Prediction rules to identify young febrile infants with serious bacterial infections (SBI) have been developed by investigators globally. Comparisons of these rules should be conducted by independent parties to avoid conflicts of interest. Two newer prediction rules use procalcitonin (PCT) as an important variable: one rule,[1] created by the authors of the Velasco[2] paper, and the PECARN Febrile Infant Rule[3] created by the authors of this letter. There are important methodological issues which must be considered when evaluating Velasco’s validation of the PECARN study. 1) The Velasco study was a retrospective analysis of a registry at one hospital in Spain, while the PECARN study was prospectively conducted at 20 centers in the United States and analyzed by an independent data center (mitigating investigator bias). 2) The rate of SBI in the Velasco study was 20.5%, much higher than the 9.3% reported by the PECARN study[3] and other investigators.[4] This suggests a different patient population or SBI epidemiology than ours, and/or enrollment bias. 3) Although the PECARN rule (using the urinalysis, absolute neutrophil count [ANC] and PCT) was derived on febrile infants 0-60 days-old, we recommend implementation only on 29-60 day-old infants, as suggested in our article.[3] In the supplement to our article, the PECARN rule using rounded cutoffs (ANC of 4000 cells/mm3 and PCT of 0.5 ng/mL) for simplicity, safety and to decrease the risk of overfitting, performed with simi...
Prediction rules to identify young febrile infants with serious bacterial infections (SBI) have been developed by investigators globally. Comparisons of these rules should be conducted by independent parties to avoid conflicts of interest. Two newer prediction rules use procalcitonin (PCT) as an important variable: one rule,[1] created by the authors of the Velasco[2] paper, and the PECARN Febrile Infant Rule[3] created by the authors of this letter. There are important methodological issues which must be considered when evaluating Velasco’s validation of the PECARN study. 1) The Velasco study was a retrospective analysis of a registry at one hospital in Spain, while the PECARN study was prospectively conducted at 20 centers in the United States and analyzed by an independent data center (mitigating investigator bias). 2) The rate of SBI in the Velasco study was 20.5%, much higher than the 9.3% reported by the PECARN study[3] and other investigators.[4] This suggests a different patient population or SBI epidemiology than ours, and/or enrollment bias. 3) Although the PECARN rule (using the urinalysis, absolute neutrophil count [ANC] and PCT) was derived on febrile infants 0-60 days-old, we recommend implementation only on 29-60 day-old infants, as suggested in our article.[3] In the supplement to our article, the PECARN rule using rounded cutoffs (ANC of 4000 cells/mm3 and PCT of 0.5 ng/mL) for simplicity, safety and to decrease the risk of overfitting, performed with similarly high test accuracy. We have validated the PECARN rule using these rounded cutoffs on another 1363 infants with nearly identical test accuracy as the original study.[5] Using these thresholds, we have now analyzed nearly 3200 febrile infants < 60 days-old and have not missed one case of bacterial meningitis. 4) If implemented as we suggest, 4 of the 5 “missed cases” of SBI reported by Velasco would not be missed.
1. Gomez B, Mintegi S, Bressan S, et al. Validation of the "Step-by-Step" approach in the management of young febrile infants. Pediatrics 2016;138:e20154381.
2. Velasco R, Gomez B, Benito J, Mintegi S. Accuracy of PECARN rule for predicting serious bacterial infection in infants with fever without a source. Arch Dis Child 2020;0;1-6.
3. Kuppermann N, Dayan PS, Levine DA, et al. A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA Pediatr 2019;173:342–51.
4. Blaschke AJ, Korgenski EK, Wilkes J, et al. Rhinovirus in febrile infants and risk of bacterial infection. Pediatrics. 2018;141:e20172384.
5. Kuppermann N, Dayan PS, VanBuren JM, et al. Validation of a prediction rule for febrile infants less than or equal to 60 days in a multicenter network. Acad Emerg Med 2020;27:S43.
Scott-Jupp et al. recent paper (Effects of consultant residence out-of-hours on acute paediatric admissions1) appeared relevant to myself as a junior doctor at the end of my training. I am interested to know whether there was learning from the resident consultant around discharge behaviour to better understand the differences?
There were approximately 40% of admissions that stayed less than 12 hours and this group were more likely to be discharged when a consultant was resident. There was no significant difference in discharge rates in children who stayed more than 12 hours1.
Should the less ill children be attending acute services anyway? Would a service consisting of resident consultants feed into propping up the acute pathway for less ill children?
A prospective observational study found up to 42.2% of ED presentations over a 14 day period were judged to have been totally avoidable if the family had had better health education2. Studies have previously looked at the appropriateness of paediatric OPD new referrals and suggest that at least 39% of them could be managed by primary care3.
I wonder whether the expansion of paediatric consultant posts due to increased ED attendance have unwittingly made secondary care reluctant to challenge the status quo of paediatric care delivery despite clear evidence that hospital is not always appropriate? If paediatric ED attendance starts to go down, would the current system become redundant? Other models...
Scott-Jupp et al. recent paper (Effects of consultant residence out-of-hours on acute paediatric admissions1) appeared relevant to myself as a junior doctor at the end of my training. I am interested to know whether there was learning from the resident consultant around discharge behaviour to better understand the differences?
There were approximately 40% of admissions that stayed less than 12 hours and this group were more likely to be discharged when a consultant was resident. There was no significant difference in discharge rates in children who stayed more than 12 hours1.
Should the less ill children be attending acute services anyway? Would a service consisting of resident consultants feed into propping up the acute pathway for less ill children?
A prospective observational study found up to 42.2% of ED presentations over a 14 day period were judged to have been totally avoidable if the family had had better health education2. Studies have previously looked at the appropriateness of paediatric OPD new referrals and suggest that at least 39% of them could be managed by primary care3.
I wonder whether the expansion of paediatric consultant posts due to increased ED attendance have unwittingly made secondary care reluctant to challenge the status quo of paediatric care delivery despite clear evidence that hospital is not always appropriate? If paediatric ED attendance starts to go down, would the current system become redundant? Other models of care such as GP hubs may be a more appropriate area in which to invest. They have already demonstrated high patient satisfaction3.
The coronavirus pandemic has challenged the way we work in many ways. In light of this, the paediatric profession has the opportunity to change our care delivery processes in a way that maximises the benefit for the child. I hope that secondary care can work more creatively with primary care, for example by running more joint clinics with GPs and developing links with community nursing/mental health teams. This will shift focus back to child centred paediatric care.
References
1. Scott-Jupp R, Carter E, Brown N. Effects of consultant residence out-of-hours on acute paediatric admissions. Arch Dis Child. Jul 2020;105(7):661-663. doi:10.1136/archdischild-2019-317553
2. Viner RM, Blackburn F, White F, et al. The impact of out-of-hospital models of care on paediatric emergency department presentations. Arch Dis Child. Feb 2018;103(2):128-136. doi:10.1136/archdischild-2017-313307
3. Montgomery-Taylor S, Watson M, Klaber R. Child Health General Practice Hubs: a service evaluation. Arch Dis Child. Apr 2016;101(4):333-7. doi:10.1136/archdischild-2015-308910
To the editor
We appreciated the Images in paediatrics ‘Necrosis of infantile haemangioma with propranolol therapy’ by Grech and colleagues1. Nevertheless, we take exception to the Authors’ statement that necrosis is due to propranolol induced-involution for several reasons: first of all, the infant was not receiving a full-dose medication (1.5 mg/kg/day) when propranolol should be given at minimum 2 mg/kg/day. Furthermore, the milestone study by Léauté-Labrèz et al showed that a daily regimen of 3 mg/kg is safe and effective in reducing haemangiomas in a cohort of 456 infants2. We do believe that considering the low dose and the proliferative phase the infant was in3, necrosis was most likely due to natural evolution of the haemangioma than drug-induced involution. The authors do not give precise measurements of the scalp lesion before and during treatment, so it is not clear how much the lesion diminished in size. In view of previous considerations, it is difficult to rule out that the lesion might just have followed its natural course. As a matter of fact, both prematurity and female gender are well known risk factors associated with ulceration4.As the authors properly underline, propranolol therapy is the treatment of choice for infantile haemangioma (IH) and adverse effects as hypoglycemia, hypotension and bradycardia are widely known. Ulceration is the most common complication of IH and so that it could be even considered an indication to continue rather than...
To the editor
We appreciated the Images in paediatrics ‘Necrosis of infantile haemangioma with propranolol therapy’ by Grech and colleagues1. Nevertheless, we take exception to the Authors’ statement that necrosis is due to propranolol induced-involution for several reasons: first of all, the infant was not receiving a full-dose medication (1.5 mg/kg/day) when propranolol should be given at minimum 2 mg/kg/day. Furthermore, the milestone study by Léauté-Labrèz et al showed that a daily regimen of 3 mg/kg is safe and effective in reducing haemangiomas in a cohort of 456 infants2. We do believe that considering the low dose and the proliferative phase the infant was in3, necrosis was most likely due to natural evolution of the haemangioma than drug-induced involution. The authors do not give precise measurements of the scalp lesion before and during treatment, so it is not clear how much the lesion diminished in size. In view of previous considerations, it is difficult to rule out that the lesion might just have followed its natural course. As a matter of fact, both prematurity and female gender are well known risk factors associated with ulceration4.As the authors properly underline, propranolol therapy is the treatment of choice for infantile haemangioma (IH) and adverse effects as hypoglycemia, hypotension and bradycardia are widely known. Ulceration is the most common complication of IH and so that it could be even considered an indication to continue rather than to stop treatment.
Best regards,
Francesca Peri, MD
Irene Berti, MD
Egidio Barbi, MD, Professor
1- Grech JA, Calleja T, Soler P, et al. Necrosis of infantile haemangioma with propranolol therapy. Archives of Disease in Childhood 2020;105:608.
2- Léauté-Labrèze C et al. A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma. N Engl J Med. 2015; 372:735-746.
3- Storch CH, Hoeger PH. Propranolol for infantile haemangiomas: insights into the molecular mechanisms of action. Br J Dermatol. 2010;163(2):269-274. doi:10.1111/j.1365-2133.2010.09848.
4- Chang CS, Kang GC. Efficacious Healing of Ulcerated Infantile Hemangiomas Using Topical Timolol. Plast Reconstr Surg Glob Open. 2016;4(2):e621. Published 2016 Feb 16.
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...
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 world. We urge caution in the use of language in these difficult times, when there is already an increased level of public concern about medical problems and medical facilities.
1. Sidpra J, Abomeli D, Hameed B, et al. Arch Dis Child Epub ahead of print: [02 July 2020]. doi:10.1136/archdischild-2020-319872
2. Campbell AM. An increasing risk of family violence during the Covid-19 pandemic: strengthening community collaborations to save lives. Forens Sci Internat Reports Epub ahead of print [12 April 2020] doi.org/10.1016/j.fsir.2020.100089
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...
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 disease.
Yours faithfully
John Furness
References
Isba R, Edge R, Jenner R, et al Where have all the children gone? Decreases in paediatric emergency department attendances at the start of the COVID-19 pandemic of 2020 Archives of Disease in Childhood 2020;105:704. https://www.rcpch.ac.uk/resources/impact-covid-19-child-health-services-... accessed 10th July 2020
Scaramuzza A, Tagliaferri F, Bonetti L, et al Changing admission patterns in paediatric emergency departments during the COVID-19 pandemic Archives of Disease in Childhood 2020;105:704-706 https://stateofchildhealth.rcpch.ac.uk/ accessed 10th July 2020 https://www.rcpch.ac.uk/resources/reset-restore-recover-rcpch-principles... accessed 10th July 2020
Brown N Highlights from this issue Archives of Disease in Childhood 2020;105:i.
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...
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 is being run is that of a passive adaptation that contradicts the very essence of a perspective of well-being and health of childhood. Actions for a concrete safeguard perspective should start now (4). The deep risk that is being run is that of a passive adaptation that contradicts the very essence of a perspective of well-being and health of children. Breaking the current state of indifference is perhaps possible if we stop thinking about the second epidemic wave.
Only when we talk about our concerns and plans for the well-being of children, with the same passion with which we talk about all the extraordinary efforts to save the lives of adults, will those who are bound by the current silence feel able to develop strategies and make investments that will change the prospects of well-being for children.
This represents a priority that has a greater relevance than that of the documentation of clinical problems related to Covid 19 infection in children.
References
1. Ladhani SN, Amin-Chowdhury Z, Amirthalingam G, et al. Prioritising paediatric surveillance during the COVID-19 pandemic. Arch Dis Child 2020;105:613–615.
2. Crawley E, Loades M, Feder G, et al. Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adults. BMJ Paediatrics Open 2020, 4:e000701. doi: 10.1136/bmjpo-2020-000701
3. Bhopal SS, Bagaria J, Bhopal R. Risks to children during the Covid-19 pandemic: some essential epidemiology. BMJ 2020;369:m2290 http://dx.doi.org/10.1136/bmj.m229
4. Green P. Risks to children and young people during Covid-19 pandemic. A shift in focus is needed to avoid an irreversible scarring of a generation. BMJ 2020;369:m1669 https://doi.org/10.1136/bmj.m1669
5. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health 2020;4(5):e10-e11. doi: 10.1016/S2352-4642(20)30108-5.
6. Tamburlini G, Marchetti F. Covid-19 pandemia: reasons and indications for reopening education services. Medico e Bambino 2020;39(5):301-304 https://www.medicoebambino.com/?id=2005_301.pdf
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...
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 infants are not yet currently widely available.” To our knowledge, there are no LMAs designed to fit this smaller population. Improper use of the currently available LMAs in more immature infants may be dangerous. (5)
Despite the great enthusiasm and interest of neonatologists on this approach for surfactant administration in infants with RDS, more evidence is needed to recommend this practice. Based on currently available evidence, surfactant administration via SAD should be limited to clinical trials.
References
1. Smee NJ, O'Shea JE. Can the laryngeal mask airway be used to give surfactant in preterm infants? Arch Dis Child. 2020 Apr 7:archdischild-2019-318562.
2. Calevo MG, Veronese N, Cavallin F, Paola C, Micaglio M, Trevisanuto D. Supraglottic airway devices for surfactant treatment: systematic review and meta-analysis. J Perinatol. 2019;39:173-183.
3. Tracy MB, Priyadarshi A, Goel D, Lowe K, Huvanandana J, Hinder M. How do different brands of size 1 laryngeal mask airway compare with face mask ventilation in a dedicated laryngeal mask airway teaching manikin? Arch Dis Child Fetal Neonatal Ed. 2018;103:F271-F276.
4. Bansal SC, Caoc i S, Dempsey E, Trevisanuto D, Roehr CC. The Laryngeal MaskAirway and Its Use in Neonatal Resuscitation: A Critical Review of Where We Are in 2017/2018. Neonatology. 2018;113:152-161.
5. Trevisanuto D, Parotto M, Doglioni N, Zanardo V, Micaglio M. Upper esophageal lesion following laryngeal mask airway resuscitation in a very low birth weight infant. Resuscitation. 2011 Sep;82(9):1251-2.
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...
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: fever is often absent, WBC counts in the blood and synovial fluid are frequently normal, and acute phase reactants are within the normal range or only mildly elevated, requiring a high index of suspicion and the use of sensitive detection methods for confirmation [3]. In France, Switzerland, and Israel, where molecular assays are routinely employed, the role of K. kingae as the prime osteoarticular pathogen in young children has been firmly established [2, 4], but the organism is conspicuously underrepresented in UK reports [1, 5]. I believe that many children with K. kingae disease were consistently overlooked in the study and are hidden in the culture-negative category, or were dismissed altogether as unconfirmed cases of septic arthritis or osteomyelitis [3]. It is to be expected that the increasing use of nucleic acid amplification tests will improve the laboratory diagnosis of skeletal system infections in early childhood and contribute to better patients’ management.
References
1. Abeywickrema M, Liu X, Kelly DF, et al. Bone and joint infections in Oxford: a 10-year retrospective review. Arch Dis Child 2020; 105:515-516.
2. Juchler C, Spyropoulou V, Wagner N, et al. The contemporary bacteriologic epidemiology of osteoarticular infections in children in Switzerland. J Pediatr 2018;194:190-196.
3. Yagupsky P. Kingella kingae: carriage, transmission, and disease. Clin Microbiol Rev 2015;28:54-79.
4. Chometon S, Benito Y, Chaker M, et al. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children. Pediatr Infect Dis J 2007;26:377-381.
5. de Graaf H, Sukhtankar P, Arch B, et al. Duration of intravenous antibiotic therapy for children with acute osteomyelitis or septic arthritis: a feasibility study. Health Technol Assess 2017;21:1-164.
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.
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...
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 screen time and unhealthy feeding will also increase.
In Italy. 9,040,000 children and youngsters and over one million children from nursery schools and early childhood education services have been forced out of schools. Among these, 42% live in overcrowded homes, 12% in poverty, 7% in domestic environments at greater risk of abuse (9).
Second, irrespective of the magnitude of the estimates - scattered across a wide range of variability - of the contribution of school closure to reduced attack rates of the infection, they cannot be simply converted in corresponding risk of increased infection attack rates consequent to school reopening, since schools and preschool services should be not be reopened just as they were before, but following a series of safety requisites regarding teachers, accompanying caregivers, school environment and children themselves.
Third, the risk of school reopening should be measured against the risk of uncontrolled child socialization which will occur anyway, particularly when parents go back to work after lockdown and children are left with grandparents, neighbors or simply remain alone.
Finally, schools and school life represent not only a pillar of community development but also an important part of community identity. The Covid-19 pandemia will cause directly and indirectly a dramatic burden of disease and an economic catastrophe for many countries. A sensible, gradual but prompt reopening of preschool and school activities will not only reduce the risk of a dramatic crisis in child rights (2) but also contribute to restore hope in our communities.
The multidimensional adverse consequences for children of the Covid-19 pandemia have been highlighted at global level by international agencies, but they do not seem to be taken in adequate consideration at country level. Based on global knowledge about the features of the Covid-19 infection and on local epidemiological data, guidelines should be prepared for school reopening at country and local level, with a more holistic perspective of families’ and children’s needs.
A different balance must be found between the risk of increasing the number of Covid-19 cases and causing serious prejudice to children's rights.
References
1. Munro APS, Faust SN Children are not COVID-19 super spreaders: time to go back to school. Archives of Disease in Childhood Published Online First: 05 May 2020. doi: 10.1136/archdischild-2020-319474
5. Rosenthal DM, Ucci M, Heys M, Hayward A, Lakhanpaul M. Impacts of Covid- 19 on vulnerable children in temporary accommodation in the UK. Lancet Public Health 2020 March 31 https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30080-3/fulltext
6. Van Lancker W, Parolin Z. Covid-19, school closures, and child poverty: a social crisis in the making. Lancet Public Health 2020 Apr 7 https://doi.org/10.1016/S2468-2667(20)30084-0
7. Green P. Risks to children and young people during Covid-19 pandemic. BMJ 2020;369:m1669 doi: 10.1136/bmj.m1669 (Published 28 April 2020)
Prediction rules to identify young febrile infants with serious bacterial infections (SBI) have been developed by investigators globally. Comparisons of these rules should be conducted by independent parties to avoid conflicts of interest. Two newer prediction rules use procalcitonin (PCT) as an important variable: one rule,[1] created by the authors of the Velasco[2] paper, and the PECARN Febrile Infant Rule[3] created by the authors of this letter. There are important methodological issues which must be considered when evaluating Velasco’s validation of the PECARN study. 1) The Velasco study was a retrospective analysis of a registry at one hospital in Spain, while the PECARN study was prospectively conducted at 20 centers in the United States and analyzed by an independent data center (mitigating investigator bias). 2) The rate of SBI in the Velasco study was 20.5%, much higher than the 9.3% reported by the PECARN study[3] and other investigators.[4] This suggests a different patient population or SBI epidemiology than ours, and/or enrollment bias. 3) Although the PECARN rule (using the urinalysis, absolute neutrophil count [ANC] and PCT) was derived on febrile infants 0-60 days-old, we recommend implementation only on 29-60 day-old infants, as suggested in our article.[3] In the supplement to our article, the PECARN rule using rounded cutoffs (ANC of 4000 cells/mm3 and PCT of 0.5 ng/mL) for simplicity, safety and to decrease the risk of overfitting, performed with simi...
Show MoreScott-Jupp et al. recent paper (Effects of consultant residence out-of-hours on acute paediatric admissions1) appeared relevant to myself as a junior doctor at the end of my training. I am interested to know whether there was learning from the resident consultant around discharge behaviour to better understand the differences?
There were approximately 40% of admissions that stayed less than 12 hours and this group were more likely to be discharged when a consultant was resident. There was no significant difference in discharge rates in children who stayed more than 12 hours1.
Should the less ill children be attending acute services anyway? Would a service consisting of resident consultants feed into propping up the acute pathway for less ill children?
A prospective observational study found up to 42.2% of ED presentations over a 14 day period were judged to have been totally avoidable if the family had had better health education2. Studies have previously looked at the appropriateness of paediatric OPD new referrals and suggest that at least 39% of them could be managed by primary care3.
I wonder whether the expansion of paediatric consultant posts due to increased ED attendance have unwittingly made secondary care reluctant to challenge the status quo of paediatric care delivery despite clear evidence that hospital is not always appropriate? If paediatric ED attendance starts to go down, would the current system become redundant? Other models...
Show MoreTo the editor
Show MoreWe appreciated the Images in paediatrics ‘Necrosis of infantile haemangioma with propranolol therapy’ by Grech and colleagues1. Nevertheless, we take exception to the Authors’ statement that necrosis is due to propranolol induced-involution for several reasons: first of all, the infant was not receiving a full-dose medication (1.5 mg/kg/day) when propranolol should be given at minimum 2 mg/kg/day. Furthermore, the milestone study by Léauté-Labrèz et al showed that a daily regimen of 3 mg/kg is safe and effective in reducing haemangiomas in a cohort of 456 infants2. We do believe that considering the low dose and the proliferative phase the infant was in3, necrosis was most likely due to natural evolution of the haemangioma than drug-induced involution. The authors do not give precise measurements of the scalp lesion before and during treatment, so it is not clear how much the lesion diminished in size. In view of previous considerations, it is difficult to rule out that the lesion might just have followed its natural course. As a matter of fact, both prematurity and female gender are well known risk factors associated with ulceration4.As the authors properly underline, propranolol therapy is the treatment of choice for infantile haemangioma (IH) and adverse effects as hypoglycemia, hypotension and bradycardia are widely known. Ulceration is the most common complication of IH and so that it could be even considered an indication to continue rather than...
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...
Show MoreDear 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?”
Show MoreAs 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...
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...
Show MoreWe 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.
Show MoreThe 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...
e-Letter
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
Show MoreDear 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...
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.
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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