1175 e-Letters

published between 2015 and 2018

  • Re: Conclusions not justified by findings

    Dear Editor,

    We thank Professor Wright for her comments, and we welcome the opportunity to provide some clarification and further analysis. 

    We reported Z-scores rather than percentiles, although some comments on approximate percentiles can be made.  Assuming that Z scores of -1.96 and -3 represent approximately the 2.5th and 0.2nd centiles respectively, 36/101 children were below the 2.5th centile, and 17/101 were below the 0.2nd centile for weight.  Additionally, our mixed effects model (accounting for multiple measurements) modelling the group trend over time estimated the mean weight Z score at 11 years to be -1.63 (approximately 5th centile). 

    Despite the overall short stature of the group, 24/101 children had a BMI Z score of less than -1.96.  So, by this approach, their weight was low even after taking into account stature.  We agree that we cannot infer causality from this observational study, but we believe a proportion of the stunted growth is explained by low weight. We are exploring other measures of malnutrition, such as skin-fold thickness. 

    Whilst our patient numbers are small, they do give some weight to the argument that PEG feeding halts the progression of malnutrition.  We investigated the rate of decline of weight after PEG insertion.  In a mixed effects model with a random intercept for individual patients, the rate of wei...

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  • Support for Dr. Goldwater's proposal that an acute respiratory infection may be a causative factor in SIDS

    I agree with Dr. Goldwater that an undetected prodromal respiratory infection can suddenly fulminate and cause acute anoxic encephalopathy. In such an instance, there may not be time for visible pulmonary histological pathology to form. Then if a lung culture is not performed or gives sepsis-negative results, the cause may be coded as SIDS rather than an ARI. See Farber S. Fulminating streptococcus infections in infancy as a cause of sudden death. N Engl J Med 211:154-158, 1934 and Mage et al. .Front Neurol. 2016 Aug 23;7:129. doi: 10.3389/fneur.2016.00129. eCollection 2016. PubMed ID 27602017

  • Tackling the childhood obesity crisis

    I wonder if this brief report by Harvey et al. highlights where we are going wrong. Firstly, the lack of response to the QIP may just reflect the fact that we have such limited ability to influence outcomes when it comes to childhood obesity. If you are working in a busy CAU it seems pointless doing things that are not going to produce a positive outcome.
    However my biggest concern is the statement: "How paediatricians act has a large impact on parents: we cannot expect them to prioritise their child’s obesity if we do not do the same." This appears to be the “nanny state” at work. The fact that parents are not recognising their children’s obesity, if this is really the case given the publicity this topic is receiving, is the main problem. This idea that patients are completely dependent on professionals to bring about change influences the outcome for many chronic conditions. Best results are obtained when patients (and carers) are actively involved in the management of the disease and are equipped to influence outcomes. This can only come about through education.
    My personal experience is that I cannot remember ever seeing an overweight child maintain any significant weight loss. The lack of parental recognition of the fact that their child is overweight is a major problem. I am not sure how long the comment "your child is overweight" stays with parents after they leave the clinic. Do parents feel that an overweight child reflects well on...

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  • Medical visits before diagnosis of type 1 diabetes mellitus in Taiwan

    The paper by Yang et al1 provided an interesting epidemiological picture regarding the healthcare use in the year before correct diagnoses are confirmed for childhood cancer, type 1 diabetes mellitus (T1DM) and other immune diseases. Despite the presence of known clinical presentations associated with these diseases, diagnoses are not usually made until after couples of medical visits, except in cases with T1DM. Nearly two thirds of newly diagnosed T1DM patients presented emergent diabetic ketoacidosis. This rate was similar to that reported in a single-center Taiwanese study2 but still much higher than those in the US and Europe.3,4 This finding raised a question whether diabetic ketoacidosis at diagnosis of T1DM was a result of missed recognition for diabetic symptoms. In this regard, I am surprised that common urological symptoms, such as proteinuria and polydipsia2, found in Taiwanese T1DM patients were not included in the ICD-9 codes grouped for the urogenital problems, although the data showed an increase in urogenital problems shortly before the diagnosis of T1DM.1 From a clinical perspective, it is also crucial to know how the access to healthcare before diagnosis differ between those with and without diabetic ketoacidosis.3 If the analysis can be stratified by this factor, we may better evaluate the performance and impact of pre-diagnostic outpatient visits on subsequent healthcare for T1DM. There is always room for improvement in terms of increasing awareness of...

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  • Authors Reply

    Thank you for your letter and for sharing your very personal experience.
    We agree with you that by the time the child who is choking is attended to by advanced medical practitioners the situation is often dire and that the best hope of a good outcome rests with prompt and effective attempts to dislodge the offending object.
    However, knowing that partial airway obstruction may quickly become complete airway obstruction, that (as in the cases we describe) First Aid measures may fail, and that even if the obstruction is relieved the consequences may be significant; we would also advocate that emergency services were alerted as early as possible.
    The Advanced Paediatric Life Support (APLS)1 guidance in the UK gives the clear advice with regard to first aid measures to be employed in the choking child.
    • If the foreign body is easily visible then carefully try to remove it.
    • If the child is coughing effectively and is conscious then encourage them to cough and monitor closely.
    • If the child has an ineffective cough but is still conscious then proceed as follows:
    o An infant should be laid horizontally with head down, supported with airway open (on the rescuer’s forearm or lap) and five sharp back blows delivered between the shoulder blades. If this fails then the infant is turned supine, still head down, and five chest thrusts (sharp and slower compressions using the same landmarks as for CPR) commenced.
    The Heimlich m...

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  • Question

    Dear Sir

    I'm Dr. Al-anbuqy Khalid working in HUDERF( Association Hospitalière de Bruxelles – Hôpital Universitaire des Enfants Reine Fabiola) with

    professor Henri Steyaert, MD, PhD ( Avenue Jean-Joseph Crocq, 15 1020 Brussels Belgium Phone : +3224773197

    Fax : +32 (0)2 477.34.49 Email : henri.steyaert@huderf.be) .We are making research over intussusception .

    My question is did you used premedication or sedation in your study in all or some patients(percentage if possible), and if yes what is /are the type of premedication or sedation did you used ?

    Best regards

    Al-anbuqy Khalid, researcher doctor

    Association Hospitalière de Bruxelles – Hôpital Universitaire des Enfants Reine Fabiola (HUDERF)
    Department of paediatric Surgery
    Adress :Avenue Jean-Joseph Crocq, 15,1020 Brussels,Belgium
    Email : Khalid.alanbuqy@huderf.be
    Phone: +32465133654

  • Response from the authors

    We are pleased to see the interest shown in our article by Drs Cheung and Lachman, but cannot agree with their assertion that our research ‘misses the point’.
    Despite widespread use, there remains limited research on the effectiveness of paediatric early warning systems (PEWS) in detecting deterioration in hospitalised children. Our paper sought to establish if there were statistically significance differences in performance between 18 published systems. Trigger systems were out-performed by scoring-systems in this relevant but narrow assessment. Our conclusion emphasizes that it is unclear what factors account for these differences in performance.
    Dr Cheung and others feel this observation of statistical inferiority of trigger system is not merited and the observed differences may be influenced by the scoring threshold selected. Dr Cheung illustrates this by comparison to the threshold selection of the C-reactive protein test as an indicator of inflammation. We found this to be rather confusing. The outcomes of trigger-based systems are, by their very nature, dichotomous. Whilst there is always a trade-off between sensitivity and specificity for scoring-based systems, the same does not apply to trigger-based systems. The system is either triggered or not. We note that Dr Cheung does not offer data to support his preference for trigger systems.
    We agree that managing deterioration in children is complex. However it is hard to imagine how this would be im...

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  • Dual-strain probiotics reduce NEC, mortality and neonatal bloodstream infections among extremely low birth weight (ELBW) infants

    Berrington and Ward Platt recently summarized current advances in the management of preterm infants born < 1000 g, so called extremely low birth weight (ELBW) infants (1). In this thoroughly done review, the authors highlighted the findings of the 2014 Cochrane review showing probiotics to reduce all-cause mortality and NEC in preterm infants, but not in the subgroup of ELBW infants (2). They hypothesized the lacking protective effect in this extremely vulnerable population to be attributable to their general immaturity, the timing of probiotic exposure or the small sample size of only 575 ELBW infants analyzed. Another recent meta-analysis did not show a significant beneficial effect of probiotics on sepsis in 771 ELBW infants included (3). This demands further studies with adequate power on the use of probiotics in infants born < 1000 g. Almost at the same time, we published a multi-center time series analysis supporting the beneficial effects of dual-strain probiotics on NEC, overall-mortality and nosocomial bloodstream infections (BSI) in preterm infants (4). Beyond that, we performed a subgroup analyses with 4683 ELBW infants. Routine use of dual-strain probiotics significantly reduced the risk of NEC (HR 0.48, 95 % CI 0.36 – 0.64), overall mortality (HR 0.59, 95 % CI 0.41 – 0.84) and nosocomial BSI (HR 0.83, 95 % CI 0.74 – 0.94) in this cohort. Further, probiotics also protected ELBW infants from mortality following NEC (HR 0.40, 95 % CI 0.19 – 0.85). Up to dat...

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  • Content vs Context in scoring systems

    The need to improve outcomes in child health is not disputed, especially in the UK where performance lags behind the rest of Europe [1]. Mechanisms which detect, and respond, to the deteriorating child in an effective manner should be validated and shared so we welcome further research by Chapman et al. [2] which demonstrates the complexity of producing tools which do this. However, we support the concern raised by Cheung and Lachman [3] in ensuring that appropriate conclusions are drawn from this work. As a research group funded to investigate these systems, from both a quantitative and qualitative viewpoint, we would like to highlight some of the dangers in use of terminology in this area. The concept that systems may be a better paradigm than scores (i.e. the amalgamation of observations into binary or composite measures which determine pre-defined actions) is not new [4] and it is already recognised that both afferent and efferent limbs are vital in order to complete what Joffe described as the, “chain of events needed to improve response to inpatient deterioration.” We note Maconochie and Lillitos use the term PES (Paediatric Early Warning System) and differentiate trigger systems from PEWS (Paediatric early warning scores). It is not however clear why trigger systems are treated as separate from PEWS as the literature contains numerous examples of where a trigger type system has been labelled as a PEWS [5]. While we entirely agree there is a challenge in labelling...

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  • Pulse oximetry in children under the magnifying glass

    Dear Authors.

    In your paper [1], you did not mention a previous prospective study performed by our group [2], on 148 otherwise healthy children referred to a Sleep Center for suspected OSA. In our study, pulse oximetry metrics were similar on the two consecutive nights. The McGill Oximery Score (MOS) on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive. We highlighted that the findings may not apply to younger infants, to adolescents, or to children with complex comorbidities.

    Our conclusions were different from yours for at least two main reasons.

    Firstly, you accepted oximetry recording lasting ≥ 4 hrs. On our opinion, this cut off is too low and it cannot be sufficiently representative of an overnight study. In our study [2], we accepted recordings lasting ≥ 6 hrs according to the ATS guidelines for sleep study.

    Secondly, you used a Nonin 9600 Pulse Oximeter with Nellcor neonatal-adult SpO2 sensor. In our study [2], we used a motion-resistant Radical 5 Masimo Pulse Oximeter. Previous studies [3,4], demonstrated the superiority of the Radical Masimo technology.

    We believe that your study was performed using suboptimal technology and the criteria for minimum acceptable recording time didn’t respect the ATS guidelines. Therefore, your results should be considered with caution.

    Convincing data already exist on pulse oximetry and the analysis of MOS as a useful tool for...

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