1581 e-Letters

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

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

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  • Low Prevalence of Kingella kingae Infections in UK Children


    Low Prevalence of Kingella kingae Infections in UK Children

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

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

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

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

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

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

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

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

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

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

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

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

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  • Other mechanisms for coeliac disease-related hypocalcaemia

    For the sake of completeness, the account of underlying causes of hypocalcaemia(Table 2)(1) should also include hypoparathyroidism-related hypocalcaemia attributable to magnesium deficiency(2), and coeliac disease-related hypocalcaemia which is not attributable to vitamin D deficiency(3). The role of hypoparathyroidism was documented in a 12 year old patient in whom hypoparathyroidism was thought to be attributable to inhibition of parathyroid hormone(PTH) release as a result of coeliac disease(CD)-related magnesium malabsorption. This patient had been admitted with hypocalcaemia, hypomagnesemia, hyperphosphataemia and subnormal serum vitamin D level of 8 mg/ml(normal 20-45 ng/ml). The plasma parathyroid hormone(PTH) level(14.6 pg/ml; normal > 12 pg/ml) was only minimally elevated, which was inappropriate in relation to the plasma calcium level of 5.1 mg/dl. Sm,all bowel biopsy showed moderate villous atrophy. Despite treatment with gluten free diet(GFD), and replacement therapy comprising vitamin D, calcium, magnesium , and aluminium hydroxide as a phosphate binder, calcium and magnesium levels were initially persistently low and phosphorus levels were persistently high. Furthermore, serum PTH levels also subsequently became undetectable. It was only after magnesium levels and calcium levels rose that phosphorus levels and serum PTH levels normalised. The authors hypothesised that CD had been the underlying cause of both the hypocalcaemia and...

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  • Cowpox inncoluaiton scare 1806

    I welcome this important historical paper emphasising the continued extreme importance of immunisation over more than 2 centuries in effectively preventing avoidable death and disability in children .
    I was very surprised though, that the authors omitted a short paper published in the ADC in 2004 which related an 1806 inoculation scare in Northampton UK,. Northampton General Infirmary commenced giving free cowpox inoculations to the poor from 1January 11th 1804. In January 1806 there was an inoculation scare that led to a marked drop in public confidence after rumours of the death of a child Peter Bell. This was thoroughly investigated by the Infirmary Committee and in the Northampton Mercury of 10th January 1806 his parents had published a signed declaration that their son's death was nothing at all to do with the cowpox inoculation.
    Public confidence was then restored

    Williams A.N, A Vaccine Scare in 19th Century Northampton Arch Dis Child. 2005 Nov;90(11):1204.

  • Preventing infant regulation problems: considering the roles of biology and parenting

    Infant sleeping, crying and feeding problems can be hugely concerning for parents. As Wolke points out,(1) a growing body of evidence points to a range of poor longer term outcomes for infants who experience persistent, severe, regulatory difficulties. Olsen and colleagues’ study(2) is important because it aims to help our understanding of the early factors that predict persistent regulatory difficulties. If we can identify these early risk factors, perhaps we can better focus our efforts to prevent these difficulties from arising.

    There have been several attempts to prevent infant sleeping and crying difficulties via parent education and support programs. Randomized controlled trials of these programs have reported small increases in infant sleep duration, increased likelihood of ‘sleeping through the night’,(3–5) reduced parent depressive symptoms, and less doubt about parenting ability at bedtime.(6) Parent education programs may modestly reduce infant sleep difficulties. Whether these infants are then less likely to develop complex regulatory problems that precede poor childhood outcomes, remains to be tested.

    We agree with Wolke’s assertion that ‘there is a major need to educate parents on how to support infants in regulatory adaptation.’ Parenting practices such as having a consistent bedtime routine, and encouraging independent settling, have been shown to improve infant sleep.(7) However, we must consider that some infants’ sleep difficulties may have...

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  • Response to Professor Cook et al.'s letter

    Dear Editor,
    We thank Professor Cook et al. for their letter in response to our Archimedes paper. We agree that waveform capnography may have benefit in earlier detection of oesophageal intubation or unplanned extubations in neonates, as has been assumed in adults. However, this assumption will require further study. Following an UK expert panel meeting, we are looking forward to investigating the use of waveform capnography monitoring in neonates.
    As previously discussed in correspondence with Dr Whitaker, there are two pertinent questions to answer here for the neonatal population:
    1) In neonates (P), does the addition of waveform capnography (I) compared to current methods of detection (colourimetric capnography, ventilator measurements, oxygen saturations and clinical examination) (C) provide an advantage in earlier detection of oesophageal intubation or unplanned extubation (O)?
    2) Does the displayed numerical value in waveform capnography correlate with PaCO2 reliably enough to guide ventilator changes?
    In our review, we specifically sought to address the second question. Those familiar with contemporary neonatal practice will know that many NICUs use transcutaneous capnography. Question 2 has a particular pertinence in neonates as their physiology is different from the adult and even paediatric population. Neonates are particularly prone to rapid changes in PaCO2, due to their changing lung compliance. Due to their lack of cerebral auto...

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

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

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