My child also has CSID. She is about to be 8 yrs old and has been on
Sucraid for the last 6-7 yrs. I am looking for an alternative to this
medication as sometimes we cannot get the medication and have to go a
strict diet until we can get some again. I will look into this alternative
and post results later.
We read with interest the review by Amirthalingam[1] and colleagues
of the potential value of a UK varicella vaccination programme. They cite
Blumental[2] and colleagues' article in the same issue which assessed the
burden of varicella and outlined some of the known complications, such as
bacterial skin and soft tissue infections, pneumonia, and neurological
complications including meningitis and encephalitis. The Blumen...
We read with interest the review by Amirthalingam[1] and colleagues
of the potential value of a UK varicella vaccination programme. They cite
Blumental[2] and colleagues' article in the same issue which assessed the
burden of varicella and outlined some of the known complications, such as
bacterial skin and soft tissue infections, pneumonia, and neurological
complications including meningitis and encephalitis. The Blumental study
included complications occurring up to 21 days after onset of the
chickenpox rash. We wish to highlight further potential complications that
are possibly excluded from that definition but may be a significant
benefit of vaccination.
There is evidence that varicella infection is associated with an
increased risk of focal cerebral arteriopathy and arterial ischemic stroke
(AIS). In a UK study of incidence, Thomas[3] and colleagues identified 49
children with AIS following chickenpox and found that, in children, the
incidence of AIS during the following 6 months was four times that of
controls (summary incidence ratio = 4.07; 95% CI 1.96-8.45). The estimated
incidence ratio in adults was 2.13 (95% CI 1.05-4.36). Considering
varicella vaccination in a cohort of more than 3 million children, Donahue
and colleagues found no association with ischemic stroke.[4]
We believe that neurological complications of AIS, which can occur
many weeks after infection, were not considered in the review by
Amirthalingam and colleagues. Most of the complications that they reported
are transient or readily treatable, although meningoencephalitis can leave
long-term neurodevelopmental sequelae. There is a high risk of long-term
disability from childhood AIS and this places significant financial burden
on healthcare systems. We believe that this relatively uncommon but
important complication should be considered when determining the cost-
effectiveness of a varicella vaccination programme for the UK.
References
1- Amirthalingam G, Ramsay M. Should the UK introduce a universal
childhood varicella vaccination programme? Arch Dis Child. 2016
Jan;101(1):2-3.
2- Blumental S, Sabbe M, Lepage P; Belgian Group for Varicella.
Varicella paediatric hospitalisations in Belgium: a 1-year national
survey. Arch Dis Child. 2016 Jan;101(1):16-22
3- Thomas SL, Minassian C, Ganesan V, Langan SM, Smeeth L. Chickenpox
and risk of stroke: a self-controlled case series analysis. Clin Infect
Dis. 2014 Jan;58(1):61-8.
4- Donahue JG, Kieke BA, Yih WK, Berger NR, McCauley JS, Baggs J,
Zangwill KM, Baxter R, Eriksen EM, Glanz JM, Hambidge SJ, Klein NP, Lewis
EM, Marcy SM, Naleway AL, Nordin JD, Ray P, Belongia EA; Vaccine Safety
DataLink Team. Varicella vaccination and ischemic stroke in children: is
there an association? Pediatrics. 2009 Feb;123(2):e228-34.
The ADC Archivist recently reported that Freedman et al had revealed
that "old-fashioned clinical examination" missed about 20% of cases of
significant dehydration in children.[1] Their assessment of this work was
not surprising because the meta-analysis in the Journal of Pediatrics
carries the headline message that even the "most accurate, noninvasive"
methods could only "identify dehydration suboptimally", and it was a...
The ADC Archivist recently reported that Freedman et al had revealed
that "old-fashioned clinical examination" missed about 20% of cases of
significant dehydration in children.[1] Their assessment of this work was
not surprising because the meta-analysis in the Journal of Pediatrics
carries the headline message that even the "most accurate, noninvasive"
methods could only "identify dehydration suboptimally", and it was a high
quality analysis which only included studies that had accurately
quantified the degree of dehydration by serial weighings.[2] However,
Freedman et al's conclusions are misleading because they only selected
papers for analysis that had evaluated a rapid triaging tool, and none
which had undertaken standard full clinical examinations.
The four papers that qualified for Freedman et al's statistical
reanalysis had used the 'Clinical Dehydration' and 'Gorelick' scores to
detect dehydration secondary to gastroenteritis. The individual components
of these tests were not mentioned in their meta-analysis paper, but either
can be performed quickly on a fully-clothed infant in less than a minute.
They rely on scoring (a) the child's general appearance (seeking signs of
thirst, restlessness, lethargy and irritability, drowsiness, limpness,
cold, sweatiness, or coma), (b) whether the eyes look sunken, (c) if the
tongue feel moist, and (d) if tears are reduced or absent, all on simple
scales. They do not include any of the following components of routine
clinical examinations: capillary refill time, pulse rate and volume,
respiratory pattern, peripheral coolness, or skin turgor. As such, these
authors are not entitled to list their triage-type scoring as being the
"most accurate, noninvasive" clinical tests for dehydration. By presenting
their data as they did, Freedman et al may have produced a false-
impression among paediatricians about the sensitivity of full, careful
clinical examinations for evaluating fluid-balance status, and by
reviewing it as they did the ADC Archivist may have inadvertantly
perpetuated this confusion.
References
1. Archivist. Assessing dehydration. Archives of Diesease in
Childhood 2015;100:999.
2. Freedman SB, Vandermeer B, Milne A, Hartling L. Diagnosing clinically
significant dehydration in children with acute gastroenteritis using
noninvasive methods: a meta-analysis. Journal of Pediatrics 2015;166:908-
16.
Monika Bajaj and Amaka Offiah are to be commended for their
thoughtful and helpful review of the benefits and risks of skeletal
imaging in cases of suspected child abuse.(1) The diagnosis of child
abuse is a complex process which requires an evidence-informed approach
combining clinical acumen with collaborative multi-agency working.
Skeletal imaging, including CT scans, provide a valuable tool for the
clinician, but,...
Monika Bajaj and Amaka Offiah are to be commended for their
thoughtful and helpful review of the benefits and risks of skeletal
imaging in cases of suspected child abuse.(1) The diagnosis of child
abuse is a complex process which requires an evidence-informed approach
combining clinical acumen with collaborative multi-agency working.
Skeletal imaging, including CT scans, provide a valuable tool for the
clinician, but, as Bajaj and Offiah point out, is not without its risks.
The clinician must take a lead in informing the parents and other
professionals of the potential benefits of imaging, the inherent risks,
and the statutory responsibilities under which we work.
The concept of informed consent in such situations is problematic.
What reasonable parent will subject their child to a potentially harmful
procedure to rule out abuse which they 'know' has not happened?
Conversely, what reasonable parent, having abused their child, will
consent to a test which may help to prove that abuse? Parents must be
informed of the small but real risks associated with skeletal imaging and
that these need to be balanced against the clinical imperative to identify
or exclude injury and the statutory duty to investigate cases of possible
harm. Where parents do not give their consent to such imaging, the case
needs to be discussed with the multi-disciplinary team, and a decision
made as to whether to work with the increased uncertainty inherent in not
having a skeletal survey or CT scan, or whether to seek a court order to
obtain such investigations outwith parental consent.
Such decisions need to be made in the light of the known short- and
long-term harms caused by child abuse. These include a small risk of
fatality from severe physical abuse, and the much more prevalent ongoing
harm suffered by children living in contexts of ongoing physical or
emotional abuse and neglect. The risk of fatality, while clearly
significant, should not be overstated. Our current analysis of Serious
Case Reviews in England from 2009-14 suggests an average of 28-33 deaths
per year directly caused by child abuse (Sidebotham, unpublished data).
In their article, Bajaj and Offiah state that 'Data from Child Death
Reviews has identified "deliberately inflicted injury, abuse or neglect"
as the single largest category of childhood deaths with modifiable factors
in England.'(2) In fact, these data show that this is the category with
the highest proportion of deaths considered modifiable (65% compared to
20% overall). However, of the 784 child deaths for which child death
overview panels considered there to be modifiable factors present, only 28
(3.6%) were due to deliberately inflicted injury, abuse or neglect. This
compares to 185 sudden unexpected and unexplained deaths (24% of all
deaths with modifiable factors present); 178 deaths from perinatal or
neonatal events (23%); and 145 (18%) from trauma and other external
factors. Far from being the 'single largest category of childhood deaths
with modifiable factors', deaths from child abuse make up a very small
proportion of those child deaths which we, as a society, may be able to
prevent.
References
1. Bajaj M, Offiah AC. Imaging in suspected child abuse: necessity or
radiation hazard? Arch Dis Child. 2015;100(12):1163-8.
2. Department for Education. Child death reviews: year ending 31st March
2012. London: Department for Education, 2013.
This editorial is a very helpful review of the current state of the
debate.
I am concerned that zoster is under diagnosed in childhood because of
lack of familiarity in both primary and secondary care. Anecdotally it is
not uncommon in a paediatric unit, in otherwise well children, but does
cause significant concern and use of resources. This needs to be
accurately captured as it may shift the economic modelling...
This editorial is a very helpful review of the current state of the
debate.
I am concerned that zoster is under diagnosed in childhood because of
lack of familiarity in both primary and secondary care. Anecdotally it is
not uncommon in a paediatric unit, in otherwise well children, but does
cause significant concern and use of resources. This needs to be
accurately captured as it may shift the economic modelling used to decide
whether to go ahead with varicella vaccination.
In their excellent review on the hypoglycaemia in childhood the
authors suggest that for the management of the hyperinsulinaemic
hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who
do not respond to diazoxide may respond to the octreotide but the efficacy
of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11
are associated with severe HH that is unresponsive to...
In their excellent review on the hypoglycaemia in childhood the
authors suggest that for the management of the hyperinsulinaemic
hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who
do not respond to diazoxide may respond to the octreotide but the efficacy
of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11
are associated with severe HH that is unresponsive to medical treatment
with diazoxide and octreotide. The treatment option for patients with
medically unresponsive forms of diffuse HH is a subtotal pancreatectomy,
but some patients who have undergone surgery continue to have recurrent
hypoglycemia, whereas diabetes mellitus and exocrine pancreatic
insufficiency develop in others (1).
The authors of the review make no mention of the possible use of the
mammalian target of rapamycin (mTOR) inhibitor sirolimus recently reported
to be effective and safe for the severe, diffuse form of HH that had been
unresponsive to maximal doses of diazoxide and octreotide (2-5). No major
adverse reactions were observed during the 1-year follow-up period in the
first 4 cases described (2). This finding is reinforced by the latest
cases report of others infant (3,4) and older children (5).
The suggested method of action of sirolimus includes the reduction of
beta-cell proliferation, inhibition of insulin production, and induced
peripheral insulin resistance (4). The sirolimus-sensitive mTORC1 pathway
is present in the exocrine pancreas and the relatively sirolimus-resistant
IGF1R/mTORC2/Akt pathway is overexpressed in the beta-cells, thereby
suggesting that sirolimus is effective in treating diffuse HH by reducing
the transdifferentiation of exocrine elements to insulin-producing cells
(5).
Even if further studies are needed, primarily to identify long-term
sequelae and side effects, sirolimus appears to be a promising therapeutic
option to treat children with severe HH unresponsive to diazoxide and
octreotide.
Federico Marchetti, Vanna Graziani
Department of Paediatrics, S. Maria delle Croci Hospital, Ravenna,
Italy.
48121 Ravenna, Italy
e-mail: fedemarche@tin.it
References
1. Ghosh A, Banerjee I, Morris AAM. Recognition, assessment and
management of hypoglycaemia in childhood Arch Dis Child Published Online
First: 30 December 2015 doi:10.1136/archdischild-2015-308337
2. Senniappan S, Brown RE, Hussain K. Sirolimus in severe
hyperinsulinemic hypoglycemia. N Engl J Med 2014;370(25):2448-9.
3. Abraham MB, Shetty VB, Price G, et al. Efficacy and safety of
sirolimus in a neonate with persistent hypoglycaemia following near-total
pancreatectomy for hyperinsulinaemic hypoglycaemia. J Pediatr Endocrinol
Metab 2015;28(11-12):1391-8
4. Meder U, Bokodi G, Balogh L, et al. Severe hyperinsulinemic
hypoglycemia in a neonate: response to sirolimus therapy. Pediatrics.
2015;136(5):e1369-72
5. Minute M, Patti G, Tornese G, Faleschini E, Zuiani C, Ventura A.
Sirolimus therapy in congenital hyperinsulinism: a successful experience
beyond infancy. Pediatrics. 2015;136(5):e1373-6
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin a...
Many thanks for the recent letter regarding a rapid assay technique
for testing fecal calprotectin1. This would indeed be useful in the
clinical setting if it allows the transmission of accurate and rapid fecal
calprotectin levels to treating clinicians. As discussed in the original
archimedes report, the difficulties surrounding the need for an adequate
cut-off remain the main barrier to the use of fecal calprotectin as a
diagnostic adjunct in necrotising enterocolitis2.
JFB Houston
1. Bin-Nun A, Booms C, Sabag N, Mevorach R, Algur N, Hammerman C.
Rapid
fecal calprotectin (FC) analysis: point of care testing for diagnosing
early necrotizing enterocolitis. Am J Perinatol. 2015;32:337-42.
2. Houston JFB, Morgan JE. Question 2: Can faecal
calprotectin be used as an effective diagnostic aid for necrotising
enterocolitis in neonates? Arch Dis Child. 2015;100:1003-6
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree en...
We thank Zylbersztejn, et al for their constructive letter and for
their support for the Countdown initiative. Their data suggests that high
rates of preterm birth and thresholds for reporting preterm birth [1] in
the UK were one of the most likely explanations for the disparities seen
between the UK and European countries such as Sweden, and we agree this is
likely (as outlined in our recent Lancet paper [2]. We agree entirely that
it is important to know where to target policy, and their data moves us on
considerably in determining priorities. This is precisely the sort of
approach needed on the Countdown technical committee and we look forward
to further collaboration.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
Colvin correctly notes that we are interested in solution-focused
research, and expresses some anxiety about our recommendations for
improving child survival. There are two issues to consider in addressing
his concerns: determining causality, and the burden of proof required to
take action.
First, Bradford Hill's criteria for considering causality are helpful
in demonstrating why the association between poverty...
Colvin correctly notes that we are interested in solution-focused
research, and expresses some anxiety about our recommendations for
improving child survival. There are two issues to consider in addressing
his concerns: determining causality, and the burden of proof required to
take action.
First, Bradford Hill's criteria for considering causality are helpful
in demonstrating why the association between poverty and social
inequalities, and many child health outcomes including mortality, is
convincing[3]. The correlation between poverty and mortality is strong and
consistent, and there is a clear gradient; poor children are more likely
to die, and the greater the gap between rich and poor, the greater the
risk[4]. Most of the other criteria are either self-evident (temporality)
or are more relevant and appropriate to simpler questions of causality,
(specificity, experiment). However Colvin also questions the plausibility
and coherence of the associations, focusing on low birth weight, preterm
birth, and teenage pregnancy as intermediary factors. The links between
poverty, social inequalities, and adverse child health outcomes are more
of a causal web than simple chain, so examination from multiple
perspectives is helpful and indeed the associations are plausible,
supported by epidemiological association, and other studies including
intervention [5, 6].
There is specific data for England and Wales, based on individual
parents' social status, demonstrating a clear social gradient in preterm
birth rates of 6.8 per cent for babies with at least one parent in a
managerial or professional occupation, compared with 7.8 per cent of
babies with parents in routine or manual occupations[7]. Socio-economic
adversity during pregnancy is also associated with an increased risk of
having a low birth weight baby [6, 8].
Plausibility is supported by other associations and evidence too. For
example, families from lower socio-economic backgrounds are likely to be
more stressed[9] and acute and chronic antenatal maternal stress and poor
maternal mental health are linked with preterm births and low birth weight
[10, 11] Depression may also lead to negative maternal behaviours, and
poor prenatal care, substance abuse, poor nutrition during pregnancy and
smoking are associated with both socio-economic disadvantage, and with
lower birth weight [12-15]. Young women from social disadvantaged
backgrounds and low educational attainment are more likely to have a
teenage pregnancy; teenage pregnancy rates are higher in more
disadvantaged areas, approximately twice as high for women living in the
most deprived areas compared with least deprived. Teenage pregnancy is
associated with an increased risk of preterm birth compared with women in
their 20 and 30s; in 2013, the overall rate of preterm births was 7.4 per
cent, but among women under 20 years the rate was 8.0 per cent [16-19].
Infant mortality rates among babies born preterm to mothers under 20 years
are higher (22.4 per thousand preterm births among mothers under 20 years)
than among older mothers (15.1 per thousand among mothers aged 35-39)[7,
16-18, 20]. Colvin's suggestion that differences in teenage pregnancy
rates are an alternative explanation ignores the strong association
between teenage pregnancy rates and deprivation on both an individual and
an area level, and the ample evidence that social disadvantage contributes
to poor outcome at birth and in childhood.
The second issue relates to the burden of proof required before
taking action. Epidemiology and health systems research are important
tools in the search for explanations and solutions, and there are
different methods and standards according to the questions asked[21].
Applying an epidemiological standard to a health systems or social policy
question is neither always sufficient nor appropriate.The logical
consequence of Colvin's argument is that a randomised controlled trial
would be necessary before taking action to reduce social inequalities.
There has never, to our knowledge, been any evidence published suggesting
detrimental health effects of reducing poverty, narrowing the gap between
rich and poor, or introducing policies promoting social protection. By
contrast, there is plenty of evidence demonstrating good. It would seem
remiss to wait for a purported but misguided epidemiological standard of
evidence. The burden of proof suggests that our recommendations are likely
to be safe and do more good than harm.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane,
Hilary Cass, Russell Viner
1. EURO-PERISTAT Project with SCPE and EUROCAT, European Perinatal
Health Report. The health and
care of pregnant women and babies in Europe in 2010,. 2013.
2. Viner, R., et al., Deaths in young people aged 0-24 years in the
UK compared with the EU15+ countries, 1970-2008: analysis of the WHO
Mortality Database. . Lancet. , 2014 384(9946): p. 880-92.
3. Bradford Hill, A., The environment and disease: association or
causation? Proceedings of the Royal Society of Medicine, 1965. 58(5): p.
295-300.
4. Marmot, M., WHO European review of social determinants of health
and the health divide. . The Lancet. , 2012. 380: p. 1011-1029.
5. Cattaneo, A., et al., Child Health in the European Union
2012, European Commission: Luxembourg.
6. Ohlsson, A. and Shah P, Determinants and prevention of low birth
weight: a synopsis of the evidence. 2008, Institute of Health Economics
Alberta, Canada
7. Office for National Statistics. Gestation-specific infant
mortality in England and Wales, 2013. 2015; Available from:
http://www.ons.gov.uk/ons/publications/re-reference-
tables.html?edition=tcm%3A77-39593
http://www.ons.gov.uk/ons/dcp171778_419800.pdf.
8. Dibben, C., M. Sigala, and A. Macfarlane, Area deprivation,
individual factors and low birth weight in England: is there evidence of
an "area effect"? J Epidemiol Community Health, 2006. 60(12): p. 1053-9.
9. Duncan, G.J., J. Brooks-Gunn, and P.K. Klebanov, Economic
deprivation and early childhood development. Child Dev, 1994. 65(2 Spec
No): p. 296-318.
10. Talge, N.M., et al., Antenatal maternal stress and long-term
effects on child neurodevelopment: how and why? J Child Psychol
Psychiatry, 2007. 48(3-4): p. 245-61.
11. Hoffman, S. and M.C. Hatch, Stress, social support and pregnancy
outcome: a reassessment based on recent research. Paediatr Perinat
Epidemiol, 1996. 10(4): p. 380-405.
12. Bradley, R.H. and R.F. Corwyn, Socioeconomic status and child
development. Annu Rev Psychol, 2002. 53: p. 371-99.
13. Brooks-Gunn, J., et al., Enhancing the cognitive outcomes of low
birth weight, premature infants: for whom is the intervention most
effective? Pediatrics, 1992. 89(6 Pt 2): p. 1209-15.
14. Korenman, S.M., JE. Sjaastas J., Long term poverty and child
development in the United States: results from the NLSY. Institute for
research on Poverty Discussion paper, . 1994, Institute for research on
Poverty.
15. Marmot, M., Marmot M. Fair Society, Healthy Lives: the Marmot
Review. Strategic review of health inequalities in England post 2010.
2010.
16. Office for National Statistics. Teenage pregnancies at lowest
level since records began. 2013 [cited 2015 April]; Available from:
http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-
wales/2011/sty-conception-estimates-2011.html.
17. Office for National Statistics. Teenage pregnancies at record
low: how does your local area compare? 2014 [cited 2015 April]; Available
from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-
and-wales/2012/sty-conception-rates.html.
18. Office for National Statistics. Conception statistics, England
and Wales, 2013. . 2015; Available from:
http://www.ons.gov.uk/ons/rel/regional-trends/area-based-
analysis/conceptions-deprivation-analysis-toolkit/conceptions-deprivation-
measures--2009-11.html.
19. Right Care, Atlas of Variation: Children. 2012.
20. Office for National Statistics, Teenage conceptions are highest
in the most deprived areas. 2014.
21. Ghaffar, A., et al., Changing mindsets in health policy and
systems research. Lancet, 2013. 381(9865): p. 436-7.
We are so sorry not to have included cerebral arterio-venous fistula
in the aetiology of unexplained tachypnoea because it is of course a rare
but classic cause. Typically the symptoms begin almost immediately after
birth if there is a large fistula and the pulmonary artery pressure
remains elevated. The fistula allows a large systemic artery to systemic
venous shunt with right atrial and right vent...
We are so sorry not to have included cerebral arterio-venous fistula
in the aetiology of unexplained tachypnoea because it is of course a rare
but classic cause. Typically the symptoms begin almost immediately after
birth if there is a large fistula and the pulmonary artery pressure
remains elevated. The fistula allows a large systemic artery to systemic
venous shunt with right atrial and right ventricular volume overload and
increased pulmonary blood flow. There is almost always a systolic or
continuous murmur over the occiput or anterior fontanel allowing a
clinical diagnosis to be made in the majority; but absence of any murmur
in the case described by your correspondent is unusual.
My child also has CSID. She is about to be 8 yrs old and has been on Sucraid for the last 6-7 yrs. I am looking for an alternative to this medication as sometimes we cannot get the medication and have to go a strict diet until we can get some again. I will look into this alternative and post results later.
Conflict of Interest:
None declared
We read with interest the review by Amirthalingam[1] and colleagues of the potential value of a UK varicella vaccination programme. They cite Blumental[2] and colleagues' article in the same issue which assessed the burden of varicella and outlined some of the known complications, such as bacterial skin and soft tissue infections, pneumonia, and neurological complications including meningitis and encephalitis. The Blumen...
The ADC Archivist recently reported that Freedman et al had revealed that "old-fashioned clinical examination" missed about 20% of cases of significant dehydration in children.[1] Their assessment of this work was not surprising because the meta-analysis in the Journal of Pediatrics carries the headline message that even the "most accurate, noninvasive" methods could only "identify dehydration suboptimally", and it was a...
Monika Bajaj and Amaka Offiah are to be commended for their thoughtful and helpful review of the benefits and risks of skeletal imaging in cases of suspected child abuse.(1) The diagnosis of child abuse is a complex process which requires an evidence-informed approach combining clinical acumen with collaborative multi-agency working. Skeletal imaging, including CT scans, provide a valuable tool for the clinician, but,...
This editorial is a very helpful review of the current state of the debate.
I am concerned that zoster is under diagnosed in childhood because of lack of familiarity in both primary and secondary care. Anecdotally it is not uncommon in a paediatric unit, in otherwise well children, but does cause significant concern and use of resources. This needs to be accurately captured as it may shift the economic modelling...
Dear Editor
In their excellent review on the hypoglycaemia in childhood the authors suggest that for the management of the hyperinsulinaemic hypoglycaemia (HH) diazoxide is the first-line therapy (1). Patients who do not respond to diazoxide may respond to the octreotide but the efficacy of this is often limited by tachyphylaxis. Mutations in ABCC8 and KCNJ11 are associated with severe HH that is unresponsive to...
Many thanks for the recent letter regarding a rapid assay technique for testing fecal calprotectin1. This would indeed be useful in the clinical setting if it allows the transmission of accurate and rapid fecal calprotectin levels to treating clinicians. As discussed in the original archimedes report, the difficulties surrounding the need for an adequate cut-off remain the main barrier to the use of fecal calprotectin a...
We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree en...
Colvin correctly notes that we are interested in solution-focused research, and expresses some anxiety about our recommendations for improving child survival. There are two issues to consider in addressing his concerns: determining causality, and the burden of proof required to take action.
First, Bradford Hill's criteria for considering causality are helpful in demonstrating why the association between poverty...
Dear Editor
We are so sorry not to have included cerebral arterio-venous fistula in the aetiology of unexplained tachypnoea because it is of course a rare but classic cause. Typically the symptoms begin almost immediately after birth if there is a large fistula and the pulmonary artery pressure remains elevated. The fistula allows a large systemic artery to systemic venous shunt with right atrial and right vent...
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