In a letter to your journal recently published, Dr Gray and his
colleagues criticised the newly published algorithm for the treatment of
meningococcal disease and septic shock in children.1,2 In particular, they
were concerned that the ‘sole trigger’ for intubation was 60ml/kg of fluid
resuscitation. This is not the case. The algorithm indicates that after
each bolus of fluid, the child should be assessed for ‘signs of sho...
In a letter to your journal recently published, Dr Gray and his
colleagues criticised the newly published algorithm for the treatment of
meningococcal disease and septic shock in children.1,2 In particular, they
were concerned that the ‘sole trigger’ for intubation was 60ml/kg of fluid
resuscitation. This is not the case. The algorithm indicates that after
each bolus of fluid, the child should be assessed for ‘signs of shock’.
Further, we are concerned that the authors’ recommendations for timing of
intubation may result in fatal delays. In the following, we consider the
physiological and practical basis for our concerns.
The pathophysiology of septic shock is characterised both by a loss
of effective circulating volume resulting in reduced preload in the heart
and by cardiac contractility dysfunction, which further diminishes cardiac
output and thus vital organ perfusion. This deficit in oxygenation, often
demonstrated by rising lactate levels stimulates increases in respiratory
effort. In these situations, the blood supply to the diaphragm can
increase more than 10-fold 3. In an animal model of shock, diaphragmatic
blood flow rose from 3% to 21% of cardiac output 4. Paralysis, sedation
and mechanical ventilation can therefore offload significant demands on
the heart, reducing respiratory (and other muscle) demands as well as
cerebral oxygen requirements. We believe that it is therefore important
that cardiovascular benefits of intubation are considered as well as
respiratory ones. Waiting until the patient is moribund is too late.
The second concern we have is that the algorithm is intended for
doctors in primary care or in local hospitals. These doctors may have
limited experience in this clinical setting and may practise in smaller
centres without the benefit of invasive monitoring and expert support
staff. In the ICU setting, a more flexible approach to the timing of
intubation may indeed be appropriate. However, there are many potential
delays to a patient’s access to a larger facility, including those
associated with diagnosis, communication, geography and even
administration. In our experience the entire process of patient transfer
takes an average of five hours. Late intubation may further delay access
to an appropriate intensive care facility
Despite our above arguments, we agree with Dr Gray and his colleagues
that children requiring over 40-60ml/kg fluid replacement may indeed be
safely managed without subsequent intubation. However we feel this may
only be suitable if the signs of shock diminish in response to fluid
replacement, in a paediatric intensive care or high dependency setting.
Furthermore, we feel we must highlight that all such cases should be
discussed with a tertiary centre as early as possible, and most need
transfer there. A delay at this time may be fatal.
Thomas Day, M.A.M.Faizal, Robert Ross-Russell, Samir Latifi, Sarah L.
Morley.
Cambridge University Hospitals NHS Trust, Cambridge, UK.
References
1. Gray MP, Gour A, Davison C, Round J, Murdoch L. Indication for
tracheal intubation in meningococcal disease and septic shock. Archives of
Disease in Childhood. 2007; 92: 827.
2. Pollard AJ, Nadel S, Ninis N, Faust SN, Levin M. Emergency
management of meningococcal disease: eight years on. Archives of Disease
in Chilhood. 2007; 92(4): 283-6
3. Supinski G. Control of respiratory muscle blood flow. American
Review of Respiratory Disease. 1986. 134(5): 1078-81.
4. Viires N, Sillye G, Aubier M, Rassidakis A, Roussos C. Regional
blood flow distribution in dog during induced hypotension and low cardiac
output. Spontaneous breathing versus artificial ventilation. Journal of
Clinical investigation. 1983. 72(3): 935-47.
So, doctors in the UK are not prescribing asthma drugs according to
published guidelines [1]. Sadly, UK medical journals are also failing to
hit the spot, by printing images of children using inappropriate inhalers,
with suboptimal technique. Although paediatricians and current asthma
guidelines recognise the difficulty that children have in using a metered-
dose inhaler (MDI) without a spacer, the photo o...
So, doctors in the UK are not prescribing asthma drugs according to
published guidelines [1]. Sadly, UK medical journals are also failing to
hit the spot, by printing images of children using inappropriate inhalers,
with suboptimal technique. Although paediatricians and current asthma
guidelines recognise the difficulty that children have in using a metered-
dose inhaler (MDI) without a spacer, the photo on the front cover of this
month's edition of the journal shows a girl using an MDI, without a
spacer, with her mouth wide open. Archives is not alone in showing an
image of a child using an inappropriate inhaler device. The Lancet
recently published an editorial highlighting the latest US asthma
guidelines, also accompanied by a photo of a boy using an MDI without a
spacer [2].
If UK doctors are to follow prescribing guidelines more closely, the
editorial teams of these two well-respected journals need to take the
lead.
Yours
Donald Payne
References
1. Cohen S, Taitz J, Jaffé A. Paediatric prescribing of asthma drugs
in the UK: are we sticking to the guideline?
Arch Dis Child 2007;92:847-849
2. New guidelines for better asthma control. The Lancet 2007;370;802
The article by Akobeng and Heller (1) is very interesting indeed and
seems to be very useful. They suggest that using the PIN-ER-t (population
impact number of eliminating a risk factor over a period of time), which
is defined as the potential number of disease events prevented in a
population over the next t years by eliminating a risk factor (2), allows
numbers to be communicated in a more friend...
The article by Akobeng and Heller (1) is very interesting indeed and
seems to be very useful. They suggest that using the PIN-ER-t (population
impact number of eliminating a risk factor over a period of time), which
is defined as the potential number of disease events prevented in a
population over the next t years by eliminating a risk factor (2), allows
numbers to be communicated in a more friendly way to show the impact of
risk factors for the disease in a population to both decision makers and
general public (1). I used their examples, presented in their article,
with some of my graduate and undergraduate students and they indeed found
this way of expressing the impact of risk factors much more friendly.
Thus, it seems that not only police makers and the general public may
benefit from this approach. My students only found a little trick to use
´no breast feeding´ as a risk factor. In fact, it is possible to phrase
PIN-ER-t as the potential number of disease events prevented in a
population over the next t years by introducing a preventive factor, in
this case breast feeding. In any case, this measure might be very useful,
in special in developing countries, where resources in general are
limited. It is possible to calculate, using the PIN-ER-t numbers obtained,
the amount of resources that could be saved if a risk factor is eliminated
or its effect minimized. For example, knowing the number of asthma cases
that could be prevented, let say, in a year, and by knowing the prevalence
of the different levels of severity of this disease in children (mild,
moderate and severe) in a certain setting, as well as how much resources
are spent by families and the health system with the disease (medications,
hospitalization etc.), it is possible to calculate how much resources on
average would be saved. With the epidemiologic transition, more and more
chronic diseases, such as asthma and obesity, have greater impact in
transition countries with large populations such as mine. I wonder whether
the authors thought about improving the PIN-ER-t measure allowing it to be
calculated when two or more diseases coexist in the same individual, for
instance, asthma and obesity. Also, how would it be calculated if those
diseases may interact or modify each other effect as it seems to happen in
this case. Anyway, I would like to congratulate the authors for this very
interesting article and the Editors for publishing it.
(1) Akobeng AK, Heller RF. Assessing the population impact of low
rates of breast feeding on asthma, coeliac disease and obesity: the use of
a new statistical method. Arch Dis Child 2007; 92: 483-485
(2) Heller RF, Buchan I, Edwards R, et al. Communicating risk at the
population level: application of population impact numbers. BMJ
2005;327:1162-5
We were interested to read the letter from Pryce and colleagues (1),
describing how, over a two year period, they detected one extra case of
congenital hypothyroidism (CHT) by reducing the threshold level of TSH
for referral from the newborn screening programme. The UK Newborn
Screening Programme Centre is currently reviewing a number of aspects of
the CHT programme, including the cut off for ref...
We were interested to read the letter from Pryce and colleagues (1),
describing how, over a two year period, they detected one extra case of
congenital hypothyroidism (CHT) by reducing the threshold level of TSH
for referral from the newborn screening programme. The UK Newborn
Screening Programme Centre is currently reviewing a number of aspects of
the CHT programme, including the cut off for referral of a presumptive
positive. We will be incorporating data from as many UK centres as
possible, including this data from Wales and before making any changes
will be consulting a wide range of stakeholders.
It is perhaps worth reminding readers that all screening programmes
are a balance of detecting as many as possible ‘true’ cases, while not
labelling too many children as false positives, however temporarily.
Reference:
1. Pryce RA, Gregory JW, Warner JT, et al.Is the current threshold
level for screening for congenital hypothyroidism too high? An audit of
the clinical evaluation, confirmatory diagnostic tests and treatment of
infants with increased blood spot thyroid-stimulating hormone
concentrations identified on newborn blood spot screening in Wales.Arch.
Dis. Child., Sep 2007; doi:10.1136/adc.2007.121988. (Accessed 17th
September 2007).
We read with great interest the article of Perez et al (1) on the
relationship of severity of meningococcal infection with anthropometrical
parameters in children. Patients with severe disease and non-survivors had
higher weight for age z scores than patients with non-severe disease. Body
mass index was significantly higher in those with severe disease.
Binder A et al (2)reported an association of the 4G...
We read with great interest the article of Perez et al (1) on the
relationship of severity of meningococcal infection with anthropometrical
parameters in children. Patients with severe disease and non-survivors had
higher weight for age z scores than patients with non-severe disease. Body
mass index was significantly higher in those with severe disease.
Binder A et al (2)reported an association of the 4G/5G plasminogen
activator inhibitor –1 (PAI-1) gene polymorphism with disseminated
intravascular coagulation in children with meningococcal disease. They
found that DIC was significantly associated with the 4G/4G genotype.
Haralambous et al investigated the association of the 4G/5G PAI-1
polymorphism and outcome in meningococcal disease (3). He found that the
4G/4G genotype was significantly associated with increased mortality.
Logistic regression indicated that the 4G/5G and the 5G/5G genotypes were
associated with a 40% and 91% reduction in the odds of dying respectively,
compared to a 4G/4G genotype.
There is also a strong association of the 4G/5G polymorphism in the PAI-1
gene with obesity. Hoffstedt J et al (4)found that in otherwise healthy
Scandinavian subjects homozygosity for 4G was more common among obese
people, whereas homozygosity for 5G was more common among lean subjects.
The relative risk for being obese was threefold higher for subjects with
the 4G/4G genotype.
These studies clearly establish the association of the 4G/4G genotype with
both the severity of meningococcal disease and obesity. This association
of 4G/4G genotype with both the severity of meningoccal disease and
obesity may explain the higher incidence of severe disease in obese
children.
Future research into the relationship of antropometric measurements and
severity of meningococcal septicemia should include investigation of 4G/5G
PAI-1 gene polymorphisms. Such research may establish whether only obese
children with the 4G/4G genotype are at an increased risk of severe
meningococcal disease.
References:
1. N Perez, L Regairaz, J Bustamante, N Osimani, D Bergna, J Morales,
M R Agosti, S Gonzalez-Ayala, C Peltzer, A Rodrigo.Severity of
meningococcal infections is related to anthropometrical parameters.
Archives of Disease in Childhood 2007;92:790-794.
2. Binder A, Endler G, Müller M, Mannhalter C, Zenz W; for the
Central European Meningococcal Genetic Study Group.4G4G genotype of the
plasminogen activator inhibitor-1 promoter polymorphism associates with
disseminated intravascular coagulation in children with systemic
meningococcemia. J Thromb Haemost. 2007 Aug 3 [Epub ahead of print].
3. Haralambous E, Hibberd ML, Hermans PW, Ninis N, Nadel S, Levin M.
Role of functional plasminogen-activator-inhibitor-1 4G/5G promoter
polymorphism in susceptibility, severity, and outcome of meningococcal
disease in Caucasian children. Crit Care Med. 2003 Dec;31(12):2788-93.
4. Hoffstedt J, Andersson IL, Persson L, Isaksson B, Arner P. The
common -675 4G/5G polymorphism in the plasminogen activator inhibitor -1
gene is strongly associated with obesity. Diabetologia. 2002 Apr;45(4):584
-7.
With respect to van Dommelen et al’s(1) interesting paper we would like
to make the following contribution.
Neonatal hypernatraemic dehydration screening is complicated by an
unclear but possibly rising incidence(2) and the need to avoid undermining
the ‘breast is best’ message whilst recognizing the severity of the
condition. The notoriously variable clinical presentation adds to this
dif...
With respect to van Dommelen et al’s(1) interesting paper we would like
to make the following contribution.
Neonatal hypernatraemic dehydration screening is complicated by an
unclear but possibly rising incidence(2) and the need to avoid undermining
the ‘breast is best’ message whilst recognizing the severity of the
condition. The notoriously variable clinical presentation adds to this
difficulty.
In common with many centres we have seen a number of dehydrated
babies following a period of sub-optimal feeding. A number of these babies
have had severe neurological impairment following thrombotic events
secondary to dehydration. We report four such cases, three breast feed and
one mixed breast / formula fed, who presented to our paediatric unit in
the last 5 years:
Case 1:
A healthy second child, born at term by LSCS for failure to progress,
discharged on day 4 having established breast feeding – 40 minutes every 3
-4 hours. Admitted at 11 days old with a four day history of being floppy,
quiet and one day of recognised poor feeding. Weight not checked since
discharge.
Found to have hypernatraemic dehydration (Na 190, birth wt 3.06kg
admission wt 2.2kg, 28% drop from birth weight). Her dehydration resulted
in acute renal failure requiring peritoneal dialysis and a cranial venous
sinus thrombosis with haemorrhagic venous infarction. No inter-current
infection, inborn error of metabolism, primary renal disorder or
gastrointestinal cause of fluid loss was identified. She is now 5 years
old and has asymmetric spastic quadriplegia and remote symptomatic
epilepsy.
Case 2:
First child, born at 42/40 by LSCS for cephalopelvic disproportion, birth
weight 3.84 kg, apgars 91, 105. Breast feeding was difficult and she was
admitted to NNU on day 4 clinically and biochemically dehydrated and
polycythaemic (Hb 24). Seizures commenced on day 4 and CT suggested a
haemorrhagic venous infarction secondary to sagittal sinus thrombosis.
This has resulted in remote symptomatic epilepsy secondary to a small,
deep, white matter lesion in the right frontal lobe. Her seizures have
improved markedly since receiving epilepsy surgery.
Case 3:
38/40 girl, 2nd child, ventriculomegaly on antenatal U/S, born at home,
birth wt 3.01 kg. Early twitching movements seen by midwife but felt to be
normal. Poor mixed breast / bottle feeding with only ~4oz milk/24 hours
taken in the few days prior to admission. Reviewed by a different midwife
each day & once by GP, feeding and social concerns noted.
Admitted at 7 days old peripherally shut down, hypothermic, having
apnoeic episodes, weight 2.50 kg (16.9% weight loss), polycythaemic (Hb
24), maximum Na 150. Microbiology demonstrated Group B streptococcal
septicaemia and meningitis and her PICU stay was complicated by DIC, a
sagittal sinus thrombosis and haemorrhagic venous infarct. At 4 years old
she has mild cerebral palsy affecting her lower limbs more than upper, is
visually impaired and has mild developmental delay.
Case 4:
Breast fed, term baby girl, first child of a 40 year old mother.
Discharged home one day after delivery. Seen at home by a community
midwife and poor feeding noted. Readmitted at 9 days old moribund with
severe hypernatraemic dehydration (Na 190, weight loss > 12%),
capillary refill time of 6 seconds, absent femoral pulses and unrecordable
blood pressure in the lower limbs. An echo excluded transposition but
demonstrated an IVC thrombosis. A prolonged PICU stay was complicated by
necrotic, perforated gut needing an iliostomy, seizures, acute tubular
necrosis and a cardiac arrest. Long term renal problems are anticipated
and survival is not assured.
We agree with Dr. Modi’s commentary(3) that sensitivity rather than
specificity should be the focus of a screening regime given the severity
of neurological problems that may follow severe dehydration. Any screening
guideline needs to have an evidence base whilst remaining pragmatic and
working within the resources available. The weighing policy advocated by
McKie et al(4) seems to meet these targets and in addition has been shown
not to discourage breast feeding. The intervention points for formula fed
infants are supported by data reported by MacDonald et al(5).
There is more to assessing and supporting breast feeding than merely
weighing babies. In an era of six hour discharges from maternity units and
fragmented, geographically distant families support can be compromised.
Community midwifery services are often stretched and there seems to be
value in a ‘red flag’ marker, in terms of weight loss, to identify those
mother-baby dyads that need additional support beyond that routinely
delivered.
For babies highlighted in this way it would be important to
distinguish, preferably in the community, between the hungry but healthy
baby and the quiet, unwell baby. Management could then proceed as ‘breast
is best’ for the well baby, for the dehydrated – rehydration. Telling the
two apart is the trick.
References
1. Van Dommelen P, van Wouwe JP, Breuning-Boers JM, van Buuren S,
Verkerk PH. Reference chart for relative weight change to detect
hypernatraemic dehydration. Arch Dis Child 2007; 92: 490-494.
2. Harding D, Cairns P, Gupta S et al. Why bother weighing breast fed
babies? Arch Dis Child Fetal Neonatal Ed 2001; 85: F145.
3. Modi N. Avoiding hypernatraemic dehydration in healthy term
infants. Arch Dis Child 2007;92: 474.
4. McKie A, Young D, MacDonald PD, Does monitoring newborn weight
discourage breast feeding? Arch Dis Child 2006; 91: 44-46.
5. MacDonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in
breast and formula fed infants. Arch Dis Child Fetal Neonatal 2003; 88:
F472
Dr. Joe Fawke MBChB MRCPH Clinical Research Fellow & Neonatal
SpR, School of Human Development, University of Nottingham
Dr WP Whitehouse, BSc, FRCP, FRCPCH, Clinical Senior Lecturer in
Paediatric Neurology, School of Human Development, University of
Nottingham, E Floor, East Block, Queen’s Medical Centre, Nottingham NG7
2UH, UK
The recently published study (1) and accompanying perspectives (2, 3)
follow the recent report of the RCPCH Standing Committee on Nutrition (4).
With the recent introduction of the Healthy Start scheme in the UK, it is
important for health care staff throughout the NHS to have a simple, yet
effective, policy for prevention of Vitamin D deficiency that can be
implemented in the community. Whilst we ag...
The recently published study (1) and accompanying perspectives (2, 3)
follow the recent report of the RCPCH Standing Committee on Nutrition (4).
With the recent introduction of the Healthy Start scheme in the UK, it is
important for health care staff throughout the NHS to have a simple, yet
effective, policy for prevention of Vitamin D deficiency that can be
implemented in the community. Whilst we agree with the authors that
further studies are required to determine the optimal Vitamin D
supplementation regimen during pregnancy, there is a more immediate need
to prevent hypocalcaemia secondary to Vitamin D deficiency in newborns. We
would advocate the following as a policy that should be adopted throughout
the UK:-: -
1. All infants from birth up to 6 months should be provided with
Vitamin D, 200IU daily, as Healthy Start Vitamin Liquid/Abidec/Dalivit*.
2. All children from 6 months to 4 years, but particularly those with
darker skin complexion, should be provided with Vitamin D, 400IU daily, as
Healthy Start Vitamin Liquid/Abidec/Dalivit*.
3. All adolescents, but particularly girls with darker skin
complexion, should be provided with Vitamin D, 400IU daily, as Healthy
Start Vitamin Tablets/Calcium and Ergocalciferol tablets*.
4. During pregnancy, women with darker skin complexion or family
history of vitamin D deficiency, in the second and third trimesters and
also postnatally if breastfeeding, should be provided with Vitamin D,
400IU daily, as Healthy Start Vitamin Tablets/Calcium and Ergocalciferol
tablets*. Pregnant women or breast feeding mothers with clear biochemical
evidence of vitamin D deficiency (serum 25 OHD < 15 ng/ml) should be
treated with at least 1000IU Vitamin D/day for 3 months.
*These are approximate doses; the actual dose may vary depending on
preparation used.
SF Ahmed, J Allgrove, NJ Bishop, C Burren, TD Cheetham, JH Davies, JW
Gregory, S Lim, MZ Mughal, L Reynolds, N Shaw, J Warner, on behalf of the
British Paediatric and Adolescent Bone Group.
References:
1. Dijkstra SH et al. High prevalence of vitamin D deficiency in
newborn infants of high-risk mothers. Arch Dis Child. 2007;92:750-3.
2. Williams AF. Vitamin D in pregnancy: an old problem still to be solved?
Arch Dis Child. 2007;92:740-1.
3. Dawodu A & Wagner CL. Mother-child vitamin D deficiency: an
international perspective. Arch Dis Child. 2007;92:737-40.
4. Leaf A. Vitamins for babies and young children. Arch Dis Child.
2007;92:160-4.
I am delighted to see dermatology featured on the covers of both blue
and green sections of the August Archives, but concerned that both
pictures are misleading. The image chosen to illustrate an article on
eczema in fact shows typical impetigo, which would worsen if treated as
eczema with topical steroid. The illustration on the cover of the
Education supplement shows caustic being applied to a few ti...
I am delighted to see dermatology featured on the covers of both blue
and green sections of the August Archives, but concerned that both
pictures are misleading. The image chosen to illustrate an article on
eczema in fact shows typical impetigo, which would worsen if treated as
eczema with topical steroid. The illustration on the cover of the
Education supplement shows caustic being applied to a few tiny molluscum
in an infant, a treatment both painful and inappropriate for this
asymptomatic self-limiting condition. Cover pictures are powerful
educational tools and should be used more carefully.
I read with interest Robin Powell’s analysis of the ramifications for
Paediatricians of the recent judgement in MB [2006] EWHC 507 (Fam) (1).
Although Mr Justice Holman made it very clear in his final words of
judgement that ‘every case and every child is unique, and this case
concerns M alone’(2) , the case will undoubtedly be used as precedent. M
is indeed unusual in that he was diagnosed with SMA1 s...
I read with interest Robin Powell’s analysis of the ramifications for
Paediatricians of the recent judgement in MB [2006] EWHC 507 (Fam) (1).
Although Mr Justice Holman made it very clear in his final words of
judgement that ‘every case and every child is unique, and this case
concerns M alone’(2) , the case will undoubtedly be used as precedent. M
is indeed unusual in that he was diagnosed with SMA1 so young and
apparently ventilated very early in his clinical course - most
neuromuscular patients being ventilated much later and for acute episodes
or establishing home ventilation (3).
All of the doctors (including expert witnesses) giving evidence (all
eminent tertiary neurologists/intensivists) signed up to a consensus
statement (4) which essentially described the futility of the case, but
also the ongoing burdens on the child where the benefits to the child were
uncertain and rapidly diminishing. The judge rejected this overwhelming
view as he could not accurately quantify the benefits to M of continued
existence though he could more easily quantify his burdens.
It has long been accepted that doctors cannot be compelled to provide
treatment against their better judgement by the courts (5) but doctors
here are effectively forced to do so every time the endotracheal tube
needs changed. By opting not to withdraw care, the medical staff are
obliged to continue to perform what they may themselves view as a battery.
Only the most junior nursing staff were in any way supportive of this
treatment.
This case is one where medical opinion was unanimous and rejected by
the courts. It seems likely given the declaration that not providing
intravenous antibiotics was lawful that despite the ongoing quality care,
pneumonia was likely to lead to M’s eventual death within a relatively
short time frame. Unfortunately the situation is not yet satisfactorily
resolved.
References:
(1) An NHS Trust v MB & Anor [2006] EWHC 507 (Fam).
(2) An NHS Trust v MB & Anor [2006] EWHC 507 (Fam)109.
(3) Arch Dis Child 2004;89;170-175.
(4) An NHS Trust v MB & Anor [2006] EWHC 507 (Fam)26.
(5) Re J {A minor}(Wardship: Medical Treatment} [1991] 1 FLR.
The recent review of suppression of menstruation by Albanese and
Hopper1 in adolescents with severe learning difficulties is the first
review of its type published in the UK. We have recently looked at the
issues surrounding puberty and management of menstruation in a group of
young women with severe learning difficulties and epilepsy who are living
at a residential school in Cheshire.
The recent review of suppression of menstruation by Albanese and
Hopper1 in adolescents with severe learning difficulties is the first
review of its type published in the UK. We have recently looked at the
issues surrounding puberty and management of menstruation in a group of
young women with severe learning difficulties and epilepsy who are living
at a residential school in Cheshire.
In our cohort there were 21 young women whose ages ranged from 12-20
years. Their age equivalent functional level on Vineland Adaptive and
Behavioural Scales was 1-2 years indicating a high level of supportive
care. Most of the individuals followed a normal pubertal developmental
path. Two had worsening of their seizure frequency around the time of
menstruation.
One third of the young women had no reported problems with menstruation
and did not require any medical management of their periods. In seven
girls dysmenorrhoea and other menstrual disturbances such as menorrhagia
were well managed with combinations of paracetamol and mefenamic acid.
Eight of the young women had taken hormonal treatments for menstruation at
some point. The combined oral contraceptive pill (OCP) was used cyclically
in seven of the young women. This allowed regulation of their menstrual
cycles and often reduction in menstrual flow and associated dysmenorrhoea.
There were no obvious associated benefits surrounding seizure frequency.
Only three of the young women remained on the oral contraceptive pill. It
was stopped in the remainder for reasons including excessive weight gain,
concerns regarding osteoporosis and other unrelated medical problems. One
of the young women still taking the OCP required further treatment with
paracetamol and mefenamic acid around the time of menstruation to further
modify symptoms. Those in whom the OCP was stopped now have their symptoms
managed by combinations of paracetamol and mefenamic acid.
In our practice Depo-Provera is not currently used in these adolescents
because of the concern over decreased acquisition of bone mineral density
in conjunction with the use of anticonvulsants. Norethisterone is
sometimes used to postpone menstruation if requested by the families or
carers.
Most of the carers and families did not have specific concerns relating to
menstrual management documented in the medical notes however it is well
recognised that many families and particularly mothers worry how their
daughters with severe learning difficulties will manage menstruation.
With appropriate support and advice concerns appear to dissipate through
time. The centre is devising an advice leaflet for families’ entitled
‘Practical management of periods’.
Two of the families had considered more definitive surgical management
options in the past however they are not currently pursuing this line of
treatment
We agree there is little evidence to guide clinicians practice in
this area and welcome your review in the first instance to stimulate
debate and encourage further studies.
Mel McMahon, Neurodisability SpR
Margaret Huyton, Associate Specialist
Dan Hindley, Consultant Paediatrician
David Lewis Centre
Mill Lane Warford Alderley Edge Cheshire SK9 7UD
Reference:
1. Albanese A, Hopper NW. Suppression of menstruation in adolescents
with severe learning difficulties. Arch Dis Child 2007;92:629-632.
In a letter to your journal recently published, Dr Gray and his colleagues criticised the newly published algorithm for the treatment of meningococcal disease and septic shock in children.1,2 In particular, they were concerned that the ‘sole trigger’ for intubation was 60ml/kg of fluid resuscitation. This is not the case. The algorithm indicates that after each bolus of fluid, the child should be assessed for ‘signs of sho...
Editor
So, doctors in the UK are not prescribing asthma drugs according to published guidelines [1]. Sadly, UK medical journals are also failing to hit the spot, by printing images of children using inappropriate inhalers, with suboptimal technique. Although paediatricians and current asthma guidelines recognise the difficulty that children have in using a metered- dose inhaler (MDI) without a spacer, the photo o...
Dear Editor,
The article by Akobeng and Heller (1) is very interesting indeed and seems to be very useful. They suggest that using the PIN-ER-t (population impact number of eliminating a risk factor over a period of time), which is defined as the potential number of disease events prevented in a population over the next t years by eliminating a risk factor (2), allows numbers to be communicated in a more friend...
Dear Editor,
We were interested to read the letter from Pryce and colleagues (1), describing how, over a two year period, they detected one extra case of congenital hypothyroidism (CHT) by reducing the threshold level of TSH for referral from the newborn screening programme. The UK Newborn Screening Programme Centre is currently reviewing a number of aspects of the CHT programme, including the cut off for ref...
Dear Editor,
We read with great interest the article of Perez et al (1) on the relationship of severity of meningococcal infection with anthropometrical parameters in children. Patients with severe disease and non-survivors had higher weight for age z scores than patients with non-severe disease. Body mass index was significantly higher in those with severe disease. Binder A et al (2)reported an association of the 4G...
Dear Editor,
With respect to van Dommelen et al’s(1) interesting paper we would like to make the following contribution.
Neonatal hypernatraemic dehydration screening is complicated by an unclear but possibly rising incidence(2) and the need to avoid undermining the ‘breast is best’ message whilst recognizing the severity of the condition. The notoriously variable clinical presentation adds to this dif...
Dear Editor,
The recently published study (1) and accompanying perspectives (2, 3) follow the recent report of the RCPCH Standing Committee on Nutrition (4). With the recent introduction of the Healthy Start scheme in the UK, it is important for health care staff throughout the NHS to have a simple, yet effective, policy for prevention of Vitamin D deficiency that can be implemented in the community. Whilst we ag...
Dear Editor,
I am delighted to see dermatology featured on the covers of both blue and green sections of the August Archives, but concerned that both pictures are misleading. The image chosen to illustrate an article on eczema in fact shows typical impetigo, which would worsen if treated as eczema with topical steroid. The illustration on the cover of the Education supplement shows caustic being applied to a few ti...
Dear Editor,
I read with interest Robin Powell’s analysis of the ramifications for Paediatricians of the recent judgement in MB [2006] EWHC 507 (Fam) (1). Although Mr Justice Holman made it very clear in his final words of judgement that ‘every case and every child is unique, and this case concerns M alone’(2) , the case will undoubtedly be used as precedent. M is indeed unusual in that he was diagnosed with SMA1 s...
Dear Editor,
The recent review of suppression of menstruation by Albanese and Hopper1 in adolescents with severe learning difficulties is the first review of its type published in the UK. We have recently looked at the issues surrounding puberty and management of menstruation in a group of young women with severe learning difficulties and epilepsy who are living at a residential school in Cheshire.
In our...
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