We welcome Dr Rees' October review as it highlights the need for a
radical re-think in safeguarding training if the paediatrician is to start
to contribute to the protection of children in the way she suggests.
Most maltreated children are seen by paediatric trainees and traditional
training has not equipped them or their seniors to view their role in the
way suggested. As well as recognition and response, training should...
We welcome Dr Rees' October review as it highlights the need for a
radical re-think in safeguarding training if the paediatrician is to start
to contribute to the protection of children in the way she suggests.
Most maltreated children are seen by paediatric trainees and traditional
training has not equipped them or their seniors to view their role in the
way suggested. As well as recognition and response, training should
include risk factors, burdens and consequences (1) focusing on the
interplay between the physical, psychological, emotional and social.
Teaching in this way will lead to improved paediatric assessments and more
meaningful management plans which consider both immediate and long term
outcomes.
The concept of the 'child protection medical' is a major barrier to doing
this as it implies Paediatricians are technicians who only look at the
presenting complaint. This hinders us and the multidisciplinary team from
thinking about the purpose or benefits of our consultation and
contribution to the child's overall assessment. Paediatricians are fearful
of child protection and may feel that there is not enough time to
undertake a complex consultation. This again is a misconception that lies
in the lack of wider knowledge of child maltreatment, so a full medical
history with relevant questions is not taken.
It is not just what we know that needs to change but clarity in how much
we can expect of paediatricians in their understanding of such a complex
and specialist subject. Rees article suggests the need for a new approach
which if taught from undergraduate level may lead to a generation of
doctors that may begin to understand maltreatment in the way suggested and
also identifies a role for the tertiary safeguarding paediatrician. This
is the key to practising modern safeguarding that can lead to better
outcomes for children.
References
1.Gilbert R, Spatz Widom C, Browne K, Fergusson D, Webb E, Janson S,
Burden and consequences of child maltreatment in high-income countries,
The Lancet, 2009; 373: 68 - 81.
Griffiths et al have studied conditional weight gain from birth to
the age of 3 years in babies from the Millennium Cohort Study and drawn
conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not
accounted for.
Weight must be clearly related to height. The authors report weight
(z score) at age 3 co...
Griffiths et al have studied conditional weight gain from birth to
the age of 3 years in babies from the Millennium Cohort Study and drawn
conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not
accounted for.
Weight must be clearly related to height. The authors report weight
(z score) at age 3 conditional on birthweight, however they have not
treated height in the same way, using only height (z score) at age 3. BMI
at age 3 was not used. This uses height (2) not height.
No account has been made of the genetic influence on growth. By the age of
3 years the genetic influence is evident on growth in height.2 Since no
data are presented for either maternal or paternal height this important
confounding effect has not been assessed.
The authors state that children not breastfed are both heavier and
fatter at 3 years. However the study does not include any measure of
fatness to justify this statement, the heavier babies could have had more
muscle/bone and even larger brains.
Child obesity is known to be associated with poverty and children
likely to be affected by this have been under-reported in this study.
The authors conclude that strategies to support mothers to follow
internationally recommended infant feeding practices are required. Very
few of the babies in this study were exclusively breastfed even to the age
of 4 months. This study does not assess the effects of current guidelines
(exclusive breastfeeding to the age of 6 months) on weight gain.
Yours sincerely
Dr C A Walshaw
Oakworth Surgery
Keighley
BD22 7HN
1 Griffiths L J, Smeeth L, Hawkins S S, Cole T J Dezatoux C. Effects
of infant feeding
Practice on weight gain from birth to 3 years. Arch. Dis. Child.
Doi:10.1136/adc.2008.
137554
2 Silventoinen K. Pietilainen KH, Tynelius P, Sorensen TI, Kaprio J,
Rasmussen F.
Genetic regulation of growth from birth to 18 years of age: the
Swedish young male
twins study. American Journal of Human Biology. May 2008, 20/3(292-
8), 1520-6300.
Dr Kemp and her colleagues have done us a great service over the
years in collating and analysing the evidence base related to
safeguarding.
I wonder however how they themselves translate their work into
practice. Consistently they report the likelihood that an abused child
will have such and such an injury. But in practice we must travel the
other direction. We must ask: in a child with such and such an inju...
Dr Kemp and her colleagues have done us a great service over the
years in collating and analysing the evidence base related to
safeguarding.
I wonder however how they themselves translate their work into
practice. Consistently they report the likelihood that an abused child
will have such and such an injury. But in practice we must travel the
other direction. We must ask: in a child with such and such an injury what
is the likelihood of abuse?
If most children are not abused and yet most have some injuries at
least occasionally, we must agree that the number of injuries caused
accidentally probably outnumbers those caused by abuse. If so injuries
commonly seen in abused children might be outnumbered by those caused
accidentally just because they occur in the numerically larger group.
In simple statistical terms the data presented does not allow one to
convert the pre test probability of abuse to a post test probability of
abuse. Without this, the data is interesting but of limited value.
We were interested to read the paper by Jones at al1 on âFrequent
medical absences in secondary school studentsâ. They conclude that âthis
study should prompt education departments and their NHS partners to look
more critically at the problem ⦠and to establish a system that provides
more comprehensive assessment and treatment.â
We were interested to read the paper by Jones at al1 on ‘Frequent
medical absences in secondary school students’. They conclude that ‘this
study should prompt education departments and their NHS partners to look
more critically at the problem … and to establish a system that provides
more comprehensive assessment and treatment.’
Within Bolton PCT such a system has been designed in order to
identify causes of frequent medical absences from school and to provide
interventions aimed at supporting students to achieve an earlier and
consistent return to school. Originally in Bolton (from the year 2000)
referrals were made by the Education Social Work Department to a Senior
Clinical Medical officer to undertake medicals on children with poor
school attendance reported as due to ill health. This provided evidence to
support an identified medical problem or for the LEA to issue a fixed
penalties notice to the parent or carer. Since the issue of school
attendance subsequently became a high priority policy concern for both the
DfES and the DoH this service was re structured to develop an innovative
Advanced Nursing Practitioner (with a school nursing background) led model
for the evaluation of health issues for children and young people with
poor school attendance. The main focus of the model was to enhance joint
working between the advanced practitioner, Education Social Worker,
schools and families. Changes have included a standardised threshold for
referral (when attendance falls to 80%), agreed minimum information sets
on referrals, agreed time frames for assessments and production of
correspondence, holistic assessment, onward referrals, investigations and
reintegration programmes to aide full return to school.
Over the last academic year 251 new referrals were received form the
Education Social Work department (previously 55 a year). There were two
peaks of referral (December 51, April 40). There were 120 referrals from
primary schools and 131 for secondary schools. Referrals included 122 boys
and 129 girls. Referrals to the service from 18 individual education
social workers varied from 1 - 41 (median 14). The main causes of school
absence were asthma, recurrent URTI, headache, sore throat, menstruation
problems, chronic fatigue, skin problems, emotional and behavioural
problems and inadequate provision for special needs within school. A
variety of onward referrals were made including ENT, community
paediatrics, dietetics, Young Carers, social care, occupational care,
physiotherapy, CAMHs and two admissions to hospital. Support packages of
care have been initiated for some together with supported reintegration
plans to enable the young person to return to regular school attendance.
Pathways are being devised for young people identified with ‘school
phobia’ (jointly with CAMHs) and also a menstruation pathway for girls
presenting with complex menstrual history.
In all cases of non attendance it is essential that preventative and
early intervention should be seen as the cornerstone of multiagency
working in order to ensure pupils right to education and to protect their
health and well being. The redesigned service in Bolton has made good
progress towards achieving these aims.
Reference
1.Jones R, Hoare P, Elton R, Dunhill Z, Sharpe M. Frequent medical
absences in secondary school students: survey and case control study. Arch
Dis Child 2009;94:763-767
We read with interest the publication by Ladomenou et al entitled
"Protective effect of exclusive breastfeeding against infections during
infancy" (1). The authors conclude that exclusive breastfeeding protects
infants against common infections and lessens the frequency and severity
of infectious episodes. This study, however, failed to reach a conclusion
about the potential protective role of breastfeeding on the sever...
We read with interest the publication by Ladomenou et al entitled
"Protective effect of exclusive breastfeeding against infections during
infancy" (1). The authors conclude that exclusive breastfeeding protects
infants against common infections and lessens the frequency and severity
of infectious episodes. This study, however, failed to reach a conclusion
about the potential protective role of breastfeeding on the severity of a
Urinary Tract Infection (UTI). We recently published our results (2)
concerning the role of breastfeeding on the development of renal lesions
in infants with UTI. Our conclusions, which show a protective effect of
breastfeeding in certain infants, may contribute to the study of
Ladomenou et al. We correlated the frequency of acute pyelonephritis (APN)
with the duration of breastfeeding in infants who experienced their first
episode of UTI. Findings of APN on Technetium-99m-dimercaptosuccinic acid
(DMSA) scintigraphy were documented in 45% of infants who were still on
breastfeeding during the infection, in 56% of infants who were being
breastfed in the past for different periods of time and in 70% of infants,
who had never been breastfed (p=ns). Among boys, APN was detected in 52%,
48% and 56% of infants with ongoing breastfeeding, different duration of
breastfeeding and no breastfeeding respectively (p=ns) whereas among girls
the corresponding values were 29%, 62.5% and 79% (p=0.008). Consequently,
a protective role of breastfeeding against the development of APN lesions
on DMSA scan was noted for girls with UTI. A possible explanation for our
failure to detect the same protective role in boys may be attributed to
mother's milk action on the intestinal flora in combination with the
anatomical differences in the lower urinary tract between the genders (3).
It is also well known that infant boys with first episode of UTI are
younger than girls (4) and consequently the protective role of
breastfeeding may be less obvious for them. Nevertheless, APN changes on
DMSA scan during a UTI is a multifactorial event and further prospective
studies are needed in order to clarify the role of breastfeeding.
LITERATURE
1. Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E.
Protective effect of exclusive breastfeeding against infections during
infancy: a prospective study. Arch Dis Child. 2010;95:1004-8
2. Doganis D, Delis D, Mavrikou M, Issaris G, Martirosova A, Stamoyiannou
L, Siafas K. The protective role of breastfeeding against pyelonephritis
in infants with urinary tract infection. Paediatriki. 2011;74:43-47.
3. Hanson LA. Protective effects of breastfeeding against urinary tract
infection. Acta Paediatr. 2004;93:154-6.
4. American Academy of Pediatrics. Committee on Quality Improvement.
Subcommittee on Urinary Tract Infection. Practice Parameter: the
diagnosis, treatment and evaluation of the Initial urinary tract infection
in febrile infants and young children. Pediatrics. 1999;103:843-52.
Prais et. al. present data showing an odds ratio of 2.8 for
hopitalization for urinary infection after circumcision by a traditional
mohel as compared to a medical practitioner. The 95% confidence interval
includes 1 and the p value is 0.06. The authors, admitting that the
results do not reach statistical significance, suggest that a larger study
would strengthen the finding. They do not admit that a larger study might
e...
Prais et. al. present data showing an odds ratio of 2.8 for
hopitalization for urinary infection after circumcision by a traditional
mohel as compared to a medical practitioner. The 95% confidence interval
includes 1 and the p value is 0.06. The authors, admitting that the
results do not reach statistical significance, suggest that a larger study
would strengthen the finding. They do not admit that a larger study might
equally well weaken the finding. Furthermore, their estimate of the
frequency of ritual versus medical circumcision in the population was
based on a sample from the Rabin Medical Centre, sited in the relatively
modern and secular central region of Israel where medical circumcision
might well be more popular, as compared to the other regions of the
country which were included in their survey of hospitalizations for post-
circumcision urinary infection. This bias could invalidate the results
altogether. The conclusion that ritual circumcision places the infant at
increased risk of urinary infection, attributed to poor dressing
techniques, is not sustained by the data and is suspect due to sampling
bias.
Dr. Bauchner and many other professionals inside and around pediatric
emergency medicine are asking: Why doesn?t staff members like parents
present in resuscitation?
Let us ask two other questions - one to the man on the street: What
would be worst: to meet your child dead after resuscitation or the
alternative: to meet your dead child dead AND to experience your dying
child under ongoing resuscitation?
The othe...
Dr. Bauchner and many other professionals inside and around pediatric
emergency medicine are asking: Why doesn?t staff members like parents
present in resuscitation?
Let us ask two other questions - one to the man on the street: What
would be worst: to meet your child dead after resuscitation or the
alternative: to meet your dead child dead AND to experience your dying
child under ongoing resuscitation?
The other question is directed to the staff:
What is more traumatic for you: unsuccessful resuscitation of a child or
unsuccessful resuscitation with the parents present?
I am sure we would get a wide spectrum of different opinions. But
these answers can give us some valuable viewpoints and two new dimensions
in addition to the academic results of traditional research.
A major finding of this study was: "Infants with dual infections (RSV
and hBoV) had a higher clinical severity score and more days of
hospitalisation"
In our hospital, and many others round the world, babies with RSV
infection are nursed in a room together and are not tested for Bocavirus.
Should this practice now stop to prevent Bocavirus crossinfection
increasing morbidity?
A major finding of this study was: "Infants with dual infections (RSV
and hBoV) had a higher clinical severity score and more days of
hospitalisation"
In our hospital, and many others round the world, babies with RSV
infection are nursed in a room together and are not tested for Bocavirus.
Should this practice now stop to prevent Bocavirus crossinfection
increasing morbidity?
We read the findings of the Feast Trial Group with interest and agree
with many comments that the results appear counter-intuitive. Given our
experience of managing children with hypovolaemic shock secondary to a
surgical cause, in Africa and beyond, we feel that it is necessary to
state that the findings of The FEAST trial should not be extrapolated to
hypovolaemic shock secondary to a surgical cau...
We read the findings of the Feast Trial Group with interest and agree
with many comments that the results appear counter-intuitive. Given our
experience of managing children with hypovolaemic shock secondary to a
surgical cause, in Africa and beyond, we feel that it is necessary to
state that the findings of The FEAST trial should not be extrapolated to
hypovolaemic shock secondary to a surgical cause (bowel obstruction,
trauma.)
The pathophysiology of hypovolaemia secondary to a surgical cause is
distinct from "impaired perfusion" secondary to severe infection. We
believe that withholding fluid bolus resuscitation from children with
hypovolaemic shock secondary to a surgical cause would result in excess
mortality.
To our concern, at a recent symposium on the management of
gastroschisis at our centre, the results of The FEAST Trial were being
used, out of context, to suggest reduced intravenous fluid resuscitation
in neonates with gastroschisis.
Yours faithfully,
Stewart Cleeve FRCS (Pead Surg),Children's Hospital, Oxford
University Hospitals, UK (stewart.cleeve@orh.nhs.uk)
Kokila Lakhoo PhD, FRCS, FCS, MRCPCH,Children's Hospital, Oxford
University Hospitals, UK (corresponding author -
kokila.lakhoo@paediatrics.ox.ac.uk)
It is simple to present male circumcision as the scientific and
sensible thing
to do. Indeed, the foreskin is one of those parts of the body, like wisdom
teeth and the appendix, that seem to be ripe for the plucking.
However, those who argue both for and against circumcision are likely
to
overstate their case. Guy Cox pointed out that some people have religious
and philosophical objections to circumcision. How...
It is simple to present male circumcision as the scientific and
sensible thing
to do. Indeed, the foreskin is one of those parts of the body, like wisdom
teeth and the appendix, that seem to be ripe for the plucking.
However, those who argue both for and against circumcision are likely
to
overstate their case. Guy Cox pointed out that some people have religious
and philosophical objections to circumcision. However, characterising this
opposition as “anti-Semitic or anti-Islamic” makes as much sense as
calling
someone who opposes slavery as anti-Christian, anti-Islamic and anti-
Semitic because the Bible and the Koran allow it.
The human foreskin is a natural part of a man’s penis. It is
therefore not
surprising that many people question the idea of removing it. Far from
being
as simple as an inoculation, circumcision is far from risk-free. Unless
the
operator is competent, and can control or eliminate infection and
bleeding,
the procedure is dangerous and even life-threatening.
The basic objection to infant circumcision is that the owner of the
foreskin is
the one to decide what to do with it. Medical huxterism may persuade a
grown woman that a ‘designer vagina’ is what she needs; however, the law
strictly prohibits genital cutting of underage girls. Paradoxically, the
genital
cutting of boys is accepted by custom and two powerful religions and even
the mildest criticism of male circumcision is likely to be decried as an
attack
upon faith.
Commonsense dictates that circumcisers must be up to the task.
However,
Great Britain may thank Omunnakwe Amechi for showing every quack in the
land that you don’t need medical qualifications to circumcise in Britain.
Even
better, quacks' handiwork isn't subject to oversight by the General
Medical Council.
<http://news.bbc.co.uk/2/low/uk_news/england/london/3244925.stm>
A judge in Ireland went one better. He instructed a jury not to bring
what he
called their white western values to bear on Osagie Igbinedion. As a
result, he
was found not guilty of reckless endangerment after his 4 week old son had
bled to death after Igbinedion circumcised him.
<http://www.rte.ie/news/2005/1007/igbinediono.html>
In the United States, cases have gone either way. Edwin Baxter, a
fervent
Christian was sentenced to jail for assault for circumcising his son
<http://www.cirp.org/news/thecolumbian12-16-04/> but the case
against
Jeffrey Henderson for circumcising his child was dismissed. Henderson said
that he was Hebrew and circumcised the child out of religious duty. The
judge found nothing in California’s legal code about circumcising a male
child, so he got off. <http://www.cirp.org/news/inlandvalleynews02-14-
05/>
Whether we are for or against circumcision, the procedure is not part
of a
Monty Python script. Circumcision needs to be properly regulated. And,
despite the advantages that are claimed for the procedure, the owner of
the
foreskin should ordinarily be the one to decide the fate of his foreskin.
We welcome Dr Rees' October review as it highlights the need for a radical re-think in safeguarding training if the paediatrician is to start to contribute to the protection of children in the way she suggests. Most maltreated children are seen by paediatric trainees and traditional training has not equipped them or their seniors to view their role in the way suggested. As well as recognition and response, training should...
Dear Editor
Griffiths et al have studied conditional weight gain from birth to the age of 3 years in babies from the Millennium Cohort Study and drawn conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not accounted for.
Weight must be clearly related to height. The authors report weight (z score) at age 3 co...
Dr Kemp and her colleagues have done us a great service over the years in collating and analysing the evidence base related to safeguarding.
I wonder however how they themselves translate their work into practice. Consistently they report the likelihood that an abused child will have such and such an injury. But in practice we must travel the other direction. We must ask: in a child with such and such an inju...
We were interested to read the paper by Jones at al1 on âFrequent medical absences in secondary school studentsâ. They conclude that âthis study should prompt education departments and their NHS partners to look more critically at the problem ⦠and to establish a system that provides more comprehensive assessment and treatment.â
Within Bolton PCT such a sy...
We read with interest the publication by Ladomenou et al entitled "Protective effect of exclusive breastfeeding against infections during infancy" (1). The authors conclude that exclusive breastfeeding protects infants against common infections and lessens the frequency and severity of infectious episodes. This study, however, failed to reach a conclusion about the potential protective role of breastfeeding on the sever...
Prais et. al. present data showing an odds ratio of 2.8 for hopitalization for urinary infection after circumcision by a traditional mohel as compared to a medical practitioner. The 95% confidence interval includes 1 and the p value is 0.06. The authors, admitting that the results do not reach statistical significance, suggest that a larger study would strengthen the finding. They do not admit that a larger study might e...
Dr. Bauchner and many other professionals inside and around pediatric emergency medicine are asking: Why doesn?t staff members like parents present in resuscitation?
Let us ask two other questions - one to the man on the street: What would be worst: to meet your child dead after resuscitation or the alternative: to meet your dead child dead AND to experience your dying child under ongoing resuscitation? The othe...
A major finding of this study was: "Infants with dual infections (RSV and hBoV) had a higher clinical severity score and more days of hospitalisation"
In our hospital, and many others round the world, babies with RSV infection are nursed in a room together and are not tested for Bocavirus. Should this practice now stop to prevent Bocavirus crossinfection increasing morbidity?
Conflict of Interest:
...Dear Editor,
We read the findings of the Feast Trial Group with interest and agree with many comments that the results appear counter-intuitive. Given our experience of managing children with hypovolaemic shock secondary to a surgical cause, in Africa and beyond, we feel that it is necessary to state that the findings of The FEAST trial should not be extrapolated to hypovolaemic shock secondary to a surgical cau...
It is simple to present male circumcision as the scientific and sensible thing to do. Indeed, the foreskin is one of those parts of the body, like wisdom teeth and the appendix, that seem to be ripe for the plucking.
However, those who argue both for and against circumcision are likely to overstate their case. Guy Cox pointed out that some people have religious and philosophical objections to circumcision. How...
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