We read with interest an article on Dapsone therapy for Henoch-Schonlein
purpura: a case series by Iqbal et al.[1] They reported the clinical course
of 8 children with Henoch-Schonlein purpura (HSP) treated with dapsone due
to the severity or persistence of their symptoms. All gained clinical
response from treatment, but six of eight relapsed after treatment was
stopped and nephritis was observed in fi...
We read with interest an article on Dapsone therapy for Henoch-Schonlein
purpura: a case series by Iqbal et al.[1] They reported the clinical course
of 8 children with Henoch-Schonlein purpura (HSP) treated with dapsone due
to the severity or persistence of their symptoms. All gained clinical
response from treatment, but six of eight relapsed after treatment was
stopped and nephritis was observed in five patients. They suggested that
dapsone could control cutaneous vasculitis rather than cure it.
Recently, persistent purpura has been reported to be associated with the
renal involvement of HSP.[2] Rigante et al. reported that relapsing disease
was also significantly related to persistent purpura, but they could not
explain the association between renal involvement and relapse.[3] We
reported that patients with relapse had higher trend to develop
nephritis.[4] Nevertheless, Iqbal et al.[1] could not show a beneficial effect
of dapsone on renal disease, which might be a limitation of this drug
although it might suppress the generation of toxic free radicals in
neutrophils and synthesis of IgG and IgA antibodies.
We have also used dapsone in 15 children (age 2.7-11.2 years, 12 males 3
females) with HSP during the past 10 years and gained a similar response
to the results of Iqbal et al.[1] There was a positive effect of dapsone on
the skin rash, but six of 15 children relapsed and five developed
nephritis. Therefore, the use of dapsone should be reevaluated in children
with HSP, because dapsone could control cutaneous vasculitis, but did not
have any positive effect on relapse or nephritis, which determine the
prognosis of HSP.
References
1. Iqbal H, Evans A. Dapsone therapy for Henoch-Schonlein purpura: a case
series. Arch Dis Child 2005;90:985-86.
2. Sano H, Izumida M, Shimizu H, et al. Risk factors of renal involvement
and significant proteinuria in Henoch-Schonlein purpura. Eur J Pediatr
2002;161:196-201.
3. Rigante D, Candelli M, Federico G, et al. Predictive factors of renal
involvement or relapsing disease in children with Henoch-Schonlein
purpura. Rheumatol Int 2005;25:45-48.
4. Kim BH, Shin JI, Park JM, et al. Predictive factors for renal
involvement in children with Henoch-Schonlein purpura. Pediatr Nephrol
2004;19:C158.
The humble tongue-tie, like the foreskin, generates enormous
quantities of hot air, with little evidence to support it. I welcome the
decision by the Archives of Disease in Childhood to commission a
Perspective on Tongue-tie in the same month that NICE (1) has issued its
positive guidance on the same topic.
Hall and Renfrew begin by stating their bias. Mine is that the
Archives of Disease i...
The humble tongue-tie, like the foreskin, generates enormous
quantities of hot air, with little evidence to support it. I welcome the
decision by the Archives of Disease in Childhood to commission a
Perspective on Tongue-tie in the same month that NICE (1) has issued its
positive guidance on the same topic.
Hall and Renfrew begin by stating their bias. Mine is that the
Archives of Disease in Childhood rejected my two articles on tongue-tie, a
prospective series and a randomised control trial (2,3), both now
published by other peer reviewed journals, but which the Archives of
Disease in Childhood rejected following very poor quality “peer review”,
and compounded the error by referring me to my Medical Director as someone
who was performing procedures which were unethical. This charge was
rejected by my Trust.
The interesting question here is how to persuade an intelligent,
professional body (in this case, paediatricians), that what they were
taught has no evidence to support it. The old textbooks, as well as
advocating bottlefeeding, state that tongue-ties essentially never cause a
problem. Hall and Renfrew have looked at the new evidence and conclude
that the textbooks are partially right – many babies with tongue-ties can
feed adequately or normally – but that the textbooks are wrong to say that
tongue-ties never cause a problem. Some babies do indeed have a problem
which can be solved by a suitably trained person dividing the tongue-tie.
It is not necessary to look for tongue-ties at birth, but if feeding
problems are noticed then anyone skilled in helping mothers to feed will
need to exclude tongue-ties as one of the many possible causes. Division
is not advised at delivery, as babies can take several days to establish
the correct feeding rhythm, but do not wait as long as us (3 weeks) as
many mothers may give up before then (we waited till the mothers asked for
help, and accept that some did give up before we could randomise
them,(13/88, 15% )(3).
I would ask two questions.
Firstly, what do the authors mean by “precise case definition”. I think
this is the identification of the problems caused by a symptomatic tongue-
tie, and suggest a triad of poor latch (which includes signs of
frustration, like head-banging), painful nipple feeding (including
ulcerated, bleeding, cracked nipples, mastitis, and lipstick nipple) and
frequent or continuous feeds.
Secondly, I am keen to hear their suggestions for objective measures of
improvement in order to study “inter-observer reliability of pre and post
intervention assessment”. The Archives of Disease in Childhood when
pressed on this issue previously, could not suggest anything. Maternal
pain scoring produces a quantifiable number, but is subjective. Test
weighing babies is known to be stressful and is not practiced in this
country. However, the national or local rate of breastfeeding is well
documented (4) and should be an objective measure of painfree, successful
breastfeeding. This group of mothers are struggling to breastfeed because
of the pain and the time it takes. If the tongue-tie is divided but there
is no improvement in symptoms, then there is no reason for the
breastfeeding rate to be different from the national average or even
lower. In both my studies (2,3) and that of Masaitis (5), the
breastfeeding rate at 3-4 months was at least 60% (twice the national
average). Arguably, it may be that, like pain scores, all assessments
should be subjective, as only the mother can really assess the quality of
the feed.
Like the AAP Section on Breastfeeding Bulletin (6), Hall and Renfrew
conclude that tongue-ties which cause problems exist, and that these
problems cannot be predicted by a static view of the tongue-tie. The
problems are relieved by division, which is simple, safe and successful,
and should be performed by a suitably trained health professional. These
are all very reassuring conclusions to those involved in ensuring that as
many babies as possible are able to breastfeed successfully.
Now that the Archives and NICE have concurred that the division of tongue-
ties in symptomatic babies is no longer unethical, I hope that more units
will allow their Infant Feeding Specialists to be trained, so that mothers
and babies in the future will be able to breastfeed painlessly for as long
as possible.
Child Health Directorate
Wessex Regional Centre for Paediatric Surgery, G Level
East Wing
Mailpoint 44
Southampton General Hospital
Tremona Road
Southampton
SO16 6YD
2) Griffiths DM (2004). Do tongue ties affect breastfeeding? J Hum
Lact 20(4): 409-14
3) Hogan M, Westcott C, Griffiths DM (2005). Randomized, controlled
trial of division of tongue-tie in infants with feeding problems. Journal
of Paediatrics and Child Health 41 (5-6), 246-250.
4) Hamlyn B, Brooker S, Oleinikova K, Wands S. Infant Feeding 2000.
The Stationery Office Norwich. HMSO 2002.
5) Masaitis NS, Kaempf JW. Developing a frenotomy policy at one
medical centre: A case study approach. J Hum Lact 1996; 12:229-32.
6) Corrylos E, Genna C W, Salloum AC. Congenital tongue-tie and its
impact on breastfeeding AAP Section on Breastfeeding Bulletin summer 2004.
Like many others, this article makes the mistaken assumption that
medical career and training in UK is facilitated only by the official
"RCPCH approved" training pathways. It totally ignores the aspirations and
career plans of the huge workforce of doctors who are employed in so
called non-training posts. In many places they equal or at times outnumber
the Training grades.
Like many others, this article makes the mistaken assumption that
medical career and training in UK is facilitated only by the official
"RCPCH approved" training pathways. It totally ignores the aspirations and
career plans of the huge workforce of doctors who are employed in so
called non-training posts. In many places they equal or at times outnumber
the Training grades.
Perhaps it is time for all concerned, including the RCPCH, to
reflect on the fact that approval of training is not necessarily a matter
of funding. Many Staff Grade doctors put in sterling performances, yet, due
to a traditional dichotmy are never considered to be in "training" when
compared to the Training SPRs.
Article 14 offers some hope for some of these doctors who have long
years of experience, but those at a much more junior level, the current
changes will only add to the sense of being "left out" of the game. I find
it really surprising that educators who spent their entire life designing
new theories of training and multi-source feedback hasnt given any
thought to designing a uniform career pathway for all concerned.
Perhaps it is no surprise that the majority of these "non-training"
posts are occupied by overseas doctors. With the implementation of MMC and
EWTD, the delienation between training posts and service posts will become
all the more obvious. Whether this is to the ultimate good of the staff
morale, the NHS and the patients is anybody's guess.
Dear Editor,
We read with interest an article on Dapsone therapy for Henoch-Schonlein purpura: a case series by Iqbal et al.[1] They reported the clinical course of 8 children with Henoch-Schonlein purpura (HSP) treated with dapsone due to the severity or persistence of their symptoms. All gained clinical response from treatment, but six of eight relapsed after treatment was stopped and nephritis was observed in fi...
Dear Editor,
The humble tongue-tie, like the foreskin, generates enormous quantities of hot air, with little evidence to support it. I welcome the decision by the Archives of Disease in Childhood to commission a Perspective on Tongue-tie in the same month that NICE (1) has issued its positive guidance on the same topic.
Hall and Renfrew begin by stating their bias. Mine is that the Archives of Disease i...
Dear Editor,
Like many others, this article makes the mistaken assumption that medical career and training in UK is facilitated only by the official "RCPCH approved" training pathways. It totally ignores the aspirations and career plans of the huge workforce of doctors who are employed in so called non-training posts. In many places they equal or at times outnumber the Training grades.
Perhaps it is time fo...
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