Safety netting in the Emergency Department (ED) is key to the practice of safe medicine. Following the article by de Vos-Kerkhof (1), we present further evidence to suggest that there is a lack of standardised safety netting. In addition, we found a disparity between paediatric trainees' perception of their safety netting practice and what they actually documented in the medical notes.

In a retrospective case notes review of 100 consecutive ED attendances to our hospital seen by the paediatric team and discharged from ED, only 16% had documentation that the families had been told about the existence of uncertainty around the diagnosis and the course of the illness. This compares unfavourably with the fact that 73% of surveyed paediatric trainees reported that they routinely mentioned this to families. Furthermore, the signs and symptoms to look for had only been documented in 27% of cases, though 88% of trainees reported discussing this with the family. 39% of the notes reviewed had no specific safety netting documentation of any kind.

It is clear that for non-consultant paediatricians, who are the clinicians seeing most referred children in ED, a gap exists between the safety netting that they report undertaking and what is documented. This may be in part because they provided verbal safety netting advice without documenting it but it also suggests that safety netting procedures are poor, despite the clinical and medico-legal imperative for adequate safety netting and documentation advocated by the National Institute for Health and Care Excellence(2).

Clearly training for junior doctors on safety netting and its documentation needs to improve. A safety netting checklist and more high quality patient information leaflets may help clinicians to offer adequate advice and information to families at the time of discharge. (297 words)

1. de Vos-Kerkhof E, Geurts DH, Wiggers M, Moll HA and Oostenbrink R. Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care. Archives of Disease in Childhood. 2016; 101: 131 -9.

2. Fields E, Chard J, Murphy MS and Richardson M. Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance. BMJ (Clinical Research Ed). 2013; 346: f2866.

Conflict of Interest:

None declared

Maria A Quigley1, Claire Carson1, Julia Morinis1,2,3.

1 National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK

2 Department of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada

3 Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada

We would like to thank Michael A Colvin for highlighting the distinction between the presence of the child's biological father in the household and the presence of the mother's partner in the household. As Dr Colvin points out, the data in Table 1 of our paper suggest that 14% of five year old children in the study do not have their father living in their home and, among the children of teenage mothers, this proportion is 53.5%. We thank Dr Colvin for highlighting this as this variable is labelled incorrectly in Table 1 of our paper and it should read as 'Partner in the home at 5 years' (i.e. this would not necessarily be the child's father) rather than 'Father in the home at 5 years'. We have also looked at the effects on child cognitive ability of having the biological father resident in the family home, both at the first survey (9 months) and at the five-year follow-up. Overall, 73% of children had their father resident at both surveys and 12.5% had their father leave by the time of the five year survey; in the families with teenage mothers, these proportions were 21.4% and 24.8% respectively. In addition, compared with children whose fathers were in the home at both surveys, there was a statistically significantly lower BAS Naming Vocabulary score in children whose fathers had left during the study (-3.8), or who were not living in the home at either survey (-7.2). In the small number of children whose fathers were not there at baseline, but had returned to the family home during the study, there was also an adverse effect on BAS Naming Vocabulary score (-4.9), hence suggesting a negative impact of family instability, as has been found in other studies, including the Millennium Cohort Study. However, after adjusting for the other variables in our models, the effect of family instability was not statistically significant and did not alter our coefficients for mother's age (data available on request). For example, model E from Table 2 of our paper shows a statistically significantly lower BAS Naming Vocabulary score in children of teenage mothers compared with children of mothers aged 25-34 (-3.8, 95% CI: -6.3 to -1.3). When we replaced 'marital status' (which does not distinguish between father and partner, or change of partner) in this model with 'family instability' (as measured by the natural father's residence in the child's home at both surveys) the effect of teenage motherhood was very similar (-3.9, 95% CI -6.4 to -1.5). Hence, we believe that the conclusions drawn from our study are robust.

Conflict of Interest:

None declared

It would be useful to ascertain whether or not the "new" sphygmanometer being compared with the Omron HEM 711(1) was an aneroid device, given the fact that those of us who lamented what we perceived to be an ill advised rejection of the mercury device welcomed the prospect that aneriod sphygmanometers "may replace the traditional mercury column in the healthcare workplace"(2). In the latter study, there were no significant differences(using the paired t-test) between the mercury standard and the aneroid device(Baum & Co), but the oscillometric device(Omron HEM-907)significantly(p=0.002) overestimated the systolic blood pressure(SBP) and significantly(p=0.0002) underestimated the diastolic blood pressure(DBP)(2). A later study study compared the Welch Allyn Tycos 767-Series Mobile aneroid sphygmanometer with the mercury device, and found no statistically significant difference for SBP but a significantly(p < 0.0001) lower reading for DBP using the aneroid device(3). Oscillometric devices, on the other hand, have proved to be almost universally unreliable. In one study, an evaluation of 9 devices showed that "accuracy appeared to deccrease at increasing blood pressure levels" with the potential consequence that "in treated hypertensive patients the necessary adaptation of treatment will not take place"(4). More recently, a comparison was made between the professional oscillometric device BpTRU, that had achieved an A grade of the British Hypertension Society validation protocol for both SBP and DBP measurement, and the standard mercury sphygmanometer(Baumanometer; WA Baum Co). A total of 5070 BP measurements were made using the two devices simultaneously. Unreliable readings(ie > 10 mm Hg difference in either SBP or DBP) were found in 755 patients. Unreliable readings occured in 15% of systolic and 6.4% of diastolic blood pressures(5). In view of the fact that "A decreasing arm circumference was a significant predictor of persistent UOBP(unreliable oscillometric BP)"(5), this observation might signify that oscillometric devices might be inherently unreliable in children References (1) Midgley PC., Wardhaugh B., Macfarlane C., Magowan R., Kelnar CJH Blood pressure in children 4-8 years: comparison of Omron HEM 711 and sphygmanometer blood pressure measurements Arch Dis Child 2009;94:955-8 (2)Elliot WJ., Young PE., DeVivo L., Feldstein J., Black HR A comparison of two sphygmanometers that may replace the traditional mercury column in the healthcare workplace Blood Pressure Monit 2007;12:23-8 (3) Ma Y., Temprosa M., Fowler S et al Evaluating the accuracy of an aneroid sphygmanometer in a clinical trial setting Am J Hypertens 2009;22:263-6 (4) Braam RL., Thien T Is the accuracy of blood pressure measuring devices underestimated at increasing blood pressure levels? Blood Pressure Monitoring 2005;10:183-9 (5)Stergiou GS., Lourida p., Tzamouranis D., Baibas NM Unreliable oscillometric blood pressure measurement;prvalence, repeatability and characteristics of the phenomenon J Human Hypertension 2009;23:794-800

Leven and Mcdonald (1) report on the common occurrence of neonatal hypernatremic dehydration in breastfed infants and how early weighting is an effective means of detecting this condition. Studies of this type are the “tip of the iceberg” of much bigger problem, that of insufficient lactation in primiparous women. It is well recognized that primiparous woman produce less milk than multiparous and that 16% of exclusively breastfed infants of primiparous women have > 10% weight loss.(2, 3) Neonatal hypernatremic dehydration is difficult to recognize on clinical grounds and can easily be confused for neonatal sepsis.(4) Insufficient lactation and excessive weight loss should be an anticipated problem. Excessive weight loss and hypernatremic dehydration is largely preventable by the judicious use of supplement infant formula or expressed breast milk.

A simple and effective way of preventing neonatal dehydration is to have breastfeeding mothers use a supplemental nursing system until successful lactation is established. This system is used with great success by lactation consultants, yet most physicians, maternity wards and breastfeeding mothers are unaware that this system exists. A supplemental nursing system consists of a container which delivers supplemental milk via a capillary tube that is taped to the mother’s nipple. The flow rate of supplemental milk through the capillary tube can be adjusted. Supplemental milk is delivered while the infant is nursing from the mother’s breast, therefore the mother’s milk supply is stimulated and the child continues to receive breast milk. The supplemental milk can be discontinued once the milk supply has come in and successful lactation has been established. The wider use of this system in the first few days of life until successful lactation is established would greatly reduce the incidence of both neonatal hypernatremic dehydration and breastfeeding jaundice. While early detection of excessive weight loss is important, the ultimate goal is prevention.

1. Leven LV, Macdonald PD. Reducing the incidence of neonatal hypernatraemic dehydration. Arch Dis Child 2008;93:811.

2. Ingram J, Woolridge M, Greenwood R. Breastfeeding: it is worth trying with the second baby. Lancet 2001;358:986-7.

3. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607-19.

4. Moritz ML, Manole MD, Bogen DL, Ayus JC. Breastfeeding-associated hypernatremia: are we missing the diagnosis? Pediatrics 2005;116:e343-7.