Dr Elliman is noted for his careful methodological analysis of vaccination studies,[1] but is not so careful in his recent analysis of physical punishment.[2]
The American Academy of Pediatric's co-sponsored scientific
consensus conference on corporal punishment used a more scientific
approach than the Elliman-Lynch summary. First, it carefully defined
spanking as a subset of corporal punish...
Dr Elliman is noted for his careful methodological analysis of vaccination studies,[1] but is not so careful in his recent analysis of physical punishment.[2]
The American Academy of Pediatric's co-sponsored scientific
consensus conference on corporal punishment used a more scientific
approach than the Elliman-Lynch summary. First, it carefully defined
spanking as a subset of corporal punishment. Second, it incorporated a
range of scientifically validated perspectives into summary statements
that were more balanced than the Elliman-Lynch perspective. Third, it
solicited the first systematic review of child outcomes of nonabusive or
customary physical punishment by parents.[3] An update of that review is due
to be published in December 2000.[4]
Both reviews concluded that non-abusive
smacking had consistently beneficial child outcomes in the most causally
conclusive studies (eg, randomized trials): Both non-compliance and
fighting decreased in 2- to 6-year-olds after non-abusive smacking was used
to back up milder disciplinary tactics, such as reasoning or time out.
Causal evidence of detrimental effects of customary physical punishment
was less conclusive and limited to overly frequent smacking (eg, 3 times weekly for 6- to 9-year-olds). In head-to-head comparisons, the effects of
non-abusive or customary smacking rarely compared unfavorably with any
disciplinary alternative, whereas its effects were significantly better
than 6 alternative disciplinary tactics, mostly in 2- to 6-year-olds.
My updated review considered all 92 studies included in the
unpublished 1999 Gershoff review cited by Elliman and Lynch. Most (76) of
her studies were excluded from my review for reasons that Elliman would
use to discount vaccination studies (eg, inappropriate measures, cross-
sectional designs).
Ellison and Lynch also presented a one-sided summary of Swedish
statistics since their 1979 smacking ban. Additional information on this
issue and other related issues can be found at
http://people.biola.edu/faculty/paulp/. The issues are complex, requiring
the same careful analysis given to concerns about vaccination.
References (1) Bedford H, Elliman D. Concerns about immunisation. BMJ 2000;320:240-3.
(2) Elliman D, Lynch MA. The physical punishment of children. Arch Dis Child 2000;83:196-8.
(3) Larzelere RE. A review of the outcomes of parental use of nonabusive or
customary physical punishment. Pediatrics 1996;98:824-8.
(4) Larzelere RE. Child outcomes of nonabusive and customary physical
punishment by parents: An updated literature review. Clinical Child and
Family Psychology Review 2000;3:199-221.
Nicholson and Bush,[1] in response to our article reporting on a
case series of 11 children presenting with pulmonary interstitial fibrosis
over a 10 year period,[2] suggest that an investigative opportunity has
been missed. We do not agree.
Nicholson and Bush have repeated their previously reported criticism
of percutaneous lung biopsy (PLB)[3] and have suggested that this
technique is p...
Nicholson and Bush,[1] in response to our article reporting on a
case series of 11 children presenting with pulmonary interstitial fibrosis
over a 10 year period,[2] suggest that an investigative opportunity has
been missed. We do not agree.
Nicholson and Bush have repeated their previously reported criticism
of percutaneous lung biopsy (PLB)[3] and have suggested that this
technique is prone both to more complications and to a greater number of
non-diagnostic samples. We have shown that PLB on a series of 9 patients
was adequate for diagnosis in all cases and did not result in
pneumothoraces significant to require thoracocentesis.[4]
In our present
report of 11 patients PLB was not associated with any major complications
and failed to provide a histological diagnosis in only one patient. This
compares favorably to Nicholson and Bush's own report of open lung biopsy
(OLB) in 27 cases[5] where 3 patients experienced significant
complications namely a pneumothorax, a haemothorax and a pleural space
infection. Moreover, 5 previously self ventilating patients required
ventilation following biopsy and 5 patients returned from biopsy with a
chest drain which had been inserted in the course of the procedure. We do
not agree that OLB is superior to PLB.
Nicholson and Bush go on to question the nomenclature of paediatric
idiopathic pulmonary fibrosis and briefly describe the histological
classifications of usual pneumonia (UIP) and desquamative interstitial
pneumonia (DIP) as we did in the introduction to our article. They
suggest the 'these histological patterns may… provide prognostic and
treatment data'. However, the distinction between UIP and DIP is
questioned[6] as they may represent different stages in the same disease
process.[7] [8] In common with previous reports[9] [10] [11] we have
shown that the severity of histological change did not relate to patient's
response to steroids or their eventual outcome.
We agree with Nicholson and Bush when they state that 'diagnostic
precision is maximised by comparison of pre-biopsy computed tomography and
corrected classified histological findings' as this was practised through
out our series. We fear that they have missed the most important aspect
of our report which is that idiopathic pulmonary fibrosis in children has
a diverse natural history and a variable prognosis that can be favourable.
The good prognosis seen in our series is different from previous case
reports indicating a greater than 50% mortality [10].
Doug Hacking
Rosalind Smyth
Nigel Shaw
George Kokai
Helen Carty
David Heaf
References
(1) Andrew Nicholson, Andrew Bush. Methodology for assessing patterns
of interstitial pneumonia in children [eLetters] Arch Dis Child 18 October 2000.
(2) Hacking D, Smyth R, Shaw N, Kokai G, Carty H, Heaf D. Idiopathic
pulmonary fibrosis in infants: good prognosis with conservative
management. Arch Dis Child 2000;83:152-7.
(3) Bush A. Diagnosis of interstitial lung disease. Pediatr Pulmonol
1996;22:81-2.
(4) Smyth R, Carty H, Thomas H, van Velzen D, Heaf D. Diagnosis of
Interstitial
lung disease by a percutaneous lung biopsy sample. Arch Dis Child 1994;70:143-4.
(5) Coren ME, Nicholson AG, Goldstraw P, Rosenthal M, Bush A. Open
lung
biopsy for diffuse interstitial lung disease in children. Eur Respir J
1999;14:817-21.
(6) Fan LL, Langston C. Chronic Interstitial Lung Disease in
Children. Pediatr Pulmonol 1993;16:184-96.
(7) Crystal RG, Fulmer JD, Roberts WC, Moss ML, Line BR, Reynolds HY.
Idiopathic pulmonary fibrosis- clinical, histologic, radiographic,
physiologic, scintigraphic, cytologic and biochemical aspects. Ann Intern Med
1976;85:769-88.
(8) Reynolds HY. Classification, definition, and correlation between
clinical and histologic staging of interstitial lung disesases. Semin
Respir Med 1984;6:1-19.
(9) Kerem E, Bentur L, England S, Resisman J, O'Brodovich K, Bryan A,
Levison H. Sequential Pulmonary function measurements during treatment of
infantile chronic interstitial pneumonitis. J Pediatr 1990;116:61-7.
(10) Osika E, Muller M-H, Boccon-Gibod L, Clement A. Idiopathic
Pulmonary Fibrosis in Infants. Pediatr Pulmonol 1997;23:49-54.
(11) Rudd R, Haslam P, Turner-Warwick M. Cryptogenic Fibrosing
Alveolitis: Relationship of Pulmonary Physiology and BAL to response to
therapy and prognosis. Am Rev Respir Dis 1981;124:1-8.
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV...
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV positive and had a Cambridge ‘CB’ post code. “At risk”
infants (ie, ex-preterms under 6 months of age or those with
bronchopulmonary dysplasia, BPD, under two years) were identified from the
records of the maternity and neonatal units serving our postal region.
The total cost for admission was calculated using length-of-stay on the
ward (bed-day cost of £255 (approx $380) and in the intensive care unit (bed-day cost
of £1136 (approx $1700). The potential cost of prophylaxis in the community was also
estimated (table).
1998/1999
1999/2000
"Low risk" infants
£93,940
£97,692
"High risk" infants
£10,455
£15,162
Savings in "high risk"
£5,228
£7,581
Prophylaxis costs
£13,1440
£16,1120
£1 approx $1.5 (November 2000 figures)
In the CB post code population, the RSV-related admission rate (95%
confidence interval) from our under 6 month old population was in the
range of 19 to 41 per 1000 (denominator estimated from the number of live
births with a CB post code; personal communication with A Sneedon, Office
for National Statistics, London). In the ex-preterm infants who were
under 6 months the proportion admitted during the two winters (1998/99
and 1999/2000) was 5/51 (9.8%, 95% CI 3.3 to 21.4%) and 4/62 (6.5%, 1.8 to
15.7%) respectively. Supposedly “low risk” infants accounted for 92%
(66/72) and 90% (54/60) of our RSV-related admissions for each winter.
There were no deaths in any of the admissions including the two with BPD.
In the first winter, 10 intensive care bed-days were needed, none in the
“high risk” population. In the second winter such infants used 12 out of
54 intensive care bed-days. Finally, inpatient costs for RSV in “high
risk” infants was about 10% and 15% of total RSV-related hospital costs
for the two winters respectively (table).
Taken together, even if there were potential savings following the
introduction of prophylaxis to specific subgroups, a target population -
arguably equally in need of protection - is being overlooked. In fact, in
our area, the potential effect of introducing prophylaxis would more than
double health authority costs for RSV, with little impact on our socalled
“lowrisk” more major caseload.
Jackie J Buck
Philip Debenham
Robert C Tasker
Department of Paediatrics
University of Cambridge Clinical School
Addenbrooke’s Hospital
Hills Road, Cambridge CB2 2QQ, UK
(1) Thomas M, Bedford-Russell A, Sharland M. Hospitalisation for RSV
infection in ex-preterm infants - implications for use of RSV immune globulin. Arch Dis Child 2000;83:122-7.
(2) Clark SJ, Beresford MW, Subhedar NV, Shaw NJ. Respiratory syncytial virus infection in high risk infants and the potential impact of prophylaxis in a United Kingdom cohort. Arch Dis Child 2000;83:313-16
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV...
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV positive and had a Cambridge ‘CB’ post code. “At risk”
infants (ie, ex-preterms under 6 months of age or those with
bronchopulmonary dysplasia, BPD, under two years) were identified from the
records of the maternity and neonatal units serving our postal region.
The total cost for admission was calculated using length-of-stay on the
ward (bed-day cost of £255 (approx $380) and in the intensive care unit (bed-day cost
of £1136 (approx $1700). The potential cost of prophylaxis in the community was also
estimated (table).
1998/1999
1999/2000
"Low risk" infants
£93,940
£97,692
"High risk" infants
£10,455
£15,162
Savings in "high risk"
£5,228
£7,581
Prophylaxis costs
£13,1440
£16,1120
£1 approx $1.5 (November 2000 figures)
In the CB post code population, the RSV-related admission rate (95%
confidence interval) from our under 6 month old population was in the
range of 19 to 41 per 1000 (denominator estimated from the number of live
births with a CB post code; personal communication with A Sneedon, Office
for National Statistics, London). In the ex-preterm infants who were
under 6 months the proportion admitted during the two winters (1998/99
and 1999/2000) was 5/51 (9.8%, 95% CI 3.3 to 21.4%) and 4/62 (6.5%, 1.8 to
15.7%) respectively. Supposedly “low risk” infants accounted for 92%
(66/72) and 90% (54/60) of our RSV-related admissions for each winter.
There were no deaths in any of the admissions including the two with BPD.
In the first winter, 10 intensive care bed-days were needed, none in the
“high risk” population. In the second winter such infants used 12 out of
54 intensive care bed-days. Finally, inpatient costs for RSV in “high
risk” infants was about 10% and 15% of total RSV-related hospital costs
for the two winters respectively (table).
Taken together, even if there were potential savings following the
introduction of prophylaxis to specific subgroups, a target population -
arguably equally in need of protection - is being overlooked. In fact, in
our area, the potential effect of introducing prophylaxis would more than
double health authority costs for RSV, with little impact on our socalled
“lowrisk” more major caseload.
Jackie J Buck
Philip Debenham
Robert C Tasker
Department of Paediatrics
University of Cambridge Clinical School
Addenbrooke’s Hospital
Hills Road, Cambridge CB2 2QQ, UK
(1) Thomas M, Bedford-Russell A, Sharland M. Hospitalisation for RSV
infection in ex-preterm infants - implications for use of RSV immune globulin. Arch Dis Child 2000;83:122-7.
(2) Clark SJ, Beresford MW, Subhedar NV, Shaw NJ. Respiratory syncytial virus infection in high risk infants and the potential impact of prophylaxis in a United Kingdom cohort. Arch Dis Child 2000;83:313-16
We appreciate Dr Koh's interest in our study, and his questions. We have divided these into three main arenas, in order to address them:
(1) The philosophy & meaning of "Hope"
Dr Koh et al pose several questions as to what Hope is. While in everyday usage, Hope stands in direct contrast to "Hopelessness" - it is unclear if this is applicable to available instruments. We chose th...
We appreciate Dr Koh's interest in our study, and his questions. We have divided these into three main arenas, in order to address them:
(1) The philosophy & meaning of "Hope"
Dr Koh et al pose several questions as to what Hope is. While in everyday usage, Hope stands in direct contrast to "Hopelessness" - it is unclear if this is applicable to available instruments. We chose the Miller Hope Scale, as it was developed within an acceptable methodological framework,[1] although others are available.[2]
"Hopelessness", assessed by the Beck scale[3] is designed to assess potential for suicide. In general, the overlap or contrast between measured domains in different available instruments has received sparse attention. To reply to Dr Koh therefore, we must revert to the definition of hope provided by Miller et al, who constructed the instrument we used: "Hope was.. a state of being characterized by an anticipation for a continued good state, an improved state or a release from a perceived entrapment".[4] In framing our own hypotheses, Miller's definition paralleled both our concepts, and those of a parents' support group for Spina Bifida (SB & HC Association Canada).
Conveying the fuller meaning of hope might require other than dictionary definitions, and possibly "other eyes", to suggest insights into what is Hope? Many examples can be offered from art or the "spiritual" world. We think that Percy Bysshe Shelley's words on Prometheus, aptly describe a daring hope triumphing over fear and despondency: "To hope till hope creates, From its own wreck the thing it contemplates."[5]
(2) Parent's Hope versus Children's Hope
Dr Koh asks why we did not measure hope in the children, and what is known of its ontogeny? Our choice of measurement instrument was predicated upon a valid tool. The Miller scale was validated only in adults, for which reason we did not assess it in the adolescents. The ontogeny of hope, is undoubtedly an area that should receive more attention. Available instruments to measure children's hope were explicitly constructed for use in psychiatrically ill children.[6] Kashani utilized Kazdin's scale to assess the change in "hopelessness" from ages 8 to 17 years, concluding it did not increase through the adolescent years.[7] To what extent these findings are relevant to non-psychiatrically ill children remains uncertain. Even more complex is the inter-relation of adult scales and childhood scales.
To what extent do they even tap similar domains and concepts? We believe these fundamental questions need study, before linking instrument results in order to correlate a childhood and adult "continuity" of hope. A related problem has engendered much discussion in the HRQL literature concerning when can children articulate their own HRQL.[8] For these several reasons, we avoided the age group less than 5 years, and cannot offer data on what age is hope either "fixed" or, further enabled.
(3) Specific Aspects of our Study
Dr Koh also questions the direction of association between hope and HRQL, and asks other specific questions of our study. Our study did ask some a-priori questions, but was subject to limitations, which we freely acknowledged. In our paper, we already pointed out that the primary limitation is that it was retrospective, and does not allow for insight into differentiating between causality or association. Whether the child's HRQL is because of a higher "Hope"-fulness - or vice-versa - is completely unknown as of now.
Other matters: The incidence of single parenthood will vary by country and regional cohorts, and is likely not an inherent bias in our study. The lower response rate in the adolescent population, we agree, raises the issue of ascertainment bias. However reactions of teenagers are somewhat complex and the post-hoc power calculation ameliorated our concerns, to some extent. Had we given these teenagers, a further burden of response implied by an additional maneuver such as the MHS as Dr Koh et al suggest, it is possible our rates might have been lower still.
We are currently planning a prospective study to address some of these important questions.
References
(1) Kirshner B, Guyatt G. A methodological framework for assessing health indices. J Chronic Dis 1985;38:27-36.
(2) Reviewed in Kirpalani H, Hope or Biology in Spina Bifida: Can a future quality of life be predicted at birth. MSc1996, McMaster University, Hamilton, Ontario.
(3) Beck AT, Wiessman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 1974;42:861-5.
(4) Miller JF, Powers MJ. Development of an instrument to measure hope. Nurs Res 1988;37:6-10.
(5) Shelley PB. Prometheus Unbound. Poems of Shelley, 1919. Ed: Hutchison T. Oxford University Press, London. Conclusion, 4th Act; Lines; 573-574, pp 263-4.
(6) Kazdin AE, Rodgers A, Colbus D. The hopelessness scale for children: psychometric characteristics and concurrent validity. J Consult Clin Psychol 1986;54:241-5.
(7) Kashini JH, Reid JC, Rosenberg TK. Levels of hopelessness in children and adolescents: a developmental perspective. J Consult Clin Psychol 1989;57:496-9.
(8) Landgraf JM Abetz LN. Measuring Health outcomes in pediatric populations: Issues in psychometrics and application. In "Quality of Life and Pharmacoeconomics in Clinical Trials", Ed: Spilker B; Lippincott-Raven; Philadelphia 1996.
My question for the authors of this study is what sort of cover or
wrap was used on the children to avoid leakage while they were wearing the
cloth diapers? Was there no cover, a wool or fleece cover, a plastic
cover, or perhaps some other material? This seems like it might inflence
the temperature as well and this information would make interpretation of
this data more useful.
As someone with a long-standing interest in the effects of heat on
the testes of farm and experimental animals, I was particularly interested
to read the article by Partsch et al (Arch Dis Child 2000;83:364-8) and the accompanying Leading Article (2000;83:281-2) by Professor Hughes. The extent
of the temperature elevation produced by the disposable plastic lined
nappies is not much less than that of 1.5 to 2...
As someone with a long-standing interest in the effects of heat on
the testes of farm and experimental animals, I was particularly interested
to read the article by Partsch et al (Arch Dis Child 2000;83:364-8) and the accompanying Leading Article (2000;83:281-2) by Professor Hughes. The extent
of the temperature elevation produced by the disposable plastic lined
nappies is not much less than that of 1.5 to 2.5oC which we observed in
adult male sheep fitted with insulating bags around their scrota (Mieusset et al, Ann NY Acad Sci 1991;637:445-58, and unpublished observations).
This amount of temperature increase applied for as little as 8 hours per day for about 5 months caused appreciable deterioration in semen quality after
about 40 days, without much change in sperm numbers, whereas when the bags
were applied continuously, sperm motility fell to practically zero within
15 days and numbers fell slightly later. Recovery occurred about 70 days
after the end of the insulation.
Furthermore, there was increased
embryonic mortality in ewes inseminated with semen collected from
insulated rams. Similar results have been reported by others in cattle
(Setchell, J Reprod Fertil 1997;114:179-94). As far as I am aware,
comparable studies have not been conducted on prepubertal animals, but it
would not be difficult to do so.
BP Setchell Pediatric Endocrinology Unit, Karolinska Hospital
Stockholm, Sweden (Professor Emeritus of Animal
Sciences University of Adelaide, Australia)
We read with interest the leading article in your journal by
Sutcliffe[1] in which the various issues associated with intracytoplasmic
sperm injection (ICSI) were discussed. We thought that in general it provided a
good general overview of the subject. However, we do take exception to Dr Sutcliffe's comments about the supposed limitations of our study,[2] which was the first to be published in which the cog...
We read with interest the leading article in your journal by
Sutcliffe[1] in which the various issues associated with intracytoplasmic
sperm injection (ICSI) were discussed. We thought that in general it provided a
good general overview of the subject. However, we do take exception to Dr Sutcliffe's comments about the supposed limitations of our study,[2] which was the first to be published in which the cognitive
development of children conceived using ICSI was compared with a control
group.
There were four areas in which Dr Sutcliffe claimed our study had
fault: lack of power, multiple observers, unstandardised testing systems,
and failure to allow for confounders. We would like to briefly deal with
each of those issues.
Power Our study was well powered to detect the differences found.
Considering the sample sizes and standard deviation of the mean MDI value
for the total cohort, there was 98% power to detect the 6-point difference
in mean MDI that we observed. Similarly the study was well powered to
detect the differences in percentage of infants with delayed development,
87% for IVF versus ICSI (2 vs 17%) and 91% for naturally conceived
controls versus ICSI (1 vs 17%). These figures compare favourably with
Sutcliffe's study,[p3] which had 91% power to detect a five-point difference
in GQ.
Multiple observers There were two testers, both of whom have
considerable experience in Developmental assessment using the Bayley
Scales of Infant Development and also in the Griffiths Mental Development
Scales. We documented in our methods section that inter-rater reliability
for assessing the Bayley's MDI by these two investigators was tested using
Kendall's tau correlation, and found to be very high at 0.953.
Unstandardised testing systems The Bayley Scales of Infant
Development (2nd edition)[4] is an age-appropriate test that has sound
psychometric properties enabling the identification of performance
differences among research groups. It was extensively re-standardised in
1991-1992, and this has resulted in an up-to-date, valid and reliable test
of infant development. The Bayley Scales of Infant Development (2nd
edition) was chosen by us because it was the most recently re-standardised
infant test available at the commencement of our study.
Dr Sutcliffe used the Griffiths Scales of Mental Development[5] to test
his children. This is also a standardised test, but it is designed for
younger infants and does have an age-related "ceiling effect", such that
the highest possible score on Griffiths GQ for children in the latter half
of their second year is decreased compared with the full possible range of
GQ values. For example, the highest possible GQ value is 150, but for
children in their 23rd month it decreases to 124. Furthermore, a ceiling
of maximum performance in each sub-scale is established when a child fails
6 items in a row. Even advanced infants in their 13th and 14th month may
not reach this criterion. Dr Sutcliffe does not report whether any infants
in either group failed to reach a ceiling on any of the Griffiths sub-
scales. Given the mean age and standard deviation of the mean for
Sutcliffe's cohorts it is possible that such ceiling effects may have
occurred in the older children, and that this could disguise true
differences between ICSI and control children.
Failure to allow for confounders This is untrue. Our Methods section
clearly states that where between-group differences were found for
perinatal and demographic variables, these variables were included as
covariates in the analyses comparing groups for outcome at 1 year. The
main demographic difference that we detected was that ICSI children were
more likely to have fathers with an unskilled occupation than either the
IVF or naturally conceived children. In our results we documented that we
performed a subset analysis in which we excluded all children from all
three groups whose fathers had an unskilled population. We documented that
for those children whose fathers had a managerial, professional or skilled
occupation the differences in proportions with a delayed MDI was still
significantly different (16% ICSI, 1% IVF and 1% natural conception). This
difference was highly statistically significant (P<_0.0001. given="given" the="the" numbers="numbers" in="in" this="this" subset="subset" power="power" for="for" detecting="detecting" difference="difference" was="was" _86.="_86." sutcliffe="sutcliffe" also="also" detected="detected" a="a" number="number" of="of" socio-demographic="socio-demographic" differences="differences" between="between" groups="groups" his="his" study="study" but="but" does="does" not="not" indicate="indicate" that="that" he="he" allowed="allowed" these="these" confounders="confounders" analyses.="analyses." p="p"/> We do agree with Dr Sutcliffe that at this point in time it is unsafe
to draw any conclusions about the long-term wellbeing of children
conceived using ICSI and that the health of the child should be paramount
in further developments of new assisted reproductive technology
techniques. We are presently reassessing our previously studied cohort at
five years of age, and have enrolled additional ICSI and naturally
conceived children to address the areas of socio-demographic imbalance
observed in the original cohort. Hopefully the results of our study and
that of the European collaborative group will help to clarify the issue of
cognitive development for children conceived using ICSI.
Garth I Leslie MD BS BSc(Med) FRACP
Clinical Associate Professor
University of Sydney Northern Clinical School
Royal North Shore Hospital
St Leonards, NSW, Australia
Frances Gibson PhD
Psychologist, Department of Neonatology
Royal North Shore Hospital
St Leonards, NSW, Australia
References
(1) Sutcliffe AG. Intracytoplasmic sperm injection and other aspects
of new reproductive technologies. Arch Dis Child 2000;83:98-100.
(2) Bowen JR, Gibson FL, Leslie GI, Saunders DM. Medical and
developmental outcome at 1 year for children conceived by intracytoplasmic
sperm injection. Lancet 1998;351:1529-34.
(3) Sutcliffe AG, Taylor B, Li J, Grudzinskas G, Thornton S, Lieberman
B. Children born after intracytoplasmic sperm injection: population
control study. BMJ 1999;318:704-5.
(4) Bayley N. Bayley scales of infant development, 2nd edition. San
Antonio: The Psychological Corporation, 1993.
(5) Griffiths R. The Griffiths mental development scales 1996
revision. Henley: Association for Research in Infant and Child
Development, Test Agency, 1996. (Revised by M Huntley)
I read with interest the comments by Leslie and Gibson concerning my
reference[1] to their study.[2] They describe their study as the first
on ICSI conceived children with controls but make no reference to the
study by Bonduelle et al[3] in the same edition of the Lancet, which had
contradictory findings. I previously corresponded[4] at the time their
study was published concerning their findings a...
I read with interest the comments by Leslie and Gibson concerning my
reference[1] to their study.[2] They describe their study as the first
on ICSI conceived children with controls but make no reference to the
study by Bonduelle et al[3] in the same edition of the Lancet, which had
contradictory findings. I previously corresponded[4] at the time their
study was published concerning their findings and wish to respond to their
points.
Power In their small single-centre study, a difference of 6.6 was found
between the mean mental development index (MDI) of the ICSI group and that
of a normally conceived control group (95.9 vs 102.5). However, a power
calculation based on this difference and the test intrinsic SD of 15
showed that to achieve 95% CI, at least 135 children would be needed in
each group. A control group of 80 children would achieve power of
only 79.4%.
It is unfortunate that Leslie and Gibson chose to refer only to the
interim findings of the UK population study of ICSI conceived children
rather than the final findings for comparisons of power. These findings
were presented at ESHRE meeting in Tours, France, 1999[5] at which Gibson
was present. These findings are presently being considered by a major
international journal but suffice it to say that the 208 ICSI conceived
toddlers and 221 normally conceived well matched controls were strikingly
similar in their neurodevelopmental abilities (5) at mean age 18 months. In this study there was a power of greater than 99% to detect a 5 point
difference in the newly standardised Griffiths scales of mental
development between study and control groups.
Multiple observers In their study there were two observers. In the UK population study
only one. Unfortunately a common reason for invalid results in such
studies is interobserver error, since 100% agreement between observers
seldom occurs.
Unstandardised testing systems Leslie and Gibson defend their use of the Bayley scales but do not
acknowledge that these scales had not been standardised in Australia. The
reassuring report from Bonduelle et al referred to above[3] also used the
Bayley scales but their translated version had been standardised against
the indigent population of Dutch speaking children.
To put the significance of non-standardisation into a more general
context, during the restandardisation of the Griffiths scales of mental
development (1996) the scales were compared to scales standardised in the
early 70s. It was noted a toddler of average ability when tested in 1996
(mean score 100) would get a mean score of 107.8 on the old scales. Leslie
and Gibson refer to testing children close to twenty-four months and
possible pitfalls of this in the application of the scales. Allowance was
made in the design of the new Griffiths scales for children of above
average ability but I acknowledge that 2 children in each group (2 out of
208 study and 2 out of 221 controls) may have been theoretically affected
by this.
Failure to allow for confounders Unfortunately the Sydney study chose to use control children
recruited from an earlier study (ie, retrospective controls). This may
have made the study results available quicker but is scientifically
unwise. Colleagues in Sydney have also questioned the different
socioeconomic features of the neighborhoods from whence the control and
study children were recruited.
Of the original 108 pregnancies, I note 38 were from embryos replaced
after cryopreservation. Minor developmental deficits have already been
noted in children born after replacement of cryopreserved embryos before
the introduction of ICSI.[6] Although in the UK study there were a few
minor confounders for neurodevelopmental outcome this was allowed for in
the analysis.
There is an ongoing European 5 nation study of ICSI conceived
children at aged 5 years (ICSI-CFO; International Collaborative Study of ICSI - Child and Family Outcomes).
Involving 650 ICSI conceived children, 650 normally conceived control
children and a 650 IVF comparison group this should give further
information about longer term outcome.[7]
The paper by Bowen, Lesley, Gibson et al[2] has increased awareness
of the necessity to enquire about outcome after ICSI. It also had many
good points such as the inclusion of multiple births and the blinding of
the two observers involved to outcome. However the anxiety the paper
caused to the families who have benefited from this treatment and their
associated fertility treatment teams worldwide was probably not warranted
in view of my comments above.
Alastair G. Sutcliffe MD, MRCP, MRCPCH
Lecturer in Child Health
Centre for Community Child Health Studies
Department of Paediatrics
Royal Free Campus
Royal Free and University College Medical School
University College London, Rowland Hill Street
Hampstead, London NW3 2PF, UK
References
(1) Sutcliffe A G. Intracytoplasmic sperm injection and other aspects
of new reproductive technologies. Arch Dis Child 2000;83:98-100.
(2) Bowen JR, Gibson FL, Leslie GI, Saunders DM. Medical and
developmental outcome at 1 year for children conceived by intracytoplasmic
sperm injection. Lancet 1998;351:1529-31.
(3) Bonduelle M, Joris H, Hofmans K, Liebaers I, Van Steirteghem.
Mental development of 201 ICSI children at 2 years of age Lancet
1998;351:1553.
(4) Sutcliffe A G, Taylor B, Li J, Grudzinskas G, Thornton S, Lieberman B, Children conceived by intracytoplasmic sperm injection.
Lancet 1998;352:578-9.
(5) Sutcliffe A G, Taylor B, Li J, Grudzinskas G, Thornton S, Lieberman B,
UK study of children born after Intracytoplasmic sperm injection [abstract 0-018]. Human Reproduction 1999;14:13.
(6) Sutcliffe AG, DeSouza SW, Cadman J, Richards B, McKinlay IA,
Lieberman B. Outcome in children from cryopreserved embryos. Arch Dis Child 1995;72:290-3.
(7) Sutcliffe AG, Bonduelle M, Tarlatzis V, Loft A, Wennerholm U-B. ICSI-CFO an International collaborative study of ICSI - child and family
outcomes: European Commission research contract No: QLG4 - 2000 - 00545.
In the management of idiopathic thrombocytopenic purpura
(ITP) Bolton-Maggs[1] stated that "when treatment is required, options
include oral steroids, intravenous immunoglobulin (IVIG) and lately, anti-D for patients who are rhesus D positive", without taking into
consideration our mega dose methylprednisolone (MDMP) administration.[2]
In
our study the patients with acute ITP were divided into three gr...
In the management of idiopathic thrombocytopenic purpura
(ITP) Bolton-Maggs[1] stated that "when treatment is required, options
include oral steroids, intravenous immunoglobulin (IVIG) and lately, anti-D for patients who are rhesus D positive", without taking into
consideration our mega dose methylprednisolone (MDMP) administration.[2]
In
our study the patients with acute ITP were divided into three groups:
no
treatment
oral steroid (2 mg/kg for 2 weeks)
MDMP (30 mg/kg
initially intravenously, orally 30 mg/kg for 3 days, and 20 mg/kg for 4
days lately[3]).
The results of our original study which includes
corresponding antiplatelet determinations, indicated that oral (2 mg/kg)
steroid in raising platelet count was not more effective than no treatment, it may actually delay the spontaneous improvement.[2] But MDMP was
very effective in 3 days which is supported by the others.[4][5] Therefore,
if treatment is required MDMP, iv or orally which is more convenient,
should not be ignored, since it is cheaper, effective and more easily
applied.
However, if parents are convinced, children with ITP could be followed
without treatment. About 20-30% chronicity in childhood ITP seems to be
higher according to our findings. Relapses occur about 5% and chronicity
in 11.4% of children respectively with conventional (2 mg/kg) steroid
which is more close to of Dickerhoff and von ruecker recent finding.[6] MDMP chronicity was observed in 4 of 59 (6.8%) children with acute ITP.
If this effect of MDMP is supported by other reserchers, it could be more
advised for the treatment of patients with acute ITP.
Þinasi Özsoylu MD
Prof of Pediatrics and Hematology
Fatih University Medical Faculty
Alparslan Türkeþ cad. No.57, 06510 Emek-ANKARA, Turkey
(2) Özsoylu Þ, Ýrken G, Karabent A. High dose intravenous methyprednisolone
for acute childhood thrombocytopenic purpura. Eur J Haematol 1989;42:431-5.
(3) Özsoylu Þ, Þaylý RT, Öztürk G. Oral megadose methylprednisolone versus
intravenous immunglobulin for acute childhood idiopathic thrombocytopenic
purpura. Pediatr Hematol Oncol 1993;10:317-21.
(4) van Hoff J, Ritchey AK. Pulse methylprednisolone therapy for acute
childhood idiopathic thrombocytopenic purpura. J Pediatr 1988;113:563-6.
(5) Del Principe D, Menichelli A. Methylprednisolone in childhood
idiopathic thrombocytopenic purpura. Acta Haematol 1988;79:224-6.
(6) Dickerhoff R, von Ruecker A. The clinical course of immune
thrombocytopenic purpura in children who did not receive intravenous
immunoglobulins or sustained prednisone treatment. Pediatrics 2000;137:629-2.
Dear Editor
Dr Elliman is noted for his careful methodological analysis of vaccination studies,[1] but is not so careful in his recent analysis of physical punishment.[2]
The American Academy of Pediatric's co-sponsored scientific consensus conference on corporal punishment used a more scientific approach than the Elliman-Lynch summary. First, it carefully defined spanking as a subset of corporal punish...
Dear Editor,
Nicholson and Bush,[1] in response to our article reporting on a case series of 11 children presenting with pulmonary interstitial fibrosis over a 10 year period,[2] suggest that an investigative opportunity has been missed. We do not agree.
Nicholson and Bush have repeated their previously reported criticism of percutaneous lung biopsy (PLB)[3] and have suggested that this technique is p...
Dear Editor
Two recent reports about hospitalisation for respiratory syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested that the introduction of prophylaxis may, potentially, be beneficial in certain subgroups. We would like to emphasise that the "bigger picture" also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions who were RSV...
Dear Editor
Two recent reports about hospitalisation for respiratory syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested that the introduction of prophylaxis may, potentially, be beneficial in certain subgroups. We would like to emphasise that the "bigger picture" also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions who were RSV...
We appreciate Dr Koh's interest in our study, and his questions. We have divided these into three main arenas, in order to address them:
(1) The philosophy & meaning of "Hope"
Dr Koh et al pose several questions as to what Hope is. While in everyday usage, Hope stands in direct contrast to "Hopelessness" - it is unclear if this is applicable to available instruments. We chose th...
My question for the authors of this study is what sort of cover or wrap was used on the children to avoid leakage while they were wearing the cloth diapers? Was there no cover, a wool or fleece cover, a plastic cover, or perhaps some other material? This seems like it might inflence the temperature as well and this information would make interpretation of this data more useful.
As someone with a long-standing interest in the effects of heat on the testes of farm and experimental animals, I was particularly interested to read the article by Partsch et al (Arch Dis Child 2000;83:364-8) and the accompanying Leading Article (2000;83:281-2) by Professor Hughes. The extent of the temperature elevation produced by the disposable plastic lined nappies is not much less than that of 1.5 to 2...
We read with interest the leading article in your journal by Sutcliffe[1] in which the various issues associated with intracytoplasmic sperm injection (ICSI) were discussed. We thought that in general it provided a good general overview of the subject. However, we do take exception to Dr Sutcliffe's comments about the supposed limitations of our study,[2] which was the first to be published in which the cog...
Dear Editor,
I read with interest the comments by Leslie and Gibson concerning my reference[1] to their study.[2] They describe their study as the first on ICSI conceived children with controls but make no reference to the study by Bonduelle et al[3] in the same edition of the Lancet, which had contradictory findings. I previously corresponded[4] at the time their study was published concerning their findings a...
In the management of idiopathic thrombocytopenic purpura (ITP) Bolton-Maggs[1] stated that "when treatment is required, options include oral steroids, intravenous immunoglobulin (IVIG) and lately, anti-D for patients who are rhesus D positive", without taking into consideration our mega dose methylprednisolone (MDMP) administration.[2]
In our study the patients with acute ITP were divided into three gr...
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