s. We would suggest that the
in...
We read with interest the suggestion that dosing charts may reduce
gentamicin prescribing errors.(1)
We fully support the concept but raise question with some of the
detail.
BNFc advises against use of unecessary decimal points.(2) They may be
misinterpreted or misread and result in 10-fold overdose.(3) Doses in the
neonatal table include trailing zero’s. We would suggest that the
information presented should accurately refelect exactly what the
clinician should prescribe, or nurse administer.
We also question the need for overly precise doses that cannot
physically be administered.
All injectable medicines should be administered in a single syringe.
Syringes enable:
• doses of less than 1ml to be measured to the nearest 0.01ml
• doses of 1 to 2.5ml to be measured to the nearest 0.1ml and
• doses of 2.5 to 5ml to be measured to the nearest 0.2ml.
We therefore question recommendations to prescribe and thus administer
doses of 238mg (34kg child) or 11.6mg (2.9kg child). Gentamicin injection
is a 10mg/ml or 40mg/ml solution. 238mg is a dose volume of 5.95ml. 11.6mg
is a dose volume of 1.16ml. Neither can be measured accurately. We would
advise that dose rounding is applied to the tables so that 238mg becomes
240mg and 11.6mg becomes 12mg.
We recently performed a point prevalence study of medicines
administered to neonates within the level three neonatal unit at Wirral
Hospitals over three non-consecutive days. Of 261 administered medicines,
31 doses were different from the prescribed amount because the nurse had
to approximate the dose. These included doses of potent medicines
including tazocin and phenytoin. We plan to repeat the study in all
neonatal units within the Cheshire and Mersey Neonatal Network to quantify
the extent of dose approximation.
In our opinion doses that are prescribed for children and neonates
should be precise, accurate, appropriate and be physically possible to
administer. Nursing staff should never have to guess an approximate dose.
Yours faithfully
Neil A. Caldwell
Consultant Pharmacist, Children’s Services/Honorary Lecturer
Wirral University Teaching Hospitals NHS Foundation Trust/Liverpool John
Moores University
Oliver Rackham
Consultant Paediatrician
Wirral University Teaching Hospitals NHS Foundation Trust
Reference:
1. Wong et al . A simplified gentamcin dosing chart is quicker and more
accurate for nurse verification and BNFc. Arch Dis Chil 2009; 94: 542-545
2. BNF for Children 2008, BMJ Group, London
3. Wong et al. Incidence and nature of dosing errors in paediatric
medications: a systematic review. Drug Safety 2004; 27: 661-670
Thompson and colleagues have shown that commonly recorded vital signs
can be used to identify children with serious infections in the pediatric-
assessment-unit and that its sensitivity is comparable to more complicated
triage systems (1). However they did not take their study to the next
logical step of developing a scoring system for triage, using these vital
signs.
Thompson and colleagues have shown that commonly recorded vital signs
can be used to identify children with serious infections in the pediatric-
assessment-unit and that its sensitivity is comparable to more complicated
triage systems (1). However they did not take their study to the next
logical step of developing a scoring system for triage, using these vital
signs.
We have developed such a scoring system and the validation study done
concurrently in the UK and India was presented at the last annual meeting
of the British Pediatric Association (2). Called the ‘SICK Score’ (an
acronym for Signs of Inflammation in Children that can Kill), it uses the
physical variables of the systemic inflammatory response syndrome (SIRS)
and its continuum - the multiple organ dysfunction syndrome (MODS). Very
much like Thompson and colleagues, the parameters used by us were heart
rate, respiratory rate, systolic blood pressure (dichotomized as
normotensive and hypotensive), temperature, oxygen saturation, capillary
refill time and consciousness on the AVPU scale. The regression
coefficients (logs of the odds ratio of death) in the development-study
cohort, were used as weights for each parameter. Validation was done
against mortality.
The area under the ROC curve for the validation study done in UK and
India was 84.1% (95% CI: 77.5 to 90.7%) and this is comparable ROC of 77%
in the validation study of PRISM 2 (3). PRISM 2 was used as it is
available free in the public domain. In an earlier validation study we
tested ‘SICK Score against PRISM score in 125 patients who needed to be
admitted to the intensive care unit. The area under the ROC was 0.76 using
SICK Score and 0.78 using PRISM score. Hosmer-Lemeshow goodness of fit was
excellent. (Hosmer-Lemeshow Chi-square = 2.13 (P = 0.3450)) (4). The
software for calculation of SICK Score is available at
http://jacob.puliyel.com/sick.php. We agree with Thompson and colleagues
that vital signs by themselves can be as useful to assess severity of
illness in children seeking medical attention.
Jacob Puliyel MRCP M Phil
Consultant
puliyel@gmail.com
St Stephens Hospital
Delhi 110054
References
1. Thompson MJ, Coad N, Harnden A, Mayon-White R, Perera R, Mant D.
How well do vital signs identify children with serious infections in
paediatric emergency care?
Arch Dis Child published 15 July 2009, 10.1136/adc.2009.159095.
2. Gupta MA, Sahni M, Puliyel JM, Rangasami J, Chakrabarti A,
Halstead R, Green DA, Puliyel A, Sreenivas V. International collaboration
validating SICK score: a non-invasive severity-of-illness assessment. Arch
Dis Child 2008;93 (Suppl 1) A10.
3. Chamberlain JM, Patel KM, Pollack MM. The Pediatric risk of
hospital admission score: A second-generation severity-of-illness score
for pediatric emergency patients. Pediatrics. 2005;115:388-396.
4. Bhal S, Tygai V, Kumar N, Sreenivas V, Puliyel JM. Signs of
inflammation in children that can kill (SICK score): Preliminary
prospective validation of a new non-invasive measure of severity-of-
illness.
J Postgrad Med. 2006;52:102-5.
Thank you for highlighting this important topic that has wider
implications
than medicine alone. As you rightly say overt conflict is rare and there
are
several steps before the courts can or should become involved, but the
possibilities should be considered.
I feel the key difference is whether the law is designed "in the best
interests"
or in terms of the "rights of the child". The arguments that follow dif...
Thank you for highlighting this important topic that has wider
implications
than medicine alone. As you rightly say overt conflict is rare and there
are
several steps before the courts can or should become involved, but the
possibilities should be considered.
I feel the key difference is whether the law is designed "in the best
interests"
or in terms of the "rights of the child". The arguments that follow differ
according to which paradigm is chosen. Case law appears to be split, with
Miss Jones being allowed to refuse, but in the case of Re W, she was not.
I do think that consenting to and refusing treatment are different issues,
if
using the “best interests” argument. The treatment that is offered is
almost
by definition in the best interests of the patient, assuming a normal
situation.
So to consent will be in the best interests, while refusing is not. If
using a
rights-based approach, then there should be no difference, unless it can
be
argued that it takes a greater mental capacity to refuse a treatment.
The two issues may be the same as it could be in the best interests
of the
child to adhere to their rights. This would appear to be the case with
Miss
Jones, and this argument is likely to be further challenged under the
Human
Rights Act.
There is then the decision as to whether the sufficiency of a person’s
capacity
is context specific. Do some decisions need greater capacity? For example,
a
five year old could have the capacity to refuse a plaster for a wound, but
not
to an appendicectomy.
If considering the question posed in a broader context, I feel that
other
aspects of the law could learn from medical consent in children. Most laws
regarding children tend to have a cut off age where a person has capacity
or
does not and does not appreciate the differing rates in which children
mature.
There is no doubt that language is contextual. Disorder as a
term, while innocuously descriptive to one, may hold a
negative connotation for another, especially those afflicted
with whatever said disorder.
Regarding brain sex, I agree with the Consensus Statement on
Management of Intersex Disorders (CoSMID) that “Structure of
the brain is not currently useful for gender assignment.”
Quan...
There is no doubt that language is contextual. Disorder as a
term, while innocuously descriptive to one, may hold a
negative connotation for another, especially those afflicted
with whatever said disorder.
Regarding brain sex, I agree with the Consensus Statement on
Management of Intersex Disorders (CoSMID) that “Structure of
the brain is not currently useful for gender assignment.”
Quantification and identification of brain sex haven't been
at all forthcoming and fruitful on humans. A prodigious
amount of neurons and synaptic connections that have to
differentiate and develop would appear to, according to my
statistical conjecture, render brain sex and other brain
attributes variable (and study incredibly difficult) due to
the immense complexity of the process. Gender that, then,
combines brain sex and social and environmental factors
would also at least, in line with brain sex that influences
it, be variable. Sex, if one limits it to the genitalia and
perhaps secondary sex characteristics, is dimorphic, as most
persons get one of two possibilities when differentiation is
complete - that is, if one ignores considerations of size
and appearance, which some don't, but I do because
functionality, to me, is paramount.
The authors of CoSMID appear to be focused on sex. Brain sex
has already been ruled out by their statement on brain
structure (see previous quote). Gender, in turn, is too
variable to be predictable, and if one reads CoSMID, it is
obvious it is not their focus. Most of their focus is at the
level of the genitalia. As such, I believe sex was the main
consideration for the designation "Disorders of Sexual
Development" (DSD).
I take issue with the use of "development." I think it
should be "differentiation" - that is, Disorders of Sexual
Differentiation - as most DSD problems originate at that
level. Development would be from puberty onwards. "Sexual
development," in this case, may imply brain development
because differentiation and development for the brain can be
used interchangeably, but, again, I believe the focus was on
sex.
I can only imagine, perhaps not even that, how it must feel
to have a condition and it be labeled a "disorder." In a
medical setting, however, "disorder" need not be
stigmatizing or expedite surgical intervention or hormone
replacement. I understand that medical professionals have
set the stage with past controversial interventions that
will cause them to be viewed with suspicion, but on the
other hand we must call a spade a spade. From what is
understood about sexual differentiation (and development),
DSD cannot be anything other than what the term claims -
disorders. Substituting "variation" for "disorder"
colloquially is of no consequence, besides the assuagement
of the afflicted, which admittedly is important, but
scientifically, one would have to wonder about adaptation.
If the focus were brain sex or gender, this might be an
interesting academic and protracted discussion, but since it
is sex (for reasons stated earlier), there are really only
one of two possibilities, as most other possibilities tend
to be dysfunctional or nonfunctional, leading to
infertility. An adaptive benefit, even neutrality, seems
doubtful. None of these considerations, however, must
necessarily lead to medical intervention or management.
Again, I realize the need to be sensitive to the perceptions
of the afflicted ("afflicted" probably will also be seen as
a wrong choice of word), but I hope with this to somewhat
lessen the supposed stigma "disorder" bears.
Emond [1] sits on the United Kingdom Joint Committee on Vaccination
and Immunisation [2] which is not disclosed here, and therefore shares
collective responsibility for United Kingdom vaccination policy,
particularly since the government handed the committee autocratic powers
earlier this year [3,4]. Given the controversy which surrounds the alleged
non-disclosure of competing interests by Andrew Wakefield in the paper
c...
Emond [1] sits on the United Kingdom Joint Committee on Vaccination
and Immunisation [2] which is not disclosed here, and therefore shares
collective responsibility for United Kingdom vaccination policy,
particularly since the government handed the committee autocratic powers
earlier this year [3,4]. Given the controversy which surrounds the alleged
non-disclosure of competing interests by Andrew Wakefield in the paper
cited [5] and the related General Medical Council hearing it must be a
concern whether the editor was aware of this, and if so why it was not
acknowledged in the present publication?
Campbell et al discovered that disruption of the MET gene was
associated with autism and gastrointestinal conditions [6]. It will be a
surprise to many autism affected families that there is no association
between autism and bowel disease, however this article would appear to
make the classic error of suggesting that Wakefield was proposing that all
cases of autism had this etiology, thus attacking a straw argument. Baron-
Cohen et al detected a rate for Autistic Spectrum Disorders in the UK
school population of 157 in 10,000 [7] compared with only 60 in 10,000
here - the data is therefore likely to be incomplete.
[1] B Sandhu, C Steer, J Golding and A Emond, 'The early stool
patterns of young children with autistic spectrum disorder', Archives of
Disease in Childhood 2009;94:497-500,
http://adc.bmj.com/cgi/content/full/94/7/497
[3] Laura Donelly, 'Scientists to be given power to decide on
vaccinations', Sunday Telegraph, 8 March 2009,
http://www.telegraph.co.uk/health/healthnews/4953256/Scientists-to-be-
given-power-to-decide-on-vaccinations.html
[4] Lucy Johntone, 'Jab makers linked to vaccine programme', Sunday
Express, 8 March 2009, http://www.express.co.uk/posts/view/88216/Jab-
makers-linked-to-vaccine-programme
[5] Wakefield AJ, Murch SH, Anthony A, et al.. Ileal-lymphoid-nodular
hyperplasia, non-specific colitis and pervasive developmental disorder in
children. Lancet 1998;351:637–41.
[6] Campbell DB, Buie TM, Winter H, Bauman M, Sutcliffe JS, Perrin
JM, Levitt P, 'Distinct genetic risk based on association of MET in
families with co-occurring autism and gastrointestinal conditions',
Pediatrics. 2009 Apr;123(4):1255.
[7] Baron-Cohen S, Scott FJ, Allison C, Williams J, Bolton P,
Matthews FE, Brayne C, 'Prevalence of autism-spectrum conditions: UK
school-based population study', Br J Psychiatry. 2009 Jun;194(6):500-9.
Johnston makes an important point regarding the judging someone’s
competence from the apparent wisdom of their decision. I’m struck by an
interesting parallel. As an editor at ADC I see papers which discuss
complex predictive tests. Examples of this might be a test to determine
the likelihood of a patient surviving a disease process. These papers are
submitted at various stages in their genesis.
Johnston makes an important point regarding the judging someone’s
competence from the apparent wisdom of their decision. I’m struck by an
interesting parallel. As an editor at ADC I see papers which discuss
complex predictive tests. Examples of this might be a test to determine
the likelihood of a patient surviving a disease process. These papers are
submitted at various stages in their genesis.
Stage one is where there has been a lot of data sifting, and
candidate results - predictors - are identified as possibly indicative of
important outcomes. Sometimes the authors of these papers apply the
indicators back on their original population and demonstrate that they
work, but under these circumstances they are required to add the strong
caveat that they work only for that population.
Stage two is where the possible predictors are prospectively applied
to a new population and the outcome observed. This is much stronger
evidence, and allows the authors to describe their tests as truly
predictive.
It strikes me that, since these ethical situation in Johnston's paper
occur in individual patients, we regard ourselves as stuck with the first
stage. We are calibrating our competence test by using the very outcome
we’re interested in. As a consequence, it is a very weak test.
What we need, instead, is a way of testing competence in some way
which does not actually involve the specific issue at stake. What form
this test might take is beyond my limited abilities, but it might involve
assessing the individual's ability to understand and retain information,
assess risk, and understand outcomes. This will be very difficult, but
surely no more difficult than the situation the young person, their family
and those who are caring for them already find themselves in.
(I thank the Birmingham Children's Hospital Ethics Advisory Group for
their help in discussion in formulating this idea)
Ian Wacogne
Consultant Paediatrician
Birmingham Children's Hospital NHS Foundation Trust
Steelhouse Lane, Birmingham, B4 6NH
We read with great interest the systematic review written by pijpers
and the response to the article by candy. Functional childhood
constipation continues to top the charts in the paediatric out patient
clinics and laxatives seem to be a sensible option along with dietary
intervention, but the authors say these are not evidence based.
The authors, after a mammoth systematic literature review, concluded
statin...
We read with great interest the systematic review written by pijpers
and the response to the article by candy. Functional childhood
constipation continues to top the charts in the paediatric out patient
clinics and laxatives seem to be a sensible option along with dietary
intervention, but the authors say these are not evidence based.
The authors, after a mammoth systematic literature review, concluded
stating ‘insufficient evidence exists supporting that laxative treatment
is better than placebo in children with constipation’. The authors admit
that the studies in the review were diverse, not placebo controlled and
with no uniform outcome measure. We agree partially with the above lack of
sufficient scientific evidence and the need for a proper definition on
childhood functional constipation.
What ever the evidence may be, we observe in our day to day practice
Laxatives
Do seem to work in isolation or in combination. This is evident in the
dose-response obtained with PEG 3350. 1, which was rightly pointed by
candy 2 in his eLetter.
The recent guidelines published on the management of childhood
constipation. 3 4 5, might not have a sound scientific bearing but does
seem to work in clinical practice, perhaps because of a logical structure
to management, which is better than one without it.
We share the concerns raised by candy, in that the abstract only
readers could misinterpret the conclusion statement and not treat
constipation with laxatives.
This could lead to another debacle similar to that of MMR which could lead
to reduced use or sub-optimal treatment of childhood constipation.
References
1. Youssef NN, Peters JM, Henderson W, et al. Dose response of PEG
3350 for the treatment of childhood fecal impaction. J Pediatr
2002;141:410–14.
2. Prof David CA Candy, Pijpers et al, eletter 30th march 2009.
3.Baker SS, Liptak GS, Colletti RB, et al.. Constipation in infants
and children: evaluation and treatment. A medical position
statement of the North American Society for Pediatric Gastroenterology and
Nutrition. J Pediatr Gastroenterol Nutr 1999;29:612–26
4.Evaluation and treatment of constipation in children:
J Pediatr Gastroenterol Nutr 2006;43:405–7
5.Felt B, Wise CG, Olson A, et al.. Guideline for the management of
pediatric idiopathic constipation and soiling. Arch Pediatr Adolesc Med
1999;153:380–5
The systematic review of mothers' experiences of bottle feeding
conducted by Lakshman et al (2009) is a valuable contribution to the
evidence base underpinning care for new mothers by maternity services. As
the authors indicate, the Unicef Baby Friendly Initiative (BFI) and recent
guidance on post natal care from the National Institute for Health and
Clinical Excellence (NICE), whilst promoting breastfeeding, also recogni...
The systematic review of mothers' experiences of bottle feeding
conducted by Lakshman et al (2009) is a valuable contribution to the
evidence base underpinning care for new mothers by maternity services. As
the authors indicate, the Unicef Baby Friendly Initiative (BFI) and recent
guidance on post natal care from the National Institute for Health and
Clinical Excellence (NICE), whilst promoting breastfeeding, also recognise
that parents need support and guidance to formula feed safely. In
addition, Trusts preparing for Level One of the Clinical Negligence Scheme
for Trusts (CNST) are required to demonstrate that the maternity service
has approved documentation that describes the process for ensuring that
all women are supported in feeding their newborn, whatever their chosen
method. As a minimum this must include the process for supporting women
who are breastfeeding and also the process for supporting women who are
artificially feeding (CNST Criterion 1.5.5).
Experience as an Infant Feeding Advisor in a Baby Friendly accredited
maternity unit indicates that this can be best achieved through
implementation of the Initiative. Previously, mothers at the hospital were
shown how to make up feeds antenatally as part of a group demonstration at
parentcraft classes. This demonstration may have occurred up to two months
before the mother needed this knowledge, and arguably left her ill
equipped to make up feeds safely on discharge from hospital. Since
implementation of the Baby Friendly best practice standards, formula
feeding mothers at the hospital are now supported on a one-to-one basis to
make up feeds until they feel confident, using their own choice of
formula, bottles and teats. They are also provided with a separate Baby
Care Record containing written information on making up powdered baby milk
and sterilising feeding equipment. In addition, the mandatory staff
training programme includes a teaching session for staff on Formula
Preparation.
Adoption of the Baby Friendly Initiative Ten Steps enhances care for
all mothers whatever their choice of infant feeding.When implemented
properly, they favour:
�Informed decision-making about infant feeding
�Individualised advice about infant feeding
�Provision of a labour ward environment that optimises early
interaction between mother and baby
�Support for mothers following discharge from hospital
UNICEF UK strongly endorses Larkshman, Ogilvie and Ong's conclusion
that parents who bottle feed require adequate education in order to
minimise the risks. However, the implication within the article that
support for breastfeeding through implementation of the WHO/UNICEF Baby
Friendly Initiative may cause inadequate care for bottle feeding mothers
is to be questioned. The Baby Friendly Initiative standards recommend that...
UNICEF UK strongly endorses Larkshman, Ogilvie and Ong's conclusion
that parents who bottle feed require adequate education in order to
minimise the risks. However, the implication within the article that
support for breastfeeding through implementation of the WHO/UNICEF Baby
Friendly Initiative may cause inadequate care for bottle feeding mothers
is to be questioned. The Baby Friendly Initiative standards recommend that
all mothers have a one-to-one discussion on infant feeding with a health
professional as a routine part of their antenatal care, with the aim being
to ensure that mothers are in a position to make a fully informed choice
regarding feeding method.
The only restriction is that group demonstrations on how to prepare
bottle feeds are prohibited. The reason being that such demonstrations in
antenatal classes undermine breastfeeding, do nothing to aid informed
decision making and are an ineffective and inadequate way of teaching.
There is no other restriction on any information as long as it is free
from advertising and accurate. In the postnatal period it is strongly
recommended that bottle feeding mothers are shown how to prepare a feed
correctly before being discharged from hospital. In the community, staff
are encouraged to have a full discussion with bottle feeding mothers to
ensure full understanding of how to bottle feed correctly and UNICEF UK
provide an audit tool to help with this process. Staff are also encouraged
to ensure that all mothers, regardless of feeding method, have a period of
skin-to-skin contact with their babies after delivery to help facilitate
bonding and that all mothers room-in with their babies so that they gain
confidence in feeding and caring for their babies. Our long experience of
working with the UK health services indicates that, far from reducing care
for bottle feeding mothers, improvement in practice for breastfeeding also
improves care for bottle feeding mothers. Conversely, poor practice for
breastfeeding almost invariably means poor practice for bottle feeding
too.
The implication that discussing breastfeeding causes guilt, pressure
and feelings of failure is over-simplistic. Evidence has repeatedly shown
that not breastfeeding has important implications for infant and maternal
health and to deny this information for fear of causing guilt is to deny
parents the right to make informed decisions. It is the way the
information is imparted which is key and for health professionals to do
this appropriately they require adequate training, which is why staff
education is such an important element of the Baby Friendly standards.
Finally, it is extremely sad that so many women reported feeling
shame and failure for not succeeding at breastfeeding and relief when they
gave up and started bottle feeding. Almost all women are physiologically
capable of breastfeeding and with the right information and support it
should not be difficult or painful. The reason that so many women find it
so hard is because they do not receive sufficient support and
education,which is why the Baby Friendly Initiative was established.
It is my hypothesis that the "secular trend," the increase in size
and earlier puberty in children is caused by an increase in the percentage
of individuals of higher testosterone within the population over time. The
driving force is an increase in women of higher testosterone within the
population over time. This exposes their fetuses to higher levels of
testosterone in utero. In groups which began the trend with already h...
It is my hypothesis that the "secular trend," the increase in size
and earlier puberty in children is caused by an increase in the percentage
of individuals of higher testosterone within the population over time. The
driving force is an increase in women of higher testosterone within the
population over time. This exposes their fetuses to higher levels of
testosterone in utero. In groups which began the trend with already high
testosterone, I suggest this increase in testosterone is the cause of the
current increases in diabetes, obesity, infections, low birth weight and
preterm babies, breast cancer and other cancers, etc within the population
over time. In groups in which the testosterone levels were not high in
the past, I suggest the secular trend may produce positive, overall
benefits. I suggest this may explain why professional schools are
increasing admitting and graduating increased numbers of women.
Furthermore, I suggest the foregoing may explain the findings of
Pearson, et al.
Dear Sir
We read with interest the suggestion that dosing charts may reduce gentamicin prescribing errors.(1)
We fully support the concept but raise question with some of the detail.
BNFc advises against use of unecessary decimal points.(2) They may be misinterpreted or misread and result in 10-fold overdose.(3) Doses in the neonatal table include trailing zero’s. We would suggest that the in...
Thompson and colleagues have shown that commonly recorded vital signs can be used to identify children with serious infections in the pediatric- assessment-unit and that its sensitivity is comparable to more complicated triage systems (1). However they did not take their study to the next logical step of developing a scoring system for triage, using these vital signs.
We have developed such a scoring system and t...
Thank you for highlighting this important topic that has wider implications than medicine alone. As you rightly say overt conflict is rare and there are several steps before the courts can or should become involved, but the possibilities should be considered.
I feel the key difference is whether the law is designed "in the best interests" or in terms of the "rights of the child". The arguments that follow dif...
Dear Editor,
There is no doubt that language is contextual. Disorder as a term, while innocuously descriptive to one, may hold a negative connotation for another, especially those afflicted with whatever said disorder.
Regarding brain sex, I agree with the Consensus Statement on Management of Intersex Disorders (CoSMID) that “Structure of the brain is not currently useful for gender assignment.” Quan...
Emond [1] sits on the United Kingdom Joint Committee on Vaccination and Immunisation [2] which is not disclosed here, and therefore shares collective responsibility for United Kingdom vaccination policy, particularly since the government handed the committee autocratic powers earlier this year [3,4]. Given the controversy which surrounds the alleged non-disclosure of competing interests by Andrew Wakefield in the paper c...
Johnston makes an important point regarding the judging someone’s competence from the apparent wisdom of their decision. I’m struck by an interesting parallel. As an editor at ADC I see papers which discuss complex predictive tests. Examples of this might be a test to determine the likelihood of a patient surviving a disease process. These papers are submitted at various stages in their genesis.
Stage one is...
We read with great interest the systematic review written by pijpers and the response to the article by candy. Functional childhood constipation continues to top the charts in the paediatric out patient clinics and laxatives seem to be a sensible option along with dietary intervention, but the authors say these are not evidence based.
The authors, after a mammoth systematic literature review, concluded statin...
The systematic review of mothers' experiences of bottle feeding conducted by Lakshman et al (2009) is a valuable contribution to the evidence base underpinning care for new mothers by maternity services. As the authors indicate, the Unicef Baby Friendly Initiative (BFI) and recent guidance on post natal care from the National Institute for Health and Clinical Excellence (NICE), whilst promoting breastfeeding, also recogni...
UNICEF UK strongly endorses Larkshman, Ogilvie and Ong's conclusion that parents who bottle feed require adequate education in order to minimise the risks. However, the implication within the article that support for breastfeeding through implementation of the WHO/UNICEF Baby Friendly Initiative may cause inadequate care for bottle feeding mothers is to be questioned. The Baby Friendly Initiative standards recommend that...
It is my hypothesis that the "secular trend," the increase in size and earlier puberty in children is caused by an increase in the percentage of individuals of higher testosterone within the population over time. The driving force is an increase in women of higher testosterone within the population over time. This exposes their fetuses to higher levels of testosterone in utero. In groups which began the trend with already h...
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