The observation that "there is no robust evidence that prophylactic
antibiotics reduce the incidence of recurrence of urinary tract infection
in children"(1), and that, instead, bacterial resistance can be as high as
67-100% in the antibiotic prophylaxis group as opposed to 0-39% in
patients who do not receive antibiotic prophylaxis(1), should be the basis
for the use of alternative strategies to prevent recurrence of urin...
The observation that "there is no robust evidence that prophylactic
antibiotics reduce the incidence of recurrence of urinary tract infection
in children"(1), and that, instead, bacterial resistance can be as high as
67-100% in the antibiotic prophylaxis group as opposed to 0-39% in
patients who do not receive antibiotic prophylaxis(1), should be the basis
for the use of alternative strategies to prevent recurrence of urinary
tract infection(UTI)in children. One such strategy is daily intake of
cranberry juice, as in the study which enrolled 84 girls aged 3-14 who had
a history of more than one episode of E.Coli UTI, and who were then
allocated to 3 subgroups, namely, G1, taking cranberry juice 50 ml/day,
G2, taking lactobacillus drink 100 ml 5 days a month, and G3, on no
specific treatment. Over a period of 6 months 18.5% patients allocated to
G1 experience recurrence of UTI as opposed to 42.3% and 48.1%,
respectively, of G2 and G3 patients(2), and these results showed cranberry
juice to be significantly(p < 0.05) more efficacious than the other
modalities in preventing UTI recurrence(2). The efficacy of cranberry
juice is attributable to its proanthocyanidin content which prevents
bacterial adherence to cellular surfaces containing receptor sequences
similar to those on uroepithelial cells(3). Bacterial adherence to mucosal
cells is, in turn, a critical step in the development of infection(3).
Atomic force microscopy has been used to measure the nanoscale adhesion
forces between fimbriated E. coli and human uropepthelial cells, and it
has been shown thatcranberry juice cocktail significantly decreases
nanoscale adhesion forces between fimbriated E coli and human
uroepithelial cells(4). Accordingly, given the proven efficacy of this
agent, and the physiological basis of its efficacy studies are required to
evaluate the use of cranberry juice for prophylaxis against UTI over
periods of time longer than 6 months
References
(1) Dai B., Liu Y., Jia J., Mei C
Long term antibiotics for the prevention of recurrent urinary tract
infection in children: a syatematic review and meta analysis
Arch Dis Child 2010;95:499-508
(2)Ferrara P., Romaniello L., Vitelli O et al
Cranberry juice for prevention of recurrent urinary tract infections; A
randomised controlled trial in children
Scand J Urol Nephrol 2009;43:369-72
(3)Beachey E
Bacterial adherence: adhesin-receptor interactions mediating the
attachment of bacteria to mucosal surfaces
Journal of Infectious Diseases 1981;143:325-345
(4)Liu Y., Pinzon-Arango PA., Gallardo-Moreno AM., Camesano TA
Direct adhesion force measurements between E coli and human uropepithelial
cells in cranberry juice cocktail
Mol Nutr Food Res 2010 June 21(PMID:20568234)
We agree there is a need for thorough investigation for risk factors
in children diagnosed with apparently "idiopathic" cerebral venous sinus
thrombosis (CVST). The commonest risk factor identified was infection
particularly of the middle ear. However, we believe it is imperative to
recognise that there may be a combination of risk factors present in
children with CVST and therefore it is important to investigate for
"hidden" risk factors even when there is a seemingly obvious cause.
We report a 13 year old boy who presented with complaints of diplopia
and headache preceded by otitis media with bloody discharge for 2 weeks.
There was a history of recurrent otitis media since early childhood.
There was no focal weakness, bladder/bowel dysfunction, convulsions
or trauma. No history of foreign travel or insect bites was given. The
birth and developmental histories were unremarkable. He was not on any
regular medications and denied taking alcohol or recreational drugs. There
was no family history of headache or bleeding or clotting disorders.
Physical examination revealed bilateral papilloedema and left VI
cranial nerve palsy suggestive of raised intracranial pressure. There was
tenderness over the right mastoid.
A cranial CT scan confirmed right lateral sinus vein thrombosis.
Opacification of the right mastoid was noted. There was no bony erosion
or hydrocephalus. Blood inflammatory markers were elevated. A blood
thrombophilia screen was also requested.
He was treated with courses of intravenous cefotaxime and gentamicin
ear drops.A right cortical mastoidectomy was performed and the symptoms of
headache and diplopia improved.The thrombophilia screen confirmed him as
being heterozygous for Factor V Leiden mutation.
In summary, this patient with CVST had an evident mastoiditis but was
also heterozygous for Factor V Leiden mutation. This reinforces the
importance of investigating such patients for prothrombotic disorders even
when an infective cause is present.
Editor, I read the recent publication by Ghaleb et al with a great
interest. Ghaleb et al concluded that prescribing
and medication administration errors are not uncommon in paediatrics,
partly as a result of the extra challenges in prescribing and
administering medication to this patient group [1].
Indeed, the prescription error is a common problem in pediatrics. Luckily,
in a recent systematic review, the rate of error w...
Editor, I read the recent publication by Ghaleb et al with a great
interest. Ghaleb et al concluded that prescribing
and medication administration errors are not uncommon in paediatrics,
partly as a result of the extra challenges in prescribing and
administering medication to this patient group [1].
Indeed, the prescription error is a common problem in pediatrics. Luckily,
in a recent systematic review, the rate of error was more common in adults
than children (about 4.5 times) [2]. "How to manage" is a big question. It
is needed to set a system to check for the prescription error as well as
promoting the awareness of practitioner before prescription. In addition,
the reformatting of the present medical curriculum to improve the quality
of prescription practice is also recommended [3]. Starting at medical
students might result in an improvement in the future life as
practitioner.
References
1. Ghaleb MA, Barber N, Franklin BD, Wong IC. The incidence and nature of
prescribing and medication administration errors in paediatric inpatients.
Arch Dis Child. 2010 Feb;95(2):113-8.
2. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM.
Prevalence, incidence and nature of prescribing errors in hospital
inpatients: a systematic review. Drug Saf. 2009;32(5):379-89.
3. Wangsaturaka D. Wiwanitkit V. An evaluation of prescription writing and
rational prescribing in Third-Year Medical Students, Faculty of Medicine,
Chulalongkorn University. Thai J Pharmacol 2000 May-Aug; 22(2): 115-20.
Dr. Sullivan makes some important points about screening for
malnutrition (1) but inevitably raises questions as to what is meant by
"malnutrition" and how
definitions might relate to clinical outcomes. The fact that there is no
consensus with regard to such fundamental issues must call into question
the basis of
"screening", now being
rolled out in hospitals such as my own. Malnutrition is not easy t...
Dr. Sullivan makes some important points about screening for
malnutrition (1) but inevitably raises questions as to what is meant by
"malnutrition" and how
definitions might relate to clinical outcomes. The fact that there is no
consensus with regard to such fundamental issues must call into question
the basis of
"screening", now being
rolled out in hospitals such as my own. Malnutrition is not easy to
define, since it is a continuum that starts with a nutrient intake
inadequate to meet physiological requirements, and is followed in due
course by metabolic and functional alterations and ultimately by changes
in body composition. The arbitrary anthropometric based definitions of
"malnutrition" are
borrowed from those used by fieldworkers in resource poor countries
attempting to determine the impact of food availability on local
populations. This leads to an obvious problem when it comes to defining
those "at risk" from
malnutrition in hospital. Where food is scarce, children between -1 and -2
SD deviations below the mean of weight for height (equivalent to Waterlow
malnutrition Grade 1)(2) may well be a vulnerable group, but for many
hospitalised children in developed countries, with acute, short term
illness, this might indicate no more than having a thin physique, or a
temporary weight loss that will be made good within days of recovery and
discharge home. In fact, exclude these from a Munich hospital study of
inpatients (3) while applying current WHO definitions and the prevalence
of malnutrition falls from 24% to around 6%.
Moy "at risk" group comprising 20% of admissions
swimming in an "unrecognised reservoir of
malnutrition" (4) are trumped by the 62%
identified as "at
risk" in the Dutch screening tool evaluation,
which strikingly also showed that the median length of stay was only 2
days for "low" and 3
days for "moderate and high
risk" groups (5). Not so much a reservoir here,
but more a tidal ocean ebbing and flowing from hospital to community and
back. "At risk" from
malnutrition sounds alarming but is not the same as being malnourished.
Implementing screening for arbitrarily defined malnutrition/risk when it
is unknown whether screening tools in any way predict outcome or permit
effective intervention is premature. The dangers of such an approach
include not only creating an unnecessary market for nutritional support
products, but also that screening becomes a "tick
box" indicator of imagined quality while in
reality serving as a substitute for sound clinical assessment of
individual children. We use anthropometric assessments as a convenient and
important indicator of nutritional status; if growth monitoring and
nutritional history taking was performed routinely and linked to action
plans for all hospital admissions, there would be no need for
"screening". The
precise indications for nutritional support as well as the benefits of
screening tools require scientific evaluation in specific groups of
patients. Meanwhile there should be individualised nutritional assessment
for all children admitted to hospital, with interventions aimed at
preventing or reversing growth deficits and specific nutritional
deficiencies (6).
2. Waterlow JC. Classification and definition of protein-calorie
malnutrition. Brit Med J 1972;3:566-569
3. Pawellek I, Dokoupil K, Koletzko B. Prevalence of malnutrition in
paediatric hospital patients. Clin Nutr 2008;27:72-6
4. Moy RJD, Smallman S, Booth IW. Malnutrition in a UK
children's hospital. J Hum Nut Dietetics
1990;3:93-100
5. Hulst JM, Zwart H, Cop WC, Joosten KFM. Dutch national survey to test
the STRONGkids nutritional screening tool in hospitalized children. Clin
Nutr 2010:29:106-111
6. Braegger C, Decsi T, Dias JA, Hartman C, Kolacek S, Koletzko B,
Koletzko, S, Mihatsch W, Moreno L, Puntis J, Shamir R, Szajewska H, Turck
D, van Goudoever J. Practical Approach to Paediatric Enteral Nutrition: A
Comment by the ESPGHAN Committee on Nutrition. J Pediatr Gastroent Nutr
2010;50:in press
To the Editor
Vanderplas et al.(1) reported the effectiveness of a specially designed bed for postural treatment of gastro-oesophageal reflux (GOR) associated symptoms. This conclusion is in contrast with a Cochrane review that already concluded that supine position with elevation of the head does not have any effect on regurgitation and acid reflux in developmentally normal infants (2). In our opinion the methodological approa...
To the Editor
Vanderplas et al.(1) reported the effectiveness of a specially designed bed for postural treatment of gastro-oesophageal reflux (GOR) associated symptoms. This conclusion is in contrast with a Cochrane review that already concluded that supine position with elevation of the head does not have any effect on regurgitation and acid reflux in developmentally normal infants (2). In our opinion the methodological approach of Vanderplas'study is questionable and consequently, the conclusions turn out to be unacceptable. As a rule, GOR in infants is a physiological condition that spontaneously resolves within the first year of age. Any conclusion concerning the efficacy of an intervention on such a benign condition should be taken into account only in randomized controlled trials. We also consider debatable that infants enrolled in the study really required any kind of treatment. In fact symptoms reported by families of the infants included in the study and listened in I-GERQ-R (crying, regurgitation, feeding refusal, back arching, wheezing, coughing, hoarseness) should not be assumed to be related to GOR anymore. Indeed lack of relation between GOR and I-GERQ-R score symptoms has been recently confirmed both in studies based on pH monitoring (3) and in trials that evaluated the clinical response to PPI (4,5). Actually 75% of infants reported in Vanderplas' study did not benefit from PPI therapy, suggesting that complained symptoms were misinterpreted as events related to GOR. Encouraging paediatricians to use an aggressive and expensive medical intervention for a physiological condition, such as infant GOR, appears unjustified and could divert the physician from the responsibility of reassuring parents and educating them to cope with infant crying.
REFERENCES
1. Vandenplas Y, De Schepper J, Verheyden S, Devreker T, Franckx J, Peelman M, Denayer E, Hauser B. A preliminary report on the efficacy of the Multicare AR-Bed in 3-week-3-month-old infants on regurgitation, associated symptoms and acid reflux. Arch Dis Child. 2010;95:26-30.
2. William Raine Craig, Ana Hanlon-Dearman, Chris Sinclair, Shayne P Taback, Michael Moffatt; Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003502.
3. Condino AA, Sondheimer J, Pan Z, Gralla J, Perry D, O'Connor JA. Evaluation of infantile acid and nonacid gastroesophageal reflux using combined pH monitoring and impedance measurement. J Pediatr Gastroenterol Nutr 2006;42:16-21.
4. Moore DJ, Tao BS, Lines DR, Hirte C, Heddle ML, Davidson GP. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr. 2003;143:219-23.
5. Orenstein SR, Hassall E, Furmaga-Jablonska W, Atkinson S, Raanan M. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. J Pediatr. 2009;154: 514-520.
As your study states, little systematic research has been done on the effects of cranio-sacral therapy in crying infants. I would like to call your attention to serious side-effects to this form of therapy. Two well-proven cases of healthy infants that died during the therapy have been described, one in the Netherlands and one in Germany. It is important to tell parents about this potential side-effect.
As your study states, little systematic research has been done on the effects of cranio-sacral therapy in crying infants. I would like to call your attention to serious side-effects to this form of therapy. Two well-proven cases of healthy infants that died during the therapy have been described, one in the Netherlands and one in Germany. It is important to tell parents about this potential side-effect.
I am not surprised you were not able to find the Dutch article (to be found on PubMed): the title of the Dutch article has been translated incorrectly: diseased, rather than deceased!
References
Jacobi G, Riepert Th , Kieslich M, Bohl J. Uber einen Todesfall wahrend der Physiotherapie nach Vojta bei einem drei Monate alten Saugling. Klin Padiatr. 2001;213:76-8.
Holla M, Ijland MM, van der Vliet AM, Edwards M, Verlaat CW Ned Tijdschr Geneeskd. Diseased infant after 'craniosacral' manipulation of the neck and spine 2009 Apr 25;153(17):828-31.
The new guidance from the National Institute for Health and Clinical
Excellence (NICE) on the management of urinary tract infection (UTI) in
children challenges the association between UTI and the development of
renal complications. This has prompted a significant reduction in
radiological investigation following uncomplicated UTI.
The recently published observational study by Mike South has
highlighted that A...
The new guidance from the National Institute for Health and Clinical
Excellence (NICE) on the management of urinary tract infection (UTI) in
children challenges the association between UTI and the development of
renal complications. This has prompted a significant reduction in
radiological investigation following uncomplicated UTI.
The recently published observational study by Mike South has
highlighted that Australian doctors are performing progressively fewer
invasive radiological investigations such as dimercaptosuccinic acid
(DMSA) and micturating cystourethrography (MCUG) following UTI over the
past 10 years (1). The rates of performance of renal ultrasound have
remained fairly constant over the past decade.
We have reviewed our practice at Good Hope Hospital in Birmingham,
U.K. with respect to the conduct of radiological investigations following
UTI.
A retrospective case note analysis of infants and
children with confirmed UTI (>10 5 cfu/ml) presenting between January
and March 2008 was audited.
49 (90% female) infants and children (ranging from 7 weeks to 16
years with a mean age of 5.76 years) were included. The cohort had
presented with first presentation (51%), recurrent (33%), atypical (14%)
or atypical and recurrent (2%) UTI.
92% of children had an ultrasound in accordance with the guidelines.
7% of these children were found to have abnormalities within the upper
urinary tract. 8% had an ultrasound when it was not indicated. No
abnormalities were detected in this group.
38% had a DMSA in line with the guidelines and 25% of these children
had a pathological discrepancy in renal function. 27% did not have a DMSA
when it was indicated.
2 children in the cohort qualified for MCUG. Only 1 child had the
investigation which revealed a normal result.
The majority of ultrasound scans within our department are compliant
with the guidelines. However, there is some discrepancy in terms of
performing DMSA scans; with the number falling even below the new
recommendations.
With the Australian population in the study being comparable to our
small cohort, we can conclude that our findings grossly support those by
South. (However due to the small number of patients it is difficult to
comment on the MCUG scan results as so few were indicated within our
cohort).
The results highlight how quickly the translation between scientific
evidence and clinical practice can occur. The question we should be asking
however is, what is the scientific basis for the new NICE guidelines? Are
they discouraging clinicians from performing vital investigations?
Coulthard et al have argued that systemic symptoms with UTI,
including fever, do not predict for renal scarring (2). If children with
afebrile UTIs are managed less assiduously, then a significant proportion
of kidney scars would be missed in infants and even more in older
children.
While is it is reassuring to know that there has been no increase in
the rates of end stage renal failure amongst Australians under 25 years
over the last decade (3); it is prudent to remain vigilant about the
outcomes in this group of patients over the coming decade subsequent to
this change in practice.
References
1. South. Radiological investigation following urinary tract
infection: changes in Australian practice.
Archives of Disease in Childhood (2009); 94; 927-930
2. Coulthard, Lambert and Keir. Do systemic symptoms predict the risk
of kidney scarring after urinary tract infection? Archives of Disease in
Childhood (2009); 94; 278-281
3. Australia and New Zealand Dialysis and Transplant Registry. ANZDAT
Registry Report 2007. Trends in kidney disease over time. See
http://www.anzdata.org.au/v1/images/updates/Trends.pdf
(accessed 11 August 2009).
Does this study now preclude cohort nursing of babies with RSV?
A major finding was: "Infants with dual infections (RSV and hBoV) had
a higher clinical severity score and more days of hospitalisation"
We put babies with RSV infection into a room together and can not be
sure none of them are also infected with Bocavirus, so is there a danger
that Bocavirus crossinfection will cause significant morbidity?...
Does this study now preclude cohort nursing of babies with RSV?
A major finding was: "Infants with dual infections (RSV and hBoV) had
a higher clinical severity score and more days of hospitalisation"
We put babies with RSV infection into a room together and can not be
sure none of them are also infected with Bocavirus, so is there a danger
that Bocavirus crossinfection will cause significant morbidity?
This paper reports on an intervention within postgraduate training
aimed at improving paediatric prescribing.1 It is commendable that marked
improvement in competence has been achieved, but the finding that one in
four trainees made a prescribing error must remain a concern for patient
safety.
At Queens University Belfast, nursing students are examined in drug
and fluid calculations and must ac...
This paper reports on an intervention within postgraduate training
aimed at improving paediatric prescribing.1 It is commendable that marked
improvement in competence has been achieved, but the finding that one in
four trainees made a prescribing error must remain a concern for patient
safety.
At Queens University Belfast, nursing students are examined in drug
and fluid calculations and must achieve 100% in order to progress. The
requirement for medical students is much less stringent even within
paediatric curricula. Paediatric medical students are timetabled to
receive a lecture on pharmacokinetics but do not have mandatory testing,
and on questioning two thirds denied any such teaching. To address the
special challenges within paediatric prescribing and administration2 and
the recognition that collaborative working is essential in preventing
errors we designed an interprofessional teaching and learning programme
for medical and nursing students.3 This workshop is delivered by
clinicians and pharmacists and focuses on drug selection, dose calculation
and accurate prescription. Students are also required to prepare drugs for
oral and intravenous administration and to discuss communication with
parents.
Quantitative and qualitative evaluation of this programme has
demonstrated significant improvements in the domains of 'knowledge and
skill', 'communication and teamwork' and 'shared learning'.3 Students
found the workshop useful, informative and relevant to clinical practice.
Further evaluation is necessary to demonstrate sustained improvement in
clinical practice. However, in the short term, this workshop addresses GMC
requirements that graduates should have the knowledge and skills to
prescribe drugs safely.4
1 Kidd L, Shand E, Beavis R, Taylor Z, Dunstan F, Tuthill D.
Prescribing competence of junior doctors: does it add up? Arch Dis Child
2010;95:219-221
2 Wong ICK, Wong LYL, Cranswick NE. Minimising medication errors in
children. Arch Dis Child 2009;94:161-164
3 Stewart M, Purdy J, Kennedy N, Burns A. An interprofessional
approach to improving paediatric medication safety. BMC Medical Education
2010;10:19
4 General Medical Council. Tomorrow's doctors. London: General
Medical Council, 2003
It is my hypothesis that the "secular trend," the increase in size
and earlier puberty occurring in children, is caused by an increase in the
percentage of individuals of higher testosterone. More specifically, I
suggest this is due to an increase in the percentage of mothers of higher
testosterone with time within the population. This exposes more fetuses to
increased maternal testosterone with time within the population....
It is my hypothesis that the "secular trend," the increase in size
and earlier puberty occurring in children, is caused by an increase in the
percentage of individuals of higher testosterone. More specifically, I
suggest this is due to an increase in the percentage of mothers of higher
testosterone with time within the population. This exposes more fetuses to
increased maternal testosterone with time within the population. This
causes permanent effects in the fetus which persist throughout the life
span. I suggest this is the cause of the parallel increases in morbidity
occurring within the population, such as obesity, cancer, breast cancer,
diabetes, etc., including prematurity, small for gestational age, etc.,
including less obvious gross effects which later contribute to "failing
schools" and other adverse behavioral outcomes in children.
I have come to the conclusion that the "increase in testosterone" may
partially be due to a reduction in "sex hormone binding globulin (SHBG)"
as a number of phenomena explained by the secular trend may be based on
changes in SHBG. A decrease in SHBG increases free testosterone levels.
I suggest the foregoing may explain the findings of Metcalf, et al.
The observation that "there is no robust evidence that prophylactic antibiotics reduce the incidence of recurrence of urinary tract infection in children"(1), and that, instead, bacterial resistance can be as high as 67-100% in the antibiotic prophylaxis group as opposed to 0-39% in patients who do not receive antibiotic prophylaxis(1), should be the basis for the use of alternative strategies to prevent recurrence of urin...
Cerebral venous sinus thrombosis-Factor V leiden heterozygosity and Infection:Double Jeopardy!
Dear Editor,
We feel compelled to write this letter regarding the article:cerebral venous sinus thrombosis-a case series including thrombolysis.
Citation: Archives of Disease in Childhood, 01 October 2009, vol./is. 94/10(790- 794), 0039888
Author(s): Mallick AA,Sharples PM,Calvert SE,Jones RW...
Editor, I read the recent publication by Ghaleb et al with a great interest. Ghaleb et al concluded that prescribing and medication administration errors are not uncommon in paediatrics, partly as a result of the extra challenges in prescribing and administering medication to this patient group [1]. Indeed, the prescription error is a common problem in pediatrics. Luckily, in a recent systematic review, the rate of error w...
Dear Sir,
Dr. Sullivan makes some important points about screening for malnutrition (1) but inevitably raises questions as to what is meant by "malnutrition" and how definitions might relate to clinical outcomes. The fact that there is no consensus with regard to such fundamental issues must call into question the basis of "screening", now being rolled out in hospitals such as my own. Malnutrition is not easy t...
I am not surprised you...
The new guidance from the National Institute for Health and Clinical Excellence (NICE) on the management of urinary tract infection (UTI) in children challenges the association between UTI and the development of renal complications. This has prompted a significant reduction in radiological investigation following uncomplicated UTI.
The recently published observational study by Mike South has highlighted that A...
Does this study now preclude cohort nursing of babies with RSV?
A major finding was: "Infants with dual infections (RSV and hBoV) had a higher clinical severity score and more days of hospitalisation"
We put babies with RSV infection into a room together and can not be sure none of them are also infected with Bocavirus, so is there a danger that Bocavirus crossinfection will cause significant morbidity?...
Sir,
This paper reports on an intervention within postgraduate training aimed at improving paediatric prescribing.1 It is commendable that marked improvement in competence has been achieved, but the finding that one in four trainees made a prescribing error must remain a concern for patient safety.
At Queens University Belfast, nursing students are examined in drug and fluid calculations and must ac...
It is my hypothesis that the "secular trend," the increase in size and earlier puberty occurring in children, is caused by an increase in the percentage of individuals of higher testosterone. More specifically, I suggest this is due to an increase in the percentage of mothers of higher testosterone with time within the population. This exposes more fetuses to increased maternal testosterone with time within the population....
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