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

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.

The article documenting children's perspectives of venepuncture in words and drawings is certainly thought-provoking but would be more compelling (and more useful in several ways) if the authors could give as much as possible of the following extra information: the median age of the cohort of 37 children; how the 37 were selected (the implication that they all found venepuncture 'extremely distressing' begs further explanation); the ages (median and range)of the 24 who found venepuncture 'worse than anything they could imagine'; the ages of the children whose comments are quoted and of those who made the drawings; the proportions of the cohort (with respective ages, range and median) who had analgesia (documenting the types, if possible) or none; the proportion in which a parent was present at the time of venepuncture; any information about the experience of the individuals carrying out the procedures. I would not, in any way, want to weaken the overall message that venepuncture is upsetting to children, sometimes horribly so - instead I hope that further data will significantly strengthen that important message.

Dear Sir, we have read with interest Latif and Berry’s paper in which the authors reported detailed reference times for the various components of the transport service.1 These data could be used for benchmarking and quality improvement in the setting of a centralised transport service.

Two basic models of neonatal transport have been developed in Europe. These are : (a) dedicated services (or centralised transport services) that carry out all transfers in a region and (b) on-call services provided by a large neonatal unit that send its own staff to retrieve the patient. The organizational choice in term of cost-benefit ratio between the two models depends mainly on the number of transports per year and on the referral area. 2 At our Institution, the neonatal emergency transport service is based on a call organizational model. Here, we report the retrieval times of our activity. Azienda Ospedaliera Padova, Regional Neonatal Transport Service provides the neonatal critical care transport in the East Veneto Region, Italy, with a total population referral of 2,3 million in a radius of approximately 150 km. In the referral area, there are approximately 25,700 births/year in 25 delivery units. Of these units, 16 are classified as Level I (s care for normal near-term and term infants), 8 as Level II (s intermediate care), and 1 as Level III (s complete neonatal intensive care). The transports are exclusively by road using an ambulance specifically designed for the purpose. Between August 2000 and December 2008, 1495 critical neonatal patients were retrieved by ground ambulance. Of 1495 neonates, 996 (68%) were less than 24 h old at the time of the call. 269 (18%) patients had a gestational age <32 weeks and/or a birth weight <1500 g. The clinical reasons for retrieval included respiratory insufficiency (66%), cardiac and cardiac-surgery disease (12%), neurological problems (9%), major surgery disease (7%), prematurity (10%). 658 (44%) patients were intubated, 164 (11%) were managed with nasopharyngeal tube and all had a intravenous line. The medians (IQR) of the components of retrieval time were as follows: - Response time (call --> depart from base) 42 min (38-51) - Stabilization time (first look --> ready to depart) 37 min (24-59) - Total mission time (call --> return back to NETS base) 180 min (160- 260)

Our reference times are different from those reported for a centralized transport service by Latif and Berry. 1 These data could be used for benchmarking and quality improvement in centers where an on a call organizational model has been adopted.

References

Abdel-Latif ME, Berry A. Analysis of the retrieval times of a centralised transport service, New South Wales, Australia. Arch Dis Child 2009;94:282-6.

Agostino R, Fenton AC, Kollèe LAA, Chabernaud JL, Carrapato MRG, Peitersen B, Sedin G, Derganc M. Organization of neonatal transport in Europe. Prenat Neonat Med 1999;4 (Suppl 1):20-34.