We read with interest the paper by Krishnan et al.1 and agree that "pulsus paradoxus" (PP) of the oximetry plethysmogram (pleth) may be useful in assessing severity of acute asthma exacerbations in children. The visual assessment they propose is one of a number of approaches which have been used, with variable success in predicting clinical outcomes2,3,4.
Rather than pulse amplitude variation associated with respiration, figure 2 in the paper1 shows predominately baseline undulation, at a rate of about 1/5 to 1/6 of pulse rate; no time base nor simultaneous respiratory waveform is included. Can the authors thus be sure that the variation is due to respiration, and if it is, could the baseline variations in fact be associated with respiratory-related changes in peripheral blood volume? As the visual pleth display is dependent on processing by the pulse oximeter, it would be helpful to know more about the oximeter used.
We have monitored respiration using Respiratory Inductance Plethysmography (RIP) bands simultaneously with oximetry pleth in children with acute wheezing illness using a SOMNOscreen plus recorder (SOMNOmedics GmbH, Germany) with Nonin oximeter module (Nonin Medical Inc., USA). We developed software in MATLAB (The MathWorks Inc., USA) for quantifying pleth pulse amplitude to assess pulsus paradoxus analogous variation. Consistent with Krishnan et al., we found that chil...
We read with interest the paper by Krishnan et al.1 and agree that "pulsus paradoxus" (PP) of the oximetry plethysmogram (pleth) may be useful in assessing severity of acute asthma exacerbations in children. The visual assessment they propose is one of a number of approaches which have been used, with variable success in predicting clinical outcomes2,3,4.
Rather than pulse amplitude variation associated with respiration, figure 2 in the paper1 shows predominately baseline undulation, at a rate of about 1/5 to 1/6 of pulse rate; no time base nor simultaneous respiratory waveform is included. Can the authors thus be sure that the variation is due to respiration, and if it is, could the baseline variations in fact be associated with respiratory-related changes in peripheral blood volume? As the visual pleth display is dependent on processing by the pulse oximeter, it would be helpful to know more about the oximeter used.
We have monitored respiration using Respiratory Inductance Plethysmography (RIP) bands simultaneously with oximetry pleth in children with acute wheezing illness using a SOMNOscreen plus recorder (SOMNOmedics GmbH, Germany) with Nonin oximeter module (Nonin Medical Inc., USA). We developed software in MATLAB (The MathWorks Inc., USA) for quantifying pleth pulse amplitude to assess pulsus paradoxus analogous variation. Consistent with Krishnan et al., we found that children with visually apparent respiratory modulation of the pleth signal were more likely to require intravenous therapy and high dependency care, and also had longer hospital stay5. We also observed that respiratory modulation of pleth was most evident during regular respiration periods, which could suggest an association with sleep state.
Respiratory modulation of the pleth signal is promising in assessment of acute wheezing illness in children, but its measurement is influenced by physiological and technical factors; these need further exploration before being adopted as a clinical tool.
1. Krishnan SG, Wong HC, Ganapathy S, Ong GY. Oximetry-detected pulsus paradoxus predicts for severity in paediatric asthma. Arch Dis Child. 2020 Jun;105(6):533-538. doi: 10.1136/archdischild-2019-318043.
2. Arnold DH, Jenkins CA, Hartert TV. Noninvasive assessment of asthma severity using pulse oximeter plethysmograph estimate of pulsus paradoxus physiology. BMC Pulm Med. 2010; 29:10:17. doi: 10.1186/1471-2466-10-17.
3. Arnold DH, Wang L, Hartert TV. Pulse Oximeter Plethysmograph Estimate of Pulsus Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to Treatment. Acad Emerg Med. 2016; 23:315-322. doi: 10.1111/acem.12886.
4. Uong A, Brandwein A, Crilly C, York T, Avarello J, Gangadharan S. Pleth Variability Index to Assess Course of Illness in Children with Asthma. J Emerg Med. 2018; 55:179-184. doi: 10.1016/j.jemermed.2018.04.058.
5. Wertheim D, Anton O, Olden C and Seddon P. Respiratory modulation of the pulse oximeter plethysmogram amplitude as a marker of severity in acutely wheezy young children. European Respiratory Journal 2020; 56: Suppl. 64, 1206. DOI: 10.1183/13993003.congress-2020.1206
We note with interest the conclusions made in the longitudinal cohort review published by Cook et al1 linking frequent night wakings in infancy with emotional disorders in later childhood. Our analysis of the paper questions whether the medical profession is overmedicalising normal sleep behaviours without fully identifying what is within normal limits.
Multiple potential confounders were not adjusted for in the analysis, including but not limited to: method of feeding, neonatal and infant medical history, sleep environment (co-sleeping and bedsharing) or the proportion of parents implementing sleep training methods. Additionally, statistical significance for these conclusions was reached by comparing the babies labelled with with ‘persistent severe sleep problems’ (19.4%) with those classed as ‘settled sleepers’ (23.7%), rather than the 56.0% of babies labelled with ‘moderate sleep problems’. Over half of the cohort were repeatedly waking at night, confirming that this is a common feature of normal infant behaviour. This paper provides a much-needed opportunity to discuss our social expectations of infant sleeping patterns and the increasing risk of overmedicalising normal sleep behaviours.
Modern western culture necessitates that adults sleep at night in order to function at work during the day. Societal changes over the last century have normalised the idea that babies too should sleep through the night, and this has slipped into the id...
We note with interest the conclusions made in the longitudinal cohort review published by Cook et al1 linking frequent night wakings in infancy with emotional disorders in later childhood. Our analysis of the paper questions whether the medical profession is overmedicalising normal sleep behaviours without fully identifying what is within normal limits.
Multiple potential confounders were not adjusted for in the analysis, including but not limited to: method of feeding, neonatal and infant medical history, sleep environment (co-sleeping and bedsharing) or the proportion of parents implementing sleep training methods. Additionally, statistical significance for these conclusions was reached by comparing the babies labelled with with ‘persistent severe sleep problems’ (19.4%) with those classed as ‘settled sleepers’ (23.7%), rather than the 56.0% of babies labelled with ‘moderate sleep problems’. Over half of the cohort were repeatedly waking at night, confirming that this is a common feature of normal infant behaviour. This paper provides a much-needed opportunity to discuss our social expectations of infant sleeping patterns and the increasing risk of overmedicalising normal sleep behaviours.
Modern western culture necessitates that adults sleep at night in order to function at work during the day. Societal changes over the last century have normalised the idea that babies too should sleep through the night, and this has slipped into the idea that a baby who is wakeful at night is somehow abnormal.
The concept that babies should self-settle away from caregivers and sleep through the night, is not the biological norm.2 These ideas, although now mainstream, ignore the fundamental role of the mother-baby dyad and the need for regular physical contact on neonatal development. It is entirely normal for babies to wake overnight, either to feed or for comfort.3
To better support the emotional challenges of early parenthood, the medical profession must appreciate the normal spectrum of neonatal and infant sleep patterns.4 By studying and understanding the social confounders around infant sleep, we can prevent the propagation of potentially unnatural and harmful ideas related to infant behaviour and development.
References
1. Cook F, Conway LJ, Giallo R, et al, Infant sleep and child mental health: a longitudinal investigation. Archives of Disease in Childhood 2020;105:655-660.
2. Bartick, M, Tomori, C & Ball, HL. Babies in boxes and the missing links on safe sleep: Human evolution and cultural revolution. Maternal & Child Nutrition 2017; 14: e12544 doi: 10.1111/mcn.12544.
3. Figueiredo B, Dias CC, Pinto TM, Field T. Exclusive breastfeeding at three months and infant sleep-wake behaviors at two weeks, three and six months. Infant Behav Dev. 2017;49:62-69. doi:10.1016/j.infbeh.2017.06.006
4. Marinelli, K. A., Ball, H. L., McKenna, J. J., & Blair, P. S. (2019). An Integrated Analysis of Maternal-Infant Sleep, Breastfeeding, and Sudden Infant Death Syndrome Research Supporting a Balanced Discourse. Journal of Human Lactation, 35(3), 510–520. https://doi.org/10.1177/0890334419851797
Re Functional Abdominal Pain: what clinicians need to know
In their article on the above subject, Andrews et al rightly emphasise that the majority of cases of recurrent abdominal pain in childhood are “functional” ie not associated with structural organic disease.
In placing this large number of potentially differing problems under one large umbrella I feel the authors are ignoring important subdivisions, each requiring a different approach. In particular, they only mention abdominal migraine twice in the whole article, and then only in passing.
The work of the late George Russell put abdominal migraine firmly on the map of UK paediatrics but it seems his message has been lost (1). With a prevalence of 4.1% of the population it seems likely that abdominal migraine is the commonest cause of children presenting with recurrent abdominal pain.
Rather than being a diagnosis of exclusion, abdominal migraine can be regarded as a positive clinical diagnosis based on a clear history. In typical cases the pain is clearly episodic and can come on in any situation. The pain is diffuse and central, and there is associated nausea and even vomiting, often associated with facial pallor and dark rings under the eyes. There is often a past history of travel sickness and usually a positive family history of migraine.
Parents seem to find being given a positive label and an explanation that makes sense to be maximally reassuring. Reassurance and explanation alo...
Re Functional Abdominal Pain: what clinicians need to know
In their article on the above subject, Andrews et al rightly emphasise that the majority of cases of recurrent abdominal pain in childhood are “functional” ie not associated with structural organic disease.
In placing this large number of potentially differing problems under one large umbrella I feel the authors are ignoring important subdivisions, each requiring a different approach. In particular, they only mention abdominal migraine twice in the whole article, and then only in passing.
The work of the late George Russell put abdominal migraine firmly on the map of UK paediatrics but it seems his message has been lost (1). With a prevalence of 4.1% of the population it seems likely that abdominal migraine is the commonest cause of children presenting with recurrent abdominal pain.
Rather than being a diagnosis of exclusion, abdominal migraine can be regarded as a positive clinical diagnosis based on a clear history. In typical cases the pain is clearly episodic and can come on in any situation. The pain is diffuse and central, and there is associated nausea and even vomiting, often associated with facial pallor and dark rings under the eyes. There is often a past history of travel sickness and usually a positive family history of migraine.
Parents seem to find being given a positive label and an explanation that makes sense to be maximally reassuring. Reassurance and explanation alone can result in clinical improvement because of the reduction is stress associated with worry about more serious conditions.
Management is similar to that of cranial migraine, consisting of reduction of stress, avoidance of trigger factors especially dietary ones, and prophylactic drug treatment if necessary (2).
References:
1) Abu-Arafeh I, Russell G “Prevalence and clinical features of abdominal migraine compared with those of migraine headache” Arch Dis Child, 1995;72(5):413-417
2) Symon DN, Russell G “Double blind placebo-controlled trial of Pizotifen syrup in the prophylaxis of abdominal migraine” Arch Dis Child, 1995; 72(1):44-50
In their report “Improving outcomes for children with asthma: role of national audit”(1), Sinha et al highlight the fact that the UK has one of the highest mortality figures from childhood asthma for high-income countries worldwide. They detect complacency regarding childhood asthma, and call for a targeted proactive model to improve matters.
The possible explanation for their observations regarding clinic attendance may be relevant to these wider issues.
The most likely explanation is that parents had not been given adequate safety netting advice regarding how to recognise and treat acute attacks. Such safety netting should have included parent- initiated steroids. Had this safety netting been in place, each of the cases reported would have already been started on oral steroids.
Another possibility is that the parents had not even been told that their child had asthma, or that asthma can kill. Many units seem to make children “earn” a diagnosis of asthma, after several years of being labelled “Viral associated wheeze”.
In my experience working as a locum around the UK, most units stop short of permitting parent- initiated steroids. Parents are simply told to use up to 10 puffs of a beta agonist and if this doesn’t work to “Seek medical advice”. However, this policy fails to recognise that severe attacks can occur in situations where medical help is not close at hand, for instance on holidays in remote places or abroad. Surely we...
In their report “Improving outcomes for children with asthma: role of national audit”(1), Sinha et al highlight the fact that the UK has one of the highest mortality figures from childhood asthma for high-income countries worldwide. They detect complacency regarding childhood asthma, and call for a targeted proactive model to improve matters.
The possible explanation for their observations regarding clinic attendance may be relevant to these wider issues.
The most likely explanation is that parents had not been given adequate safety netting advice regarding how to recognise and treat acute attacks. Such safety netting should have included parent- initiated steroids. Had this safety netting been in place, each of the cases reported would have already been started on oral steroids.
Another possibility is that the parents had not even been told that their child had asthma, or that asthma can kill. Many units seem to make children “earn” a diagnosis of asthma, after several years of being labelled “Viral associated wheeze”.
In my experience working as a locum around the UK, most units stop short of permitting parent- initiated steroids. Parents are simply told to use up to 10 puffs of a beta agonist and if this doesn’t work to “Seek medical advice”. However, this policy fails to recognise that severe attacks can occur in situations where medical help is not close at hand, for instance on holidays in remote places or abroad. Surely we should endeavour to make all families as self-reliant as possible in future emergencies rather than “doctor dependent”?
Parents of children with epilepsy are given advice on how to use buccal midazolam to shorten prolonged convulsions, and children with a risk of anaphylaxis are given adrenaline injectors to enable early life-saving intervention. Why do we not act similarly in all cases of childhood asthma?
Research in the 1980s may still be relevant today. In a study of asthma deaths in children in the Northern region, it was found that 80% of these deaths could have been prevented. The most important factor in these cases was lack of appropriate safety netting.
Perhaps the next audit should be on the content and distribution of safety netting for childhood asthma.
Dr Nigel Speight
Locum consultant
Durham
1) Sinha I et al, Arch Dis Child October Vol 105 No 10
2) “Survey of asthma deaths in the Northern region 1970-85”, H J Fletcher, S A Ibrahim, N Speight, Arch Dis Child 1990; 65: 163-167
I read with interest the review on functional abdominal pain and link to anxiety. However, there is no mention of the potential aetiology for anxiety.
In our school age paediatric neurodevelopmental clinic , children and young people with diagnoses of Autism Spectrum Disorder often present with escalating levels of anxiety in relation to school attendance that is reflected in a range of physical symptoms that may include abdominal pain, headaches and sleep disturbance . Indeed ,they have often been under the care of the acute paediatric service and prescribed a variety of medications. School attendance has often been affected and/or there have been concerns about learning and behaviour leading to referral to the Neurodevelopmental /Community Paediatric clinic
Once reasonable adjustments and environmental modifications have been implemented to support the individual , anxiety diminishes and physical symptoms improve. This has been most noticeable during the recent lockdown with many young people with ASD flourishing without the incapacitating anxiety that is associated with the busy, complex, social environment of school.
A detailed psycho - social and neurodevelopmental history and consideration of the possibility of Autism Spectrum Disorder is likely to be helpful for this group of children and young people.
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.
We read with interest the paper by Krishnan et al.1 and agree that "pulsus paradoxus" (PP) of the oximetry plethysmogram (pleth) may be useful in assessing severity of acute asthma exacerbations in children. The visual assessment they propose is one of a number of approaches which have been used, with variable success in predicting clinical outcomes2,3,4.
Rather than pulse amplitude variation associated with respiration, figure 2 in the paper1 shows predominately baseline undulation, at a rate of about 1/5 to 1/6 of pulse rate; no time base nor simultaneous respiratory waveform is included. Can the authors thus be sure that the variation is due to respiration, and if it is, could the baseline variations in fact be associated with respiratory-related changes in peripheral blood volume? As the visual pleth display is dependent on processing by the pulse oximeter, it would be helpful to know more about the oximeter used.
We have monitored respiration using Respiratory Inductance Plethysmography (RIP) bands simultaneously with oximetry pleth in children with acute wheezing illness using a SOMNOscreen plus recorder (SOMNOmedics GmbH, Germany) with Nonin oximeter module (Nonin Medical Inc., USA). We developed software in MATLAB (The MathWorks Inc., USA) for quantifying pleth pulse amplitude to assess pulsus paradoxus analogous variation. Consistent with Krishnan et al., we found that chil...
Show MoreDear Editor,
We note with interest the conclusions made in the longitudinal cohort review published by Cook et al1 linking frequent night wakings in infancy with emotional disorders in later childhood. Our analysis of the paper questions whether the medical profession is overmedicalising normal sleep behaviours without fully identifying what is within normal limits.
Multiple potential confounders were not adjusted for in the analysis, including but not limited to: method of feeding, neonatal and infant medical history, sleep environment (co-sleeping and bedsharing) or the proportion of parents implementing sleep training methods. Additionally, statistical significance for these conclusions was reached by comparing the babies labelled with with ‘persistent severe sleep problems’ (19.4%) with those classed as ‘settled sleepers’ (23.7%), rather than the 56.0% of babies labelled with ‘moderate sleep problems’. Over half of the cohort were repeatedly waking at night, confirming that this is a common feature of normal infant behaviour. This paper provides a much-needed opportunity to discuss our social expectations of infant sleeping patterns and the increasing risk of overmedicalising normal sleep behaviours.
Modern western culture necessitates that adults sleep at night in order to function at work during the day. Societal changes over the last century have normalised the idea that babies too should sleep through the night, and this has slipped into the id...
Show MoreRe Functional Abdominal Pain: what clinicians need to know
In their article on the above subject, Andrews et al rightly emphasise that the majority of cases of recurrent abdominal pain in childhood are “functional” ie not associated with structural organic disease.
Show MoreIn placing this large number of potentially differing problems under one large umbrella I feel the authors are ignoring important subdivisions, each requiring a different approach. In particular, they only mention abdominal migraine twice in the whole article, and then only in passing.
The work of the late George Russell put abdominal migraine firmly on the map of UK paediatrics but it seems his message has been lost (1). With a prevalence of 4.1% of the population it seems likely that abdominal migraine is the commonest cause of children presenting with recurrent abdominal pain.
Rather than being a diagnosis of exclusion, abdominal migraine can be regarded as a positive clinical diagnosis based on a clear history. In typical cases the pain is clearly episodic and can come on in any situation. The pain is diffuse and central, and there is associated nausea and even vomiting, often associated with facial pallor and dark rings under the eyes. There is often a past history of travel sickness and usually a positive family history of migraine.
Parents seem to find being given a positive label and an explanation that makes sense to be maximally reassuring. Reassurance and explanation alo...
Dear Editor
In their report “Improving outcomes for children with asthma: role of national audit”(1), Sinha et al highlight the fact that the UK has one of the highest mortality figures from childhood asthma for high-income countries worldwide. They detect complacency regarding childhood asthma, and call for a targeted proactive model to improve matters.
The possible explanation for their observations regarding clinic attendance may be relevant to these wider issues.
The most likely explanation is that parents had not been given adequate safety netting advice regarding how to recognise and treat acute attacks. Such safety netting should have included parent- initiated steroids. Had this safety netting been in place, each of the cases reported would have already been started on oral steroids.
Another possibility is that the parents had not even been told that their child had asthma, or that asthma can kill. Many units seem to make children “earn” a diagnosis of asthma, after several years of being labelled “Viral associated wheeze”.
In my experience working as a locum around the UK, most units stop short of permitting parent- initiated steroids. Parents are simply told to use up to 10 puffs of a beta agonist and if this doesn’t work to “Seek medical advice”. However, this policy fails to recognise that severe attacks can occur in situations where medical help is not close at hand, for instance on holidays in remote places or abroad. Surely we...
Show MoreI read with interest the review on functional abdominal pain and link to anxiety. However, there is no mention of the potential aetiology for anxiety.
In our school age paediatric neurodevelopmental clinic , children and young people with diagnoses of Autism Spectrum Disorder often present with escalating levels of anxiety in relation to school attendance that is reflected in a range of physical symptoms that may include abdominal pain, headaches and sleep disturbance . Indeed ,they have often been under the care of the acute paediatric service and prescribed a variety of medications. School attendance has often been affected and/or there have been concerns about learning and behaviour leading to referral to the Neurodevelopmental /Community Paediatric clinic
Once reasonable adjustments and environmental modifications have been implemented to support the individual , anxiety diminishes and physical symptoms improve. This has been most noticeable during the recent lockdown with many young people with ASD flourishing without the incapacitating anxiety that is associated with the busy, complex, social environment of school.
A detailed psycho - social and neurodevelopmental history and consideration of the possibility of Autism Spectrum Disorder is likely to be helpful for this group of children and young people.
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...
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