92 e-Letters

published between 2018 and 2021

  • Misuse and alarmist use of the word pandemic

    Sidpra et al1 reported seeing 10 patients with suspected abusive head trauma between 23 March and 23 April 2020, when previously their unit only saw 0.67 cases per month. They concluded that this indicated a pandemic. In support, they cited (providing an incorrect journal name) a published review suggesting an increased risk of family violence2, but in fact the review cited referred to decreasing reports of child abuse and neglect during the Covid-19 pandemic.

    Sidra et al made no mention of the likely explanation for their observations, namely a change in referral patterns. A number of children’s wards in hospitals in London and elsewhere in the UK have been taken over by adult Covid-19 patients, coupled with the closure of some paediatric urgent care centres and emergency departments, resulting in the diversion of ill children to other centres.

    If, as is suggested, the apparent 1493% increase in inflicted head injury cases is indeed the result of adverse psychosocial factors resulting from efforts to reduce Covid-19 transmission, then one would expect paediatric services worldwide to be deluged with other types of inflicted injury, which as yet has not been reported.

    Without other supporting data, and only using information from a single unit, we are not convinced that there is a sound case for the authors' conclusion that these 10 cases represent a ‘pandemic’. The word pandemic means a disease that is prevalent over a whole country or the whole...

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  • Where have all the children gone? Home. Why?

    Dear Editor

    Congratulations and thanks to Isba R et al on documenting the impact of Covid-19 on attendances to UK paediatric emergency departments and assessment units in lockdown [1]. Their data is mirrored by that collected by RCPCH [2] and Italy [3] They ask “Where have all the children gone?”
    As they point out the first concern was that children with serious illness were not being brought to hospital. RCPCH data suggests this is the minority of cases. [2] Other questions we should ask are, “Has the balance of benefit for families tipped in favour of staying away from hospital? Is there any evidence that supports that hypothesis?”
    RCPCH State of Child Health [4] documented a paediatric population with less acute illness but attending hospital more: the “Worried Well”. Furthermore whilst child physical health is improving mental and emotional wellbeing is deteriorating. [4]
    We must watch mortality and morbidity closely. To date there is no data to suggest this has increased in children. If it does not increase then we should ask ourselves the uncomfortable question, “Have we over diagnosed physical illness and contributed to anxiety?” Put another away, “Have UK paediatricians contributed to the anxiety of a population?”
    As we, “Reset, Restore and Recover,” [5] we must not shy away from considering this uncomfortable possibility as we address the secondary affects of the pandemic [6]. We must revaluate the relative risk of all childhood di...

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  • Protect children from Covid-19: the “secondary pandemia”

    Dear Editor,
    Ladhani SN et al (1) underline during the pandemic from Covid-19 the importance of reporting pediatric population surveillance data, and the pediatricians are encouraged to get involved with research and clinical trials to better understand the immunopatho-physiology and identify effective treatments for COVID-19 in children.

    However, as the authors themselves point out, the Covid-19 pandemic has been shown to be much milder as clinical manifestations in the infant and child than in the adult. Bhopal S et al (2) examined mortality data for 0-19 year olds, showing that across France, Germany, Italy, Korea, Spain, the United Kingdom, and the United States there were 44 deaths from covid-19 in 0-19 year olds (total population 135.691.226) up to 19 May 2020. Over a normal three month period, in these countries, published Global Burden of Disease data estimate that more than 13.000 deaths would be expected from all causes in this age group, including over 1000 from unintentional injury and 308 from lower respiratory tract infection including influenza.

    Because of their isolation, children are having documented risks that we are getting used to calling Covid-19 side effects or secondary pandemic (3,4): from delays in diagnosing some clinically relevant diseases (5), to educational deprivation (6), to the care needs of certain categories of children fragile with social and health needs that have interrupted their care project. The deep risk that...

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  • Surfactant administration via laryngeal mask in preterm infants: a word of caution

    We read with interest Dr. Smee et al.’s article on surfactant administration via laryngeal mask (LMA) in infants with respiratory distress syndrome: an intriguing topic, suggesting a minimally invasive approach to ensure a well-established therapy.
    The authors stated that “use of LMA to administer surfactant is feasible in infants ≥ 1200g, reducing the need for intubation and mechanical ventilation”. (1) Despite a recent meta-analysis showing that this approach may have some advantages on short term outcomes, (i.e. reduction in need for intubation and mechanical ventilation), available evidence was based on small, poor-quality studies. (2)
    In addition, there are many unanswered questions on the application of this approach in neonates. It is not known which supraglottic airway device (SAD) may be best suited (there are at least 7 different types of commercially available size-1 SADs), the characteristics of the cuff (inflatable or not-inflatable) and the most appropriate size, (3,4) whether a catheter inside the mask should be used and if yes, where the catheter’s tip should be positioned (proximally or distally), under vision or blindly. There is uncertainty on whether the patient needs mild sedation, general or topical anesthesia, or nothing at all, and around the best mode to support respiratory efforts and potential complications (i.e. hypoxia or bradycardia) during the procedure. (1)
    The authors also reported that “LMAs to fit the more immature infan...

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  • Low Prevalence of Kingella kingae Infections in UK Children


    Low Prevalence of Kingella kingae Infections in UK Children

    Pablo Yagupsky, MD
    Clinical Microbiology Laboratory, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel

    Corresponding Author: Pablo Yagupsky, Clinical Microbiology Laboratory, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel 84101. Phone number: (972) 506264359. Fax number: (972) 86403541. e-mail: PYagupsky@gmail.com

    Dear Editor:
    In a recent article, Abeywickrema et al. summarized 10 years of pediatric joint and bone infections in Oxford, and concluded that Staphylococcus aureus was the most common etiology [1]. Although this concept was widely accepted in the past, the increasing use of sensitive nucleic acid amplification tests has demonstrated that Kingella kingae is the leading agent of skeletal system infections in the 6-48 month-old population, causing up to 88% of the cases in this age group [2]. Abeywickrema et al., however, isolated the bacterium in only 3 of the 74 (4%) patients in whom the etiology could be determined [1]. Kingella kingae is notoriously fastidious and the traditional culture methods and microscopy employed by the researchers are usually unable to detect its presence in joint and bone exudates [3]. Invasive K. kingae infections other than endocarditis are characterized by a mild local and systemic inflammation: fev...

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  • In support of safe hospital care of children and staff during the Covid-19 Pandemic

    Since the introduction of the national delay phase response to Covid-19 Coronavirus in the republic of Ireland on March 12th and subsequent advise to stay at home from March 27th, essential paediatric cardiac services have had to continue in a limited capacity.
    In that time, our national tertiary referral centre has seen 428 children in the out-patient's setting, 223 on the cardiac day ward, and performed an intervention (cardiac surgery or cardiac catheterization) in 140 cases. This includes 41 cardiac by-pass cases, 22 non-bypass cases, 49 interventional cardiac catheterization cases and 6 hybrid procedures involving both the cardiac surgery and cardiac catheterization teams.
    Of the 49 patients screened pre-operatively, not one positive (and asymptomatic) case was identified.
    Adhering to government advice on social distancing and appropriate PPE where indicated, not a single member of the extended medical team has been known to cntract Covid-19 Coronavirus from contact with patients or their families in this time.
    This anecdotal case experience from one institution supports the proposal to allow children to return to school regardless of comorbidities, in recognition of the considerable long-term educational and social harm that exclusion would result in.

  • Time to go back to school: several good reasons beyond low infection risk

    Munro APS &  Faust SL, in their viewpoint (1) quite correctly build on the evidence of low risk of contagion and rare complications of Covid-19 infection among children to call for reopening of schools. There are, however, several other good reasons to be considered.

    First, as all international agencies have highlighted, prolonged closure yields serious consequences for all children and particularly for those already living in difficult circumstances, such as extreme poverty, disability, or violent environments (2,3). UNESCO estimates that at least 177 countries have instituted school closures at national level and several other countries have established closings at regional or local level (4). With over 90% of students worldwide (more than 1.5 billion young people) currently out of the educational context, it is clear that the greatest threats from Covid-19 to children and adolescents are to be found in educational loss, poorer nutrition, increased exposure to intrafamiliar violence, rising incidence of mental health disorders and lack of physical activity rather than in the clinical consequences of Covid-19 infection (4-8). Inequality in education and health will increase dramatically as consequences are inevitably greater for vulnerable children due to social, material and educational poverty, disability and chronic diseases, special educational needs, and lack of access to distance learning technologies (1). The risk of dangerous habits, such as increasing...

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  • Children are being kept at home to protect the elderly from COVID-19

    Munro and Faust call for children to return to school despite the outstanding clinical and epidemiological questions outlined in their Viewpoint “Children are not COVID-19 super spreaders: time to go back to school”[1]. We think that their core argument – that children are minimally infected with SARS-CoV2, that they spread it less than adults, and that even children with comorbidities are relatively spared the most serious effects of COVID-19 – can be augmented with the question “is it ethical to confine children to the home for the protection of the elderly?”.

    In England, 11 COVID-19 deaths were reported in 0-19 year olds up to 5 May 2020[2]. For the same period in Germany this number is three[3], and in France five[4]. During that time, the Global Burden of Disease study estimates that in each of those countries, over a thousand 0-19 year olds died from all-causes, including several hundred from road traffic injury and tens from pneumonia[5].

    We do not keep children at home to protect them from these causes of death, so why are we doing this for COVID-19? We think the public, especially parents, need to understand that this is being done mainly for the benefit of adults (and especially the elderly and other vulnerable groups). This is a societal choice with immediate and potentially life-long consequences which needs careful evaluation of risks and benefits. While scientific evaluation takes place and will take time, the communication of our decision clea...

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  • The risk of ibuprofen-related acute kidney injury is just as important

    The question of the safety of ibuprofen in lower respiratory tract infection(LRTI)(1) should be part of a bigger question. That question is the issue of the safety of ibuprofen in a child who is at risk of dehydration. A febrile child with LRTI is at risk of dehydration because of increased insensible fluid loss via the skin. Furthermore, in the presence of LRTI-related tachypnoea, there will be increased insensible fluid loss via the upper respiratory tract . These fluid losses are compounded when the child is too ill to maintain a good oral fluid intake.
    In volume depleted states, such as the scenario depicted above, vasodilatory prostaglandins maintain adequate renal blood flow(RBF) and adequate glomerular filtration rate(GFR)(2). Nonsteroidal anti inflammatory drugs(NSAIDs) undermine those compensatory mechanisms by inhibiting prostaglandin synthesis(2). The consequence is the onset of NSAID-related acute kidney injury(AKI), as postulated by Misurac et al(3). These investigators postulated that NSAID-related inhibition of prostaglandin synthesis was the underlying cause of AKI in 21 of their 27 cases of NSAID-related AKI. In the remaining 6 children with AKI, acute interstitial nephritis(also attributable to NSAIDs) was the underlying cause.. Fifteen of the 20 children for whom dosing data were available took NSAID doses in the recommended range. Ibuprofen was the culprit NSAID in 67% of cases. Misurac et al also identified 54 other cases...

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  • Response letter to Nutritional rickets under 16 years: UK surveillance results

    Dear Editor

    Infant vitamin D supplementation prevents not just rickets but also hypocalcaemic seizures and cardiomyopathy (CMP). The BPSU survey (1) captures rickets incidence which, we feel compelled to highlight, represents only the tip of the iceberg of widespread vitamin D deficiency (VDD) in the population.

    In the UK, child surveillance checks are led by general practitioners (GPs). Most GPs do not receive postgraduate paediatric training and have inadequate undergraduate paediatric exposure, as acknowledged by the RCPCH president: “by any stretch of the imagination, GP training in the UK in paediatrics is woefully inadequate” (2). Recognising rickets requires paediatric experience as exemplified by recent cases of VDD induced CMP- one child’s death was preceded by multiple unfruitful visits to GPs and casualty (3). As the BPSU survey reached out only to paediatricians and not GPs, the extent of underreporting and under diagnosis is likely huge, limiting comparison with countries where paediatricians oversee primary care. The conclusion that rickets incidence in the UK is lower than expected downplays the extent of the underlying public health crisis, particularly when a significant number of cases were excluded [table 2 of (1)]. The true disease burden is unravelled when family members of affected children are investigated (3).

    Similar to previous studies, rickets incidence here is 90 to 166 fold higher in Asian and Black children compared to wh...

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