I agree with the editorialists that bed sharing is a decision that
each parent must make based on their own risk profile and the benefits
that they receive. A dogmatic single message approach is not appropriate
for this widespread practice when it has such a small affect on absolute
risk of SIDS in many families. I would like to bring to their attention a
very useful app (available for android and apple devices) from the...
I agree with the editorialists that bed sharing is a decision that
each parent must make based on their own risk profile and the benefits
that they receive. A dogmatic single message approach is not appropriate
for this widespread practice when it has such a small affect on absolute
risk of SIDS in many families. I would like to bring to their attention a
very useful app (available for android and apple devices) from the infant
sleep lab at Durham University, called Infant Sleeplab. It includes a risk
stratification tool for parents on bed-sharing as well as other evidence-
based information on infant sleep. https://www.isisonline.org.uk/app/
Conflict of Interest:
I have used the Infant Sleeplab app and associated website to inform my own parenting decisions. I have shared a bed with my second child since she was a few weeks of age.
I read with great interest the arguments whether 0.9% saline with 5%
dextrose would be a more appropriate choice than 0.45% saline with 5%
dextrose for maintenance fluids in hospitalized children. In 1975, WHO and
the United Nations Children's Fund (UNICEF) decided to promote a single
ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80,
base 30, and glucose 111 (2%) for use among diverse populations....
I read with great interest the arguments whether 0.9% saline with 5%
dextrose would be a more appropriate choice than 0.45% saline with 5%
dextrose for maintenance fluids in hospitalized children. In 1975, WHO and
the United Nations Children's Fund (UNICEF) decided to promote a single
ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80,
base 30, and glucose 111 (2%) for use among diverse populations. This
composition enabled a single solution to be used for treatment of
diarrhoea caused by different infectious agents and associated with
varying degrees of electrolyte loss. WHO-ORS has been demonstrated during
>25 years of use to be safe and effective at rehydration and
maintenance for children and adults with all types of infectious
diarrhea.1 However, more recent multiple controlled trials summarized in a
meta-analysis by Hahn et al has supported adoption of a lower osmolarity
ORS with proportionally reduced concentrations of sodium and glucose.2
Lower osmolarity ORS was associated with less vomiting, less stool output,
and reduced need for unscheduled intravenous infusions compared with
standard ORS among infants and children with non-cholera diarrhoea. In
cholera infection, there was no clinical difference between subjects
treated with the lower osmolarity solution and those treated with the
standard solution, apart from an increased incidence of asymptomatic
hyponatremia.3 On the basis of these findings, UNICEF and WHO convened a
technical meeting of experts on oral rehydration at New York that
recommended a reduced osmolarity solution for global use.4 In May 2002,
WHO announced a new ORS formulation consistent with these recommendations,
with 75 mEq/L sodium, 75 mmol/L glucose, and total osmolarity of 245
mOsm/L.5 The newer WHO-ORS was also recommended for use in treating adults
and children with cholera. The need for unscheduled supplemental IV
therapy in children given this solution was reduced by 33%. In a combined
analysis of this study and studies with other reduced osmolar-ity ORS
solutions (osmolarity 210-268 mOsm/l, sodium 50-75 mEq/l) stool output was
also reduced by about 20% and the incidence of vomiting by about 30%. The
245 mOsm/l solution also appeared safe and at least as effective as
standard ORS for use in children with cholera. It would now appear that
the earlier argument on WHO-ORS has come a full circle with JA Morgan's
article that presents current evidence that strongly favours the use of
isotonic fluids (0.9% saline with 5% dextrose) as standard for intravenous
maintenance fluid prescription in children, and 0.45% saline with 5%
dextrose and other similar hypotonic solutions should be reserved for
specific cases and used on a case-by-case basis.6 The one thing that is
universally agreed is that the use of 0.18% saline is not recommended as
standard maintenance fluid either by WHO or by Morgan.
References
1. Managing Acute Gastroenteritis Among Children:
Oral Rehydration, Maintenance, and Nutritional Therapy. Morbidity and
Mortality Weekly Report. Recommendations and Reports November 21, 2003 /
Vol. 52 / No. RR-16
2. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration
solution for treating dehydration due to diarrhoea in children: systematic
review. BMJ 2001; 323: 81-5.
3. Alam NH, Majumder RN, Fuchs GJ. Efficacy and safety of oral
rehydration solution with reduced osmolarity in adults with cholera: a
randomised double-blind clinical trial. CHOICE Study Group. Lancet 1999;
354:296-9.
4. World Health Organization. Reduced osmolarity oral rehydration
salts (ORS) formulation. New York, NY: UNICEF House, 2001. Available at
http://www.who.int/child-adolescent-
health/New_Publications/NEWS/Expert_consultation.htm.
5. World Health Organization. Oral rehydration salts (ORS): a new
reduced osmolarity formulation. Geneva, Switzerland: World Health
Organization, 2002.
6. Jessie Anne Morgan. Question 2: Should 0.9% saline be used for
maintenance fluids in hospitalised children? Arch Dis Child 2015; 100:715-
717 doi:10.1136/archdischild-2015-308821
I just have a simple question for Dr Morgan in relation to her
Archimedes article entitled "Should 0.9% saline be used for maintenance
fluids in hospitalised children?"[1]. Is she telling me that the
recommended maintenance sodium intake for a 10kg child who would normally
be prescribed 1000 mls/day of fluid based on 100 mls/kg/day, is 150 mmol
or 15 mmol/kg/day. This is far in excess of the recommended NaCl intake of
2g...
I just have a simple question for Dr Morgan in relation to her
Archimedes article entitled "Should 0.9% saline be used for maintenance
fluids in hospitalised children?"[1]. Is she telling me that the
recommended maintenance sodium intake for a 10kg child who would normally
be prescribed 1000 mls/day of fluid based on 100 mls/kg/day, is 150 mmol
or 15 mmol/kg/day. This is far in excess of the recommended NaCl intake of
2g per day for a child aged 1-3 years which equates to 34 mmol/day [2]. I
suggest that more thought should be given to the prescribing of
maintenance fluids rather than blindly giving 0.9% saline. The
recommendations to only give 0.9% saline are based on misunderstandings of
salt and water handling and are just trying to cover up poor training in
fluid and electrolyte prescribing. I would refer readers to a review
written by Dr Malcolm Coulthard for this journal back in 2008 following a
decision by the National Patient Safety Agency to recommend a switch in
the standard paediatric intravenous maintenance fluid from 0.18% to 0.45%
saline to prevent children from developing serious hyponatraemia.
REFERENCES
1. Morgan JA. Should 0.9% saline be used for maintenance fluids in
hospitalised children?" Arch Dis Child doi:10.1136/adc.2015.308821
2. NHS Choices. Salt: the facts. NHS Choices. Your Health, your choices.
Available from http://www.nhs.uk/livewell/goodfood/pages/salt.aspx
(accessed 22 May 2015)
3. Coulthard MG. Will changing maintenance intravenous fluid from 0.18% to
0.45% saline do more harm than good? Arch Dis Child 2008;93:335-340.
I have always been confused at the bad reputation acquired by oral
salbutamol which, in the UK, has been confined to pharmacological oblivion
on the contradictory premises that it is both ineffective and responsible
for unacceptable side effects. Paradoxically, intravenous salbutamol is
becoming evermore popular in the treatment of severe asthma. Given the
acceptance that intravenous salbutamol is effective, oral salbutam...
I have always been confused at the bad reputation acquired by oral
salbutamol which, in the UK, has been confined to pharmacological oblivion
on the contradictory premises that it is both ineffective and responsible
for unacceptable side effects. Paradoxically, intravenous salbutamol is
becoming evermore popular in the treatment of severe asthma. Given the
acceptance that intravenous salbutamol is effective, oral salbutamol will
also be effective as long as there is not complete first pass metabolism,
which there is clearly not if it can cause adverse effects.
Ample published data attest to the fact that oral salbutamol is
effective. Much of which has beehn summarised in a presentation to the WHO
(1) The accepted teaching is that children of any age can be trained to
use an mdi and spacer and that in the UK this should be the only method of
administering salbutamol to children in the community. However, in reality
many families struggle with this, and in many instances it is a job that
requires more than the number of available adults. If the process of
administration appears traumatic parents will be wary of administering it,
and If the child screams during administration they will only get a small
amount of salbutamol into the lungs- though some may go into the stomach
through the backs of the throat. Furthermore despite being trained in the
use of mdis and spacers, field studies show that many families forget how
to use them which can mean the child receiving no medication at all.
In these situations oral salbutamol can provide an easy effective
alternative to an mdi and spacer. I would suggest that oral salbutamol has
a role to play in UK practice as well.
1. Should Oral Salbutamol Remain on the WHO Pediatric Model List?
Sani s Second Meeting of the Subcommittee of the Expert Committee on the
Selection and Use of Essential Medicines
Geneva, 29 September to 3 October 2008
http://www.who.int/selection_medicines/committees/subcommittee/2/Salbutamol_review.pdf
(accessed 3.8.15)
We read with interest the article by Puntis and Zamvar(1), reporting
their experience of children with congenital sucrase-isomaltase deficiency
(CSID) including response to enzyme replacement therapy with Sucraid
(sucrasidase). We report our own experience of a child with CSID which
offers an additional perspective and therapeutic option.
Our patient is a girl who was diagnosed with CSID at 8 months of age. She
was refer...
We read with interest the article by Puntis and Zamvar(1), reporting
their experience of children with congenital sucrase-isomaltase deficiency
(CSID) including response to enzyme replacement therapy with Sucraid
(sucrasidase). We report our own experience of a child with CSID which
offers an additional perspective and therapeutic option.
Our patient is a girl who was diagnosed with CSID at 8 months of age. She
was referred with a history of persistent diarrhoea beginning in the first
few weeks of life. She was passing watery, non-bloody stools 15-20 times
per day. She was initially formula fed. Upper gastrointestinal endoscopy
was macroscopically normal as was histology from gastric and duodenal
mucosa. Analysis of duodenal disaccharidases revealed low sucrase and
isomaltase levels (0 and 13 respectively, normal ranges 18-66 and 60-180,
all units nmol/min/mg protein) with a normal lactase in keeping with CSID.
Dietary carbohydrate manipulation under dietetic supervision resulted in
no symptomatic improvement. Enzyme replacement was then commenced with
invertase (11,600 units three-times/day) with good clinical response and
complete resolution of her diarrhoea. She is now 2 years old, thriving,
and tolerating normal diet without diarrhoea. During a brief period where
invertase was unavailable locally she received Sucraid which unfortunately
resulted in an increase in her diarrhoea. This resolved when restarting
invertase.
Invertase (beta-fructofuranosidase), like sucrasidase, is a yeast
derived enzyme, usually derived from Saccharomyces strains(2,3,4). It
catalyses the hydrolysis of sucrose, but does this by cleavage of the
fructose CO bridge rather than the glucose CO bridge targeted by
sucrase(4,5). Invertase has the potential to offer considerable cost
savings in the treatment of CSID. Treatment for our patient costs
approximately 75GBP/month (11,600 units three times/day) compared to
600GBP/month for Sucraid (8,500 units with meals)(1) while remaining
clinically effective. We suggest invertase is a viable alternative to
Sucraid for this condition.
References
1. Puntis JWL, Zamvar V. Congenital sucrose-isomaltase deficiency:
diagnostic challenges and response to enzyme replacement therapy. Arch
Dis Child 2015; 100:869-871.
2. Gascon S, Neumann NP, Lampen JO. Comparative study of the
properties of the purified internal and external invertases from yeast.
The Journal of Biological Chemistry 1968; 243(7):1573-1577.
3. Treem W et al. Evaluation of liquid yeast-derived sucrase enzyme
replacement in patients with sucrase-isomaltase deficiency.
Gastroenterology 1993;105:1061-1068.
4. Kulshrestha S et al. Invertase and its applications - a brief
review. Journal of Pharmacy Research 2013; 7(9):792-797.
5. Koshland DE, Stein SS. Correlation of bond breaking with enzyme
specificity. Cleavage point of invertase. Journal of Biological
Chemistry 1954; 208(1):139-148.
I came upon this article by chance and realised it is infact my
daughter Emilys case.She was born on 10/11/11 and passed away from nkh on
16/11/11.Knowing her case has been used to highlight non ketotic
hyperglycinemia is very heartwarming.I am in daily contact with families
with children living with this terrible condition and they all remain
positive a cure will eventually be found,i am aware researchers in the uk
hav...
I came upon this article by chance and realised it is infact my
daughter Emilys case.She was born on 10/11/11 and passed away from nkh on
16/11/11.Knowing her case has been used to highlight non ketotic
hyperglycinemia is very heartwarming.I am in daily contact with families
with children living with this terrible condition and they all remain
positive a cure will eventually be found,i am aware researchers in the uk
have begun to study this disease which is very positive as up until now DR
Van Hove who is based in the USA has been our only source of information
and breakthroughs regarding non ketotic hyperglycinemia.
Dear Editor,
We read with interest the article by Dowd and coll. (1) and we would like
to share the results of a similar study we carried out in a cluster of
Primary Schools in Florence, Italy, that show similarities with those
reported by Dowd. Our aim was to assess possible correlations between
mothers' BMI and their child's BMI; children's BMI and correctness of
mothers' perception of their child nutritional status pe...
Dear Editor,
We read with interest the article by Dowd and coll. (1) and we would like
to share the results of a similar study we carried out in a cluster of
Primary Schools in Florence, Italy, that show similarities with those
reported by Dowd. Our aim was to assess possible correlations between
mothers' BMI and their child's BMI; children's BMI and correctness of
mothers' perception of their child nutritional status perception; mothers'
BMI and correctness of their perception of their own child's weight
status. We included children aged 6-11. Mothers were asked to define their
child's nutritional status as "slender", "just right" or "chubby".
Mothers' BMIs were categorized as underweight (<18.5), normal (18.5-
24.9), overweight (?25). Children's BMIs were turned into centile for age
and sex (WHO charts). Children were classified as underweight
(?15.9thcentile), normal (16th-84.9th), overweight (?85th). Finally, we
classified as correct mothers' perceptions when "slender" corresponded to
a "underweight" child, "just right" corresponded to a "normal" BMI child
or "chubby" corresponded to an "overweight" child. In all the remaining
cases the perceptions of mothers were considered incorrect.
209 mother-children couples (mean age of children 8,45 years, males=52.6%)
were analyzed; 29.7% children and 33.9% mothers had a BMI resulted
overweight.
Accordingly to Dowd's study, mothers with overweight BMI were more likely
to have a child with overweight BMI (78.3%) than normal-weight mothers
(58.1%;OR 2.59,CI95% 1.4-4.8).
However, overweight mothers were more likely to have a correct perception
of their child's nutritional status (65.2%) than normal-weight mothers
(46,1%; OR 2.18,CI95% 1.24-3.83).
Finally, mothers were more likely to have a correct perception of their
child's real nutritional status when their child had a normal BMI (72.1%)
than when their child was overweight/obese (18.8%;OR 11.1,CI95% 5.49-
22.63).
Our research shows that the excess of weight in a child brings higher odds
of poor perception of the nutritional status of the child itself by
mother. On the contrary, our data suggest that overweight mothers have a
better perception of their children's nutritional status. We speculate
this might be because in our population overweight mothers have a good
awareness of the risks of their condition leading them to be more
sensitive to their child weight.
Reference
1-Dowd KP, Kirwan RP, Hannigan A, Purtill H, O'Gorman CS. The association
between maternal perceptions of own weight status and weight status of her
child: results from a national cohort study. Arch Dis Child 2015
doi:10.1136/archdischild-2015-308721
Andrew Riordan writes, as ever, with excellent good sense about the
duration of courses of antibiotics. (1)
Doctors who have trained with me will have heard me talk about this.
We are falsely comforted by some numbers, which are highly likely to
themselves to be false. The "true" duration of antibiotic therapy ought
to be an awkward number - 3.4 days, or 8.7 days. It shouldn't be a neat...
Andrew Riordan writes, as ever, with excellent good sense about the
duration of courses of antibiotics. (1)
Doctors who have trained with me will have heard me talk about this.
We are falsely comforted by some numbers, which are highly likely to
themselves to be false. The "true" duration of antibiotic therapy ought
to be an awkward number - 3.4 days, or 8.7 days. It shouldn't be a neat
number like 5, 7, 10 or 14.
This leads to a second thought. Why are we comforted by 5, 7, 10,
and 14?
5 and 10 are easy. They are because we like to work in base 10.
This is because we (mostly) have ten fingers. (as an aside, it would be
much more convenient to have evolved to be interested in base 12, since 10
is only divisible by 2 and 5, whereas 12 is divisible by 6, 4, 3 and 2.
Anyone who uses this argument to advance continuing with imperial
measurements has forgotten the 16 ounces in a pound, the 14 pounds in a
stone, the three feet in a yard, and so on.)
7 and 14 are slighty less easy. The obvious answer is we like them
because the week is 7 days long. But why is the week 7 days? Biblical
answers aside, it is to do with the lunar cycle, which is actually 29.5
days but approximated to our ancestors as 28 days, breaking nicely into
four quarters.
So I give you a challenge. The next time you see some crusty old
fool (like me, for example) proclaiming on a ward round "This patient must
have 7 days of antibiotics, and not 5" do a little translation in your
head, and try to hear "This patient must have a quarter of a lunar cycle
of antibiotics, and not the same number of days as I have fingers on one
hand" instead. You'll get an interesting insight into how you need to
judge things clinically and not by silly rules.
Now, don't start me on the fact that you're "allowed" 10 white cells
in the CSF...
Ian Wacogne
Consultant Paediatrician
1. Riordan A. 5, 7, 10 or 14 days: appropriate duration of
treatment for bacteraemia or an example of 'antimicrobial bingo'?
Arch. Dis. Child. 2015 0:archdischild-2015-309132v1-archdischild-2015-
309132; doi:10.1136/archdischild-2015-309132
Conflict of Interest:
I do not believe I have any competing interests in this matter, but I am a deputy editor across the ADC group.
According to the current paradigm vitamin A supplementation works by
preventing vitamin A deficiency, and it was predictable that the lack of
effect of neonatal vitamin A supplementation in the recent African trials
was interpreted as being due to absence of vitamin A deficiency. It
follows that there may still be a role for NVAS in deficient subgroups(1).
The Archivist approves this conclusion.
According to the current paradigm vitamin A supplementation works by
preventing vitamin A deficiency, and it was predictable that the lack of
effect of neonatal vitamin A supplementation in the recent African trials
was interpreted as being due to absence of vitamin A deficiency. It
follows that there may still be a role for NVAS in deficient subgroups(1).
The Archivist approves this conclusion.
However, there are alternative interpretations. First, there is no
overall correlation between vitamin A status and the effect of neonatal
vitamin A supplementation (2). For instance, the randomised trial showing
the strongest effect was conducted in Indonesia in a setting with no
maternal vitamin A deficiency (3), and the recent Tanzanian trial, which
found one of the worst effects, had quite considerable maternal vitamin A
deficiency (4). Second, while absence of vitamin A deficiency could
explain that there was no effect of vitamin A supplementation it is hard
to see how it could explain the tendency for increased mortality after
neonatal vitamin A supplementation, which reaches significance in a meta-
analysis of the African trials (data not shown). Third, another finding
which cannot be explained from the current perspective is that the effect
of neonatal vitamin A supplementation becomes worse with age in females.
Haider and Bhutta's meta-analysis included only follow-up to 6 months of
age. But all studies with follow-up to 12 months and data presented by sex
find increased female mortality between 6 and 12 months of age (Benn et
al. Lancet, in press).
Thus, there is no data to support that the effects of neonatal
vitamin A supplementation can be explained merely from the perspective of
underlying vitamin A deficiency. Additionally there is substantial
evidence that vitamin A is an immune-modulator (5,6). The heterogeneous
results of the neonatal vitamin A supplementation trials certainly suggest
that there are important environmental factors, apart from underlying
vitamin A deficiency, which modulate the response to neonatal vitamin A
supplementation, and worryingly the effect may be harmful in some
contexts. Thus, introducing neonatal vitamin A supplementation in
presumably deficient populations may cause unwarranted effects if we do
not understand the mechanisms.
References
(1) Haider BA, Bhutta ZA. Neonatal vitamin A supplementation: time to move
on. The Lancet 2015; 385(9975): 1268-71.
(2) Benn CS. Combining Vitamin A and Vaccines: Convenience or Conflict?
Dan Med J 2012; 59(1): B4378.
(3) Humphrey JH, Agoestina T, Wu L, et al. Impact of neonatal vitamin A
supplementation on infant morbidity and mortality. J Pediatr 1996; 128:
489-96.
(4) Masanja H, Smith ER, Muhihi A, et al. Effect of neonatal vitamin A
supplementation on mortality in infants in Tanzania (Neovita): a
randomised, double-blind, placebo-controlled trial. Lancet 2015; 385: 1324
-32.
(5) Raiten DJ, Sakr Ashour FA, Ross AC, et al. Inflammation and
Nutritional Science for Programs/Policies and Interpretation of Research
Evidence (INSPIRE). J Nutr 2015; 145(5): 1039S-108S.
(6) Arts RJ, Blok BA, van Crevel R, et al. Vitamin A induces inhibitory
histone methylation modifications and down-regulates trained immunity in
human monocytes. J Leukoc Biol 2015; doi: 10.1189/jlb.6AB0914-416R.
We read with interest Turtle and colleagues recommendations on
screening for and management of aortic dissection (AD) in Turner syndrome
(TS)[1]. The authors recommend multiple pediatric cardiac MRIs for girls
with TS, but do not discuss the costs, harms, or effectiveness of such a
program. The cost of at least two to three cardiac MRIs for low risk girls
alone would be high, but could be much higher if extra clinical fol...
We read with interest Turtle and colleagues recommendations on
screening for and management of aortic dissection (AD) in Turner syndrome
(TS)[1]. The authors recommend multiple pediatric cardiac MRIs for girls
with TS, but do not discuss the costs, harms, or effectiveness of such a
program. The cost of at least two to three cardiac MRIs for low risk girls
alone would be high, but could be much higher if extra clinical follow-up
and extra interventions with their complications are added. More
concerning is the lack of information about whether this screening
program, at any cost, will benefit those with TS.
Appealing alternatives to universal screening include targeted
screening. Given that AD occurs at 40/100,000 per year in TS [2], bicuspid
aortic valve (BAV) is present in 95% of cases of dissection[3] and BAV is
present in 30% of patients with TS[4], the incidence of dissection in
those without BAV can be estimated to be 2/70,000 = 2.9/100,000 per year.
This is approximately equal to the reported general population risk of
2.9/100,000 per year [5]. Given that echocardiogram is 94% sensitive for
BAV in TS [4], a very low risk group can already be identified. Using
other risk factors such as hypertension, aortic dilatation diagnosed on
echocardiogram, and age in addition to presence of BAV could provide an
even more efficient targeted screening program.
Protection of girls with TS from AD is an important aim. However,
universal MRI screening does not meet at least two of the Wilson-Jungner
criteria for a screening test [6]: evidence that the risks outweigh the
benefits and that the costs are balanced against the benefits. Given that
AD in TS is a rare event in a special population, definitive information
on screening may never exist. However, uncertainty should be met with
careful consideration of all possible options, including targeted
screening.
References:
1. Turtle EJ, Sule AA, Webb DJ, Bath LE. Aortic dissection in
children and adolescents with Turner syndrome: risk factors and management
recommendations. Arch Dis Child. 2015:archdischild - 2014-307080 - .
doi:10.1136/archdischild-2014-307080.
2. Gravholt CH, Landin-Wilhelmsen K, Stochholm K, et al. Clinical and
epidemiological description of aortic dissection in Turner's syndrome.
Cardiol Young. 2006;16(5):430-436. doi:10.1017/S1047951106000928.
3. Carlson M, Airhart N, Lopez L, Silberbach M. Moderate aortic
enlargement and bicuspid aortic valve are associated with aortic
dissection in Turner syndrome: report of the international turner syndrome
aortic dissection registry. Circulation. 2012;126(18):2220-2226.
doi:10.1161/CIRCULATIONAHA.111.088633.
4. Sachdev V, Matura LA, Sidenko S, et al. Aortic valve disease in
Turner syndrome. J Am Coll Cardiol. 2008;51(19):1904-1909.
doi:10.1016/j.jacc.2008.02.035.
5. Meszaros I, M?rocz J, Szl?vi J, et al. Epidemiology and
clinicopathology of aortic dissection. Chest. 2000;117(5):1271-1278.
http://www.ncbi.nlm.nih.gov/pubmed/10807810. Accessed May 19, 2015.
6. Wilson J, Jungner G. Principles and practice of screening for
disease. Geneva: World Health Organization, 1968. Public Health Pap. 2011.
/citations?view_op=view_citation&continue=/scholar%3Fhl%3Den%26as_sdt%3D0,5%26scilib%3D1%26scioq%3DPrinciples%2Band%2Bpractice%2Bof%2Bscreening%2Bfor%2Bdisease.%2BGeneva&citilm=1&citation_for_view=u
-P2C-wAAAAJ:u5HHmVD_uO8C&hl=en&oi=p. Accessed March 21, 2015.
I agree with the editorialists that bed sharing is a decision that each parent must make based on their own risk profile and the benefits that they receive. A dogmatic single message approach is not appropriate for this widespread practice when it has such a small affect on absolute risk of SIDS in many families. I would like to bring to their attention a very useful app (available for android and apple devices) from the...
I read with great interest the arguments whether 0.9% saline with 5% dextrose would be a more appropriate choice than 0.45% saline with 5% dextrose for maintenance fluids in hospitalized children. In 1975, WHO and the United Nations Children's Fund (UNICEF) decided to promote a single ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80, base 30, and glucose 111 (2%) for use among diverse populations....
I just have a simple question for Dr Morgan in relation to her Archimedes article entitled "Should 0.9% saline be used for maintenance fluids in hospitalised children?"[1]. Is she telling me that the recommended maintenance sodium intake for a 10kg child who would normally be prescribed 1000 mls/day of fluid based on 100 mls/kg/day, is 150 mmol or 15 mmol/kg/day. This is far in excess of the recommended NaCl intake of 2g...
I have always been confused at the bad reputation acquired by oral salbutamol which, in the UK, has been confined to pharmacological oblivion on the contradictory premises that it is both ineffective and responsible for unacceptable side effects. Paradoxically, intravenous salbutamol is becoming evermore popular in the treatment of severe asthma. Given the acceptance that intravenous salbutamol is effective, oral salbutam...
We read with interest the article by Puntis and Zamvar(1), reporting their experience of children with congenital sucrase-isomaltase deficiency (CSID) including response to enzyme replacement therapy with Sucraid (sucrasidase). We report our own experience of a child with CSID which offers an additional perspective and therapeutic option. Our patient is a girl who was diagnosed with CSID at 8 months of age. She was refer...
I came upon this article by chance and realised it is infact my daughter Emilys case.She was born on 10/11/11 and passed away from nkh on 16/11/11.Knowing her case has been used to highlight non ketotic hyperglycinemia is very heartwarming.I am in daily contact with families with children living with this terrible condition and they all remain positive a cure will eventually be found,i am aware researchers in the uk hav...
Dear Editor, We read with interest the article by Dowd and coll. (1) and we would like to share the results of a similar study we carried out in a cluster of Primary Schools in Florence, Italy, that show similarities with those reported by Dowd. Our aim was to assess possible correlations between mothers' BMI and their child's BMI; children's BMI and correctness of mothers' perception of their child nutritional status pe...
Dear Editor,
Andrew Riordan writes, as ever, with excellent good sense about the duration of courses of antibiotics. (1)
Doctors who have trained with me will have heard me talk about this. We are falsely comforted by some numbers, which are highly likely to themselves to be false. The "true" duration of antibiotic therapy ought to be an awkward number - 3.4 days, or 8.7 days. It shouldn't be a neat...
According to the current paradigm vitamin A supplementation works by preventing vitamin A deficiency, and it was predictable that the lack of effect of neonatal vitamin A supplementation in the recent African trials was interpreted as being due to absence of vitamin A deficiency. It follows that there may still be a role for NVAS in deficient subgroups(1). The Archivist approves this conclusion.
However, there...
We read with interest Turtle and colleagues recommendations on screening for and management of aortic dissection (AD) in Turner syndrome (TS)[1]. The authors recommend multiple pediatric cardiac MRIs for girls with TS, but do not discuss the costs, harms, or effectiveness of such a program. The cost of at least two to three cardiac MRIs for low risk girls alone would be high, but could be much higher if extra clinical fol...
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