Cranial Ultrasound As Non-Invasive Diagnostic Technique In The
Diagnosis Of The Subdural Haemorrhages
I read with interest the original article entitled “Neuroradiological
aspects of subdural haemorrhages” in the Arch Dis Child 2005;90:947–95.
Datta et al. undertook a retrospective analysis of 74 patients under the
age of 2 years with subdural haemorrhage or subdural effusion diagnosed
between 1992 and...
Cranial Ultrasound As Non-Invasive Diagnostic Technique In The
Diagnosis Of The Subdural Haemorrhages
I read with interest the original article entitled “Neuroradiological
aspects of subdural haemorrhages” in the Arch Dis Child 2005;90:947–95.
Datta et al. undertook a retrospective analysis of 74 patients under the
age of 2 years with subdural haemorrhage or subdural effusion diagnosed
between 1992 and 2001.1 They described that ultrasound was performed
before computed tomography in 12 cases; subdural haemorrhages were not
seen in seven of these. However, ages of the patients ultrasound performed
were not presented. Datta et al. suggested that ultrasound has no role in
excluding a subdural haemorrhage, even in experienced hands, but may be
used to monitor resolution of subdural haemorrhage diagnosed on computed
tomography /magnetic resonanse imaging and in looking for subtle shearing
lesions at grey-white interface. I believe that it can not be generalized
about the capacity of cranial ultrasound because the numbers of the
patients in their retrospective study were less, and that the mean ages of
patient groups were important for choosing imaging tecnique. On the other
hand, in an epidemiological study by Hobbs et al. the definition used was
‘‘any child under 2 years at diagnosis with subdural haemorrhage,
haematoma, or effusion of any severity, arising from whatever cause and
diagnosed on computed tomography, magnetic resonanse imaging, or
ultrasound scan or at postmortem examination’’. This study was the largest
study of subdural haemorrhage in infancy in the UK.2 Cranial ultrasound
scan was a diagnostic technique in the diagnosis of the subdural
haemorrhage according to this study. However, Gaevyi et al. examined 275
children with acute craniocerebral trauma. And various types of
intracranial hemorrhages and contusions of the brain were differentiated
by means of cranial ultrasonography. They concluded that cranial
ultrasonography is a highly informative diagnostic method, particularly in
infancy, which makes it possible to visualize the craniocerebral injuries
and study them continuously during treatment. Intraoperative ultrasound
was conducted in older children with suspected intracranial hematoma,
which allowed the pathological process to be clearly located.3 Advanced
cranial ultrasound techniques such as high resolution ultrasound and
colour-doppler sonography may give useful prognostic information at
relatively early stages following the injury. Rupprecht et al. concluded
that high resolution ultrasound and colour-doppler sonography are able to
reliably differentiate between a subdural and a subarachnoid fluid
collection.4 I think that both the diagnosis and the follow-up of subdural
haemorrhage can be made by means of cranial ultrasonography, and that
ultrasound is a reliable non-invasive, cheap method for assessing subdural
haemorrhages in infancy, especially in newborn period. This assessment
approach might have the potential to be developed in to a valid
radiological assessment tool. Nevertheless, more studies are needed before
any conclusion can be drawn.
Correspondence to:
Ahmet Sert
Selcuk Universitesi Meram Tip Fakultesi
Cocuk Sagligi ve Hastaliklari
42080 Konya Turkey
1. Datta S, Stoodley N, Jayawant S, et al. Neuroradiological aspects of
subdural haemorrhages. Arch Dis Child 2005;90:947–51.
2. Hobbs C, Childs A-M, Wynne J, et al. Subdural haematoma and effusion in
infancy: an epidemiological study. Arch Dis Child 2005;90:952–5.
3. Gaevyi OV, Artarian AA, Korolev AG. Ultrasonography of the brain in
children with craniocerebral trauma. Zh Vopr Neirokhir Im N N Burdenko
1991;4:16-9.
4. Rupprecht T, Lauffer K, Storr U, et al. Extra-cerebral intracranial
fluid collections in childhood: differentiation between benign
subarachnoid space enlargement and subdural effusion using color-coded
duplex ultrasound. Klin Padiatr 1996;208(3):97-102.
In 2003, the Royal College of Paediatrics recommended “training in
adolescent health should be mandatory for undergraduates…”. Although the
recent article “Teaching medical students to examine children” briefly
acknowledged the challenges undergraduates face when examining
adolescents, the authors sadly did not take the opportunity to emphasise
the importance of such training. Rather, the authors sugg...
In 2003, the Royal College of Paediatrics recommended “training in
adolescent health should be mandatory for undergraduates…”. Although the
recent article “Teaching medical students to examine children” briefly
acknowledged the challenges undergraduates face when examining
adolescents, the authors sadly did not take the opportunity to emphasise
the importance of such training. Rather, the authors suggested that “it
may be sensible to consider whether what will be learnt from any
particular examination could be learnt equally well from adult patients at
a different period in training”. We would argue that there are significant
differences in the clinical assessment of adolescents as compared to that
of younger children and/or adults. As there are now more adolescents than
under 10s in the UK and greater proportions in ethnic minorities(1), it is
timely to consider how we can integrate adolescent health into the
undergraduate core curriculum.
For example, issues such as growth and development during adolescence
and the presentation of specific diseases during adolescence cannot be
demonstrated during examination of adults. With any consultation the
importance of establishing trust and empathy during the history taking to
facilitate the physical examination should not be forgotten, and this is
particularly true with young people who often perceive barriers in health
care(2). Health professionals should acknowledge that the physical
examination is a potential opportunity for young people to disclose health
concerns when their parents are not present. Furthermore, the physical
examination provides an opportunity to educate young people about their
bodies.
Young people value healthcare professionals who are supportive and
consistent; they also value communication which is honest, realistic and
jargon-free(3). Privacy and confidentiality is also of prime importance
to them and it is important not to assume a young person will always
choose their parent as a chaperone.
The presence of students has been reported to negatively impact
communication between adolescents and doctors(3,4). Young people however
are often more than willing to be a “case study” in a learning
environment, separate from their consultation, when they are learning the
skills to manage their own health.
We would therefore propose that the way to move adolescent medicine
and health care forward in the UK is to adequately train the medical
students of the present day. Rather than dismissing adolescents as too
complex for undergraduates, adolescent health should be considered as an
excellent teaching model to include in the core curriculum to explore
issues such as growth and development, ethics, transitional care,
professional attitudes, triadic consultation etc. Formal training in
adolescent health has been shown to be effective in improving doctors'
skills which are maintained after several years(5).
There are now many readily available resources to facilitate
adolescent health training at undergraduate level to educate medical
students before face-to-face contact with adolescent patients including
the excellent video clips on the www.youthhealthtalk.org website, hosted
by the DIPEX group at the University of Oxford, the use of adolescent
actors and the involvement of the young people themselves in the
assessment of trainees(6).
The outcome of the current GMC consultation exercise involving children
and young people regarding their views on how they think doctors should
behave will hopefully inform us about what young people want from
tomorrow’s doctors.
As we discussed previously simple messages can be conveyed by
inclusive terminology when discussing service provision as well as in
current medical literature i.e. children AND young people, paediatrics AND
adolescent health(7). As the RCPCH and the Department of Health work
together to develop training programmes in adolescent health and to ensure
health services are young person friendly(8); let us also ensure medical
education is too.
References:
(1)Coleman J, Schofield J. Key data on Adolescence 2005. Trust for
the Study of Adolescence, Brighton, UK, 2005
(2)Oppong-Odiseng ACK, Heycock EG. Adolescent health services –
through their eyes. Arch Dis Child 1997;77:115-119.
(3)Shaw KL, Southwood TR, McDonagh JE on behalf of the British
Paediatric Rheumatology Group. User perspectives of transitional care for
adolescents with juvenile idiopathic arthritis. Rheumatology (Oxford).
2004 Jun;43(6):770-778
(4)Beresford B, Sloper P. Chronically ill adolescents’ experiences
of communicating with doctors: a qualitative study. J Ado Health 2003;
33:172-179.
(5)Sanci L et al, Sustainability of change with quality general
practitioner education in adolescent health, Medical Education 2005;
39(6):557-560
(6)Blake K, Vincent N, Wakefield S et al. A structured communication
adolescent guide (SCAG): assessment of reliability and validity. Medical
Education 2005; 39: 482-491
(7)McDonagh JE, Walker V, Foullerton M et al. Young people – lost in
transition. Arch Dis Child 2006; 91(2): 201
(8)Royal College of Paediatrics and Child Health. Bridging the Gap:
Health Care for Adolescents. June 2003; Royal College of Paediatrics and
Child Health, Coming out of the shadows. A strategy to promote
participation of children and young people in RCPCH activity (June 2005)
www.rcpch.ac.uk
Taheri’s article: “The link between short sleep duration and obesity:
we should recommend more sleep to prevent obesity” shows an association
between less sleep and obesity not only in adults, but also in young
children (1). Short sleep duration at age 30 months predicts obesity at 7
years. Taheri postulates that sleep loss at this young age may alter the
hypothalamic regulation of appetite and energy e...
Taheri’s article: “The link between short sleep duration and obesity:
we should recommend more sleep to prevent obesity” shows an association
between less sleep and obesity not only in adults, but also in young
children (1). Short sleep duration at age 30 months predicts obesity at 7
years. Taheri postulates that sleep loss at this young age may alter the
hypothalamic regulation of appetite and energy expenditure. Modern Western
society is very complex. Thirty years ago parents were told to adhere to
very strict childrearing schedules. This approach was abandoned and
rightly so. However, now a child rearing approach without any structure at
all appears to be the norm. Excessive crying of an infant is a common
problem in many western societies and this is partially caused by the lack
of structure in baby care. Baby’s that cry excessively may also sleep
less. Furthermore, infants that persist in excessive crying (after four
months of age) often have sleep problems at an older age (2).
We recently published results of a randomized trial in which we
compared a standardized approach of regularity and stimulus reduction to
the same approach supplemented with swaddling in order to reduce excessive
crying and to improve sleep in 398 infants aged 1 week to 12 weeks (3).
Parents were coached in three face-to-face contacts and 6 telephone calls
how to apply the regularity and stimuli reduction. We applied a recurrent
pattern of baby care to provide structure and regularity without being
rigid or inflexible (not an on-the-hour schedule). Parents applied a
sequence of 1) sleep, 2) feeding, 3) playing/positive interaction with
baby, 4) alone and awake in a playpen, and 5) when tired, the baby was put
to bed and tucked in tightly, after which a new cycle started. Two hundred
and four infants received this intervention, for another 194 it was
supplemented with swaddling. Essential is the repetitiveness of the
elements; feeding the infant directly after waking up (under the
assumption that a well rested baby is able to drink more effectively), not
feeding to stop crying, and after being in the playpen putting the child
to bed sleepy but still awake. Sleep as reported by parents in 24-hour
diaries increased within one week with approximately one and a half hour
and after the intervention of 12 weeks sleep increased with approximately
2 hours (figure 1). Swaddling did not have an added benefit (table 1).
Besides improving sleep, several elements of this approach may be of
interest for the prevention of overweight and obesity. In the first place
we instructed parents to place the baby in the playpen and not in a baby
bouncer, maxi-cosi or other moving chair. In a playpen the child moves
himself instead of being moved. Furthermore, we taught parents not to use
feeding to stop the crying, as parents of excessively crying infants have
the tendency to offer extra feeds. Coping with crying is in fact the first
child-rearing problem a parent is confronted with. In fact, we pose that
enlarging knowledge of parents about self-regulation capacities of their
child and supporting parents’ self-efficacy in handling crying, might be a
key factor in the fight against obesity. In The Netherlands the approach
of regularity and stimuli reduction is being implemented in all well-baby
clinics.
We have just started a follow-up study, in which we will evaluate the
BMI of the children in the trial at age 3-5 years.
B.E. van Sleuwen & M.P. L’Hoir
References:
1) Taheri S. The link between short sleep duration and obesity: we
should recommend more sleep to prevent obesity. Arch Dis Child 2006;91:881
-4.
2) Barr RG. Crying in the fist year of life: good news in the midst
of distress. Child Care Health Dev 1998;24:425-39.
3) Sleuwen BE van, L’Hoir MP, Engelberts AC, Busschers WB, Westers P,
Blom MA, Schulpen TWJ, Kuis W. Comparison of behavior modification with
and without swaddling as interventions for excessive crying. J Pediatr
2006;149:512-7.
Corresponding author
M.P. L’Hoir, PhD
Wilhelmina Children’s Hospital University Medical Center Utrecht
Phillips et al have appropriately brought to light the lack of
consistency in treatment of chemotherapy induced febrile neutropenia in
children.(1) We agree with the authors that formulation of a national
guideline will help to simplify and streamline the approach to this common
problem in paediatric oncology.
The authors have suggested that it may be possible to treat some
children with anti...
Phillips et al have appropriately brought to light the lack of
consistency in treatment of chemotherapy induced febrile neutropenia in
children.(1) We agree with the authors that formulation of a national
guideline will help to simplify and streamline the approach to this common
problem in paediatric oncology.
The authors have suggested that it may be possible to treat some
children with antibiotic regimens of reduced intensity and duration, based
on risk stratification. However, most such studies quoted were based on
adult data. The few paediatric studies mentioned did not yield sufficient
data for formulating a clear cut risk assessment scheme. In this regard,
it might be worth pointing out that a recent extensive study in children
has proposed and validated an objective risk assessment scoring system
based on simple parameters.(2) This study identified 'low', 'intermediate'
and 'high' risk groups, with the latter two carrying a relative risk of 13
-fold and 50-fold respectively, for severe infectious complications.
Uniformity is also required with regard to the choice of antibiotics
according to risk. Most units in UK use a combination of a beta lactam
antibiotic with an aminoglycoside for the treatment of febrile
neutropenia. However, recent studies have demonstrated the relative
efficacy and safety of monotherapy with cefepime, a fourth generation
cephalosporin.(3) It has also been shown that lower risk febrile
neutropenias can be successfully treated with an initial brief period of
intravenous antibiotics, followed by 'stepping down' to oral ciprofloxacin
or cefixime.(4,5) It should be noted that cefepime, although in common use
in USA, is yet to be licensed for use in children in UK. The lack of
similar randomised trials from UK seems to be the limiting factor in
initiating a change of practice among paediatricians in favour of less
intense therapy. However, such a shift will have significant positive
impact on various parameters including cost effectiveness, turnover of in-
patient beds, length of hospital stay, reduced toxicity from treatment and
elimination of the need for aminoglycoside level monitoring. Monotherapy
is also known to reduce the potential for emergence of drug resistant
bacteria, as opposed to a combination of antibiotics.
It is hoped that the new unified guideline being prepared by United
Kingdom Childrens Cancer Study Group (UKCCSG) in collaboration with
Paediatric Oncology Nurses Forum (PONF) will attempt to address and
clarify these issues. In view of the substantial number of children with
neutropenic fever and the centralisation of care in tertiary paediatric
oncology units, a national study specifically looking at these aspects
seems quite feasible. This may provide the basis for changing the current
practice of over thirty years in favour of a new evidence based and risk-
directed approach.
(2) Rondinelli PI, Kde CR, de Camargo B. A proposed score for
predicting severe infection complications in children with chemotherapy
induced febrile neutropenia. J Pediatr Hematol Oncol 2006; 28(10) : 665-
670.
(3) Ariffin H, Ai CL, Lee CL, Abdullah WA. Cefepime monotherapy for
treatment of febrile neutropenia in children. J Paediatr Child Health
2006; 42(12) : 781-784.
(4) Paganini H, Rodriguez-Brieshcke T, Zubizaretta P. Oral
ciprofloxacin in the management of children with cancer with lower risk
febrile neutropenia. Cancer 2001; 91(8) : 1563-1567.
(5) Shenep JL, Flynn PM, Baker DK et al. Oral cefixime is similar to
continued intravenous antibiotics in the empirical treatment of febrile
neutropenic children with cancer. Clin Infect Dis 2001; 32(1) : 36-43.
We read with interest, the paper from Cardiff by Ravi Kumara et al
(1) on the presentation of Paediatric coeliac disease.
We did a similar retrospective study in the Wolverhampton region in
midlands, looking at children diagnosed with coeliac disease from 1992 -
2005. The total number of children diagnosed was 25. (4 children diagnosed
from 1992-1998 and 21 from 1999-2005).The ratio of boys to g...
We read with interest, the paper from Cardiff by Ravi Kumara et al
(1) on the presentation of Paediatric coeliac disease.
We did a similar retrospective study in the Wolverhampton region in
midlands, looking at children diagnosed with coeliac disease from 1992 -
2005. The total number of children diagnosed was 25. (4 children diagnosed
from 1992-1998 and 21 from 1999-2005).The ratio of boys to girls was
14:11. Six out of twenty-five children (24%) were of asian origin.
The median age at diagnosis was 43 months. Median age of diagnosis of
asian children was102 months as compared to 30 months in Caucasian
children.
Coeliac serology was positive in all children. Antiendomysial
antibodies were done in all children; Anti-tissue transglutaminase done in
9, while Antigliandin antibodies were done in 15 children.
Biopsy was positive in 18 children and is awaited in 7. All the
children who did not have biopsy done had presented with typical
gastrointestinal symptoms with positive serology.
Presenting features of the children were similar to Ravi kumara et al
study (1). Only 15 (60 %) presented with typical gastrointestinal symptoms
while 10 (40%) of the children had atypical symptoms at presentation. The
typical presentation included diarrhoea, failure to thrive, anorexia &
abdominal distention. The atypical presentation included short stature,
recurrent abdominal pain, irritable bowel syndrome, constipation and
persistent iron deficiency anaemia.
In four children (16%), persistent iron deficiency anaemia was the
presenting complaint, while iron deficiency anaemia was also noted in
eighteen (72%) of the children at initial investigation. Persistent iron
deficiency anaemia as a presenting feature is higher than Ravi kumara et
al (1 in 50).
Conclusion
Results are similar to the study by Ravi kumara et al (1). The sample
size is smaller as it represents population of a smaller city.
Iron deficiency anaemia was the most common finding in the children
and might be the only clue to diagnosis.
The study by Ravi kumara et al does not specify the ethnicity of
children. Our study has shown that 24% of the children in the study had
asian origins. This might be a reflection of ethnic composition of local
population. All these children had atypical presentations and were
diagnosed later.
Coeliac disease has been described in children from Asian countries
(2, 3) , however it has not been described in studies from UK. This may be
explained by paucity of knowledge of presentation of coeliac disease in
asian children, which may have atypical presentation. (3)
References:
1. Ravikumara M, Tuthill DP, Jenkins HR. The changing clinical
presentation of coeliac disease. Arch Dis Child 2006;91:969–71.
2. Amrinder Singh Puri, Sanjay Garg, Rajnish Monga, Pankaj Tyagi ,
Manoj Kumar Saraswat. Spectrum of atypical celiac disease in North Indian
children. Indian Pediatrics : Aug 2004;41:822 – 827
3. Poddar, Ujjal; Thapa, Babu Ram; Nain, Chander Kanwal; Prasad,
Arun; Singh, Kartar. Celiac Disease in India: Are They True Cases of
Celiac Disease? Journal of Pediatric Gastroenterology & Nutrition.
35(4):508-512, October 2002.
We welcome your interest in our paper(1) and in general agree with
your comments. However, in our paper we wanted to emphasise the actions,
which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood
tests for those with paracetamol level below the treatment line at 4 hours
post overdose and an overdose <150 mg/kg. However, t...
We welcome your interest in our paper(1) and in general agree with
your comments. However, in our paper we wanted to emphasise the actions,
which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood
tests for those with paracetamol level below the treatment line at 4 hours
post overdose and an overdose <150 mg/kg. However, the time of
ingestion is not always clear and paracetamol toxicity may follow multiple
doses or chronic use(2). If there is any doubt about either of these and
especially in younger children with viral infection receiving multiple
doses we suggest that it is sensible to repeat liver function tests after
24 hours.
We agree that in children who have taken paracetamol deliberatively
should undergo a psychosocial review prior to discharge, so repeating
liver function tests may not necessarily increase the hospital stay.
Should it be appropriate that they be discharged within 24 hours, than a
clinical judgement should be made on the need for repeat blood tests.
It is correct that blood tests may be repeated at the end of NAC
infusion.. But in those with the most severe illness especially where the
INR is above 2, an early blood test at 12 hours may guide further
management. This helps the team to contact a specialist liver centre for
advice and referral and in severe cases, facilitates continuation of NAC
without interruption.
S B K Mahadevan
P J McKiernan
D A Kelly
The Liver Unit
Birmingham Children’s Hospital
Steelhouse Lane
Birmingham B4 6NH
References:
1) S B K Mahadevan, P J McKiernan, P Davies, and D A Kelly
Paracetamol induced hepatotoxicity. Arch Dis Child 2006; 91:598-603.
2) Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with
acetaminophen: hepatoxicity after multiple doses in children. J Pediatr.
1998;132(1):22-7.
Dear Editor,
Cranial Ultrasound As Non-Invasive Diagnostic Technique In The Diagnosis Of The Subdural Haemorrhages I read with interest the original article entitled “Neuroradiological aspects of subdural haemorrhages” in the Arch Dis Child 2005;90:947–95. Datta et al. undertook a retrospective analysis of 74 patients under the age of 2 years with subdural haemorrhage or subdural effusion diagnosed between 1992 and...
Dear Editor,
In 2003, the Royal College of Paediatrics recommended “training in adolescent health should be mandatory for undergraduates…”. Although the recent article “Teaching medical students to examine children” briefly acknowledged the challenges undergraduates face when examining adolescents, the authors sadly did not take the opportunity to emphasise the importance of such training. Rather, the authors sugg...
Dear Editor,
Taheri’s article: “The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity” shows an association between less sleep and obesity not only in adults, but also in young children (1). Short sleep duration at age 30 months predicts obesity at 7 years. Taheri postulates that sleep loss at this young age may alter the hypothalamic regulation of appetite and energy e...
Dear Editor,
Phillips et al have appropriately brought to light the lack of consistency in treatment of chemotherapy induced febrile neutropenia in children.(1) We agree with the authors that formulation of a national guideline will help to simplify and streamline the approach to this common problem in paediatric oncology.
The authors have suggested that it may be possible to treat some children with anti...
Dear Editor,
We read with interest, the paper from Cardiff by Ravi Kumara et al (1) on the presentation of Paediatric coeliac disease.
We did a similar retrospective study in the Wolverhampton region in midlands, looking at children diagnosed with coeliac disease from 1992 - 2005. The total number of children diagnosed was 25. (4 children diagnosed from 1992-1998 and 21 from 1999-2005).The ratio of boys to g...
Dear Editor,
We welcome your interest in our paper(1) and in general agree with your comments. However, in our paper we wanted to emphasise the actions, which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood tests for those with paracetamol level below the treatment line at 4 hours post overdose and an overdose <150 mg/kg. However, t...
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