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
signific...
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
We read with interest Marko Kerac's excellent article on wasting
amongst under 6-month old infants in developing countries (1). There is
a considerable amount of excellent research on how to identify
malnutrition. We also have comprehensive, effective, evidence on how to
manage malnutrition and reduce mortality (2). However, we and others have
audited the identification of malnutrition in children...
We read with interest Marko Kerac's excellent article on wasting
amongst under 6-month old infants in developing countries (1). There is
a considerable amount of excellent research on how to identify
malnutrition. We also have comprehensive, effective, evidence on how to
manage malnutrition and reduce mortality (2). However, we and others have
audited the identification of malnutrition in children admitted to
hospital and found that it is often unrecognized and so the appropriate
management is not instituted. Unfortunately there is a paucity of good
quality research on why many health professionals in developing countries
fail to identify malnutrition in hospitalized children and even if they do
why they are not instigating the published and widely disseminated
guidelines. Failure to recognize malnutrition can have catastrophic
consequences, as mortality rates can be reduced from as high as 50% to 5%
by simply using the WHO "10-step" guidance (2).
Our audit and literature review suggested potential barriers to the
identification of malnutrition included: that the focus of attention was
an infective illness or other co-morbidities, low staff to patient ratio,
lack of supplies, poor health care infrastructures (leading to poor
conditions on wards), inadequate or non-existent undergraduate and in-
service training and a lack of successful dynamics within the work-force.
With malnutrition contributing to 53% of child deaths (3), it is
imperative that we address the failure to identify malnutrition and the
implementation of management guidelines.
References
1. Kerac, M., Blencowe, H., Grijalva-Eternod, C., McGrath, M.,
Shoham, J., Cole, T., Seal, T. Prevalence of wasting among under 6-month-
old infants in developing countries and implications of new case
definitions using WHO growth standards: a secondary data analysis,
Archives of diseases in childhood. 2011 ;96:1008-1013 Published Online
First: 2 February 2011 doi:10.1136/adc.2010.191882
2. WHO. Guidelines for the in-patient treatment of severely
malnourished children, 2003.
3. Caulfield, L.E., de Onis, M., Bl?ssner, M., Black, R.E.
Undernutrition as an underlying cause of child deaths associated with
diarrhea, pneumonia, malaria, and measles. The American Journal of
Clinical Nutrition. 2004 July 1, 2004;80(1):193-8.
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 exclusivel...
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.
We thank Professor Hall for drawing our attention to this issue. At
present there are no relevant published recommendations in the UK but we
would agree that both vaccination against VZV and influenza should be
offered and recommended to children receiving long term aspirin.
We feel Dr Markovitch (1) was over critical of Hilton et al (2).
Although we agree that there was a paucity of evidence to allow them to
rebut Dr Wakefield’s suggestion that MMR could in some children cause
autism, we believe that they still could have been clearer in reporting
the full situation. The suggestion that the MMR vaccine should be given as
its separate components came, not from a scientific paper, but as an
a...
We feel Dr Markovitch (1) was over critical of Hilton et al (2).
Although we agree that there was a paucity of evidence to allow them to
rebut Dr Wakefield’s suggestion that MMR could in some children cause
autism, we believe that they still could have been clearer in reporting
the full situation. The suggestion that the MMR vaccine should be given as
its separate components came, not from a scientific paper, but as an
announcement by a single researcher at a press conference. Within a month
of the publication of the Lancet paper, a number of authors of the paper
re-emphasised the importance of the combined MMR vaccine and that they had
not proven a link between it and autism (3). It is these facts that should
have been more strongly communicated, thus allowing people to attach the
appropriate level of credence to Dr Wakefield’s views. If editors of
journals had made more of this, healthcare professionals might have been
better equipped for their discussions with parents.
We agree with Dr Markovitch that “…..they [editors] should offer
honest accounts of best practice couched in language that generalist
health care professional readers and the non-scientists writing for the
public media can understand.” However, they should include all the
relevant details including a balance that is truly reflective of the
scientific evidence. The individual health professional is often unable to
review the evidence themselves, through lack of time or access to the
relevant material, and relies on journals such as those critiqued by
Hilton et al to provide the information in a full but concise manner.
Although this approach may not make for earth shattering headlines, it is
responsible. We don’t suggest that editors should be censorious but it
behoves them to couch unsubstantiated hypotheses in an appropriately
cautious manner.
1. Markovitch H. Editors should not be propagandists. Arch Dis Child
2009; 94: 827-8.
2. Hilton S, Hunt K, Langan M, Hamilton V, Petticrew M. Reporting of MMR
evidence in professional publications: 1988-2007. Arch Dis Child 2009; 94:
831-3.
3. Murch S, Thompson M, Walker-Smith J. Autism, inflammatory bowel disease
and MMR vaccine. Lancet 1998; 351: 908.
We welcome Dr Rees' October review as it highlights the need for a
radical re-think in safeguarding training if the paediatrician is to start
to contribute to the protection of children in the way she suggests.
Most maltreated children are seen by paediatric trainees and traditional
training has not equipped them or their seniors to view their role in the
way suggested. As well as recognition and response, training should...
We welcome Dr Rees' October review as it highlights the need for a
radical re-think in safeguarding training if the paediatrician is to start
to contribute to the protection of children in the way she suggests.
Most maltreated children are seen by paediatric trainees and traditional
training has not equipped them or their seniors to view their role in the
way suggested. As well as recognition and response, training should
include risk factors, burdens and consequences (1) focusing on the
interplay between the physical, psychological, emotional and social.
Teaching in this way will lead to improved paediatric assessments and more
meaningful management plans which consider both immediate and long term
outcomes.
The concept of the 'child protection medical' is a major barrier to doing
this as it implies Paediatricians are technicians who only look at the
presenting complaint. This hinders us and the multidisciplinary team from
thinking about the purpose or benefits of our consultation and
contribution to the child's overall assessment. Paediatricians are fearful
of child protection and may feel that there is not enough time to
undertake a complex consultation. This again is a misconception that lies
in the lack of wider knowledge of child maltreatment, so a full medical
history with relevant questions is not taken.
It is not just what we know that needs to change but clarity in how much
we can expect of paediatricians in their understanding of such a complex
and specialist subject. Rees article suggests the need for a new approach
which if taught from undergraduate level may lead to a generation of
doctors that may begin to understand maltreatment in the way suggested and
also identifies a role for the tertiary safeguarding paediatrician. This
is the key to practising modern safeguarding that can lead to better
outcomes for children.
References
1.Gilbert R, Spatz Widom C, Browne K, Fergusson D, Webb E, Janson S,
Burden and consequences of child maltreatment in high-income countries,
The Lancet, 2009; 373: 68 - 81.
Griffiths et al have studied conditional weight gain from birth to
the age of 3 years in babies from the Millennium Cohort Study and drawn
conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not
accounted for.
Weight must be clearly related to height. The authors report weight
(z score) at age 3 co...
Griffiths et al have studied conditional weight gain from birth to
the age of 3 years in babies from the Millennium Cohort Study and drawn
conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not
accounted for.
Weight must be clearly related to height. The authors report weight
(z score) at age 3 conditional on birthweight, however they have not
treated height in the same way, using only height (z score) at age 3. BMI
at age 3 was not used. This uses height (2) not height.
No account has been made of the genetic influence on growth. By the age of
3 years the genetic influence is evident on growth in height.2 Since no
data are presented for either maternal or paternal height this important
confounding effect has not been assessed.
The authors state that children not breastfed are both heavier and
fatter at 3 years. However the study does not include any measure of
fatness to justify this statement, the heavier babies could have had more
muscle/bone and even larger brains.
Child obesity is known to be associated with poverty and children
likely to be affected by this have been under-reported in this study.
The authors conclude that strategies to support mothers to follow
internationally recommended infant feeding practices are required. Very
few of the babies in this study were exclusively breastfed even to the age
of 4 months. This study does not assess the effects of current guidelines
(exclusive breastfeeding to the age of 6 months) on weight gain.
Yours sincerely
Dr C A Walshaw
Oakworth Surgery
Keighley
BD22 7HN
1 Griffiths L J, Smeeth L, Hawkins S S, Cole T J Dezatoux C. Effects
of infant feeding
Practice on weight gain from birth to 3 years. Arch. Dis. Child.
Doi:10.1136/adc.2008.
137554
2 Silventoinen K. Pietilainen KH, Tynelius P, Sorensen TI, Kaprio J,
Rasmussen F.
Genetic regulation of growth from birth to 18 years of age: the
Swedish young male
twins study. American Journal of Human Biology. May 2008, 20/3(292-
8), 1520-6300.
Dr Kemp and her colleagues have done us a great service over the
years in collating and analysing the evidence base related to
safeguarding.
I wonder however how they themselves translate their work into
practice. Consistently they report the likelihood that an abused child
will have such and such an injury. But in practice we must travel the
other direction. We must ask: in a child with such and such an inju...
Dr Kemp and her colleagues have done us a great service over the
years in collating and analysing the evidence base related to
safeguarding.
I wonder however how they themselves translate their work into
practice. Consistently they report the likelihood that an abused child
will have such and such an injury. But in practice we must travel the
other direction. We must ask: in a child with such and such an injury what
is the likelihood of abuse?
If most children are not abused and yet most have some injuries at
least occasionally, we must agree that the number of injuries caused
accidentally probably outnumbers those caused by abuse. If so injuries
commonly seen in abused children might be outnumbered by those caused
accidentally just because they occur in the numerically larger group.
In simple statistical terms the data presented does not allow one to
convert the pre test probability of abuse to a post test probability of
abuse. Without this, the data is interesting but of limited value.
We were interested to read the paper by Jones at al1 on âFrequent
medical absences in secondary school studentsâ. They conclude that âthis
study should prompt education departments and their NHS partners to look
more critically at the problem ⦠and to establish a system that provides
more comprehensive assessment and treatment.â
We were interested to read the paper by Jones at al1 on ‘Frequent
medical absences in secondary school students’. They conclude that ‘this
study should prompt education departments and their NHS partners to look
more critically at the problem … and to establish a system that provides
more comprehensive assessment and treatment.’
Within Bolton PCT such a system has been designed in order to
identify causes of frequent medical absences from school and to provide
interventions aimed at supporting students to achieve an earlier and
consistent return to school. Originally in Bolton (from the year 2000)
referrals were made by the Education Social Work Department to a Senior
Clinical Medical officer to undertake medicals on children with poor
school attendance reported as due to ill health. This provided evidence to
support an identified medical problem or for the LEA to issue a fixed
penalties notice to the parent or carer. Since the issue of school
attendance subsequently became a high priority policy concern for both the
DfES and the DoH this service was re structured to develop an innovative
Advanced Nursing Practitioner (with a school nursing background) led model
for the evaluation of health issues for children and young people with
poor school attendance. The main focus of the model was to enhance joint
working between the advanced practitioner, Education Social Worker,
schools and families. Changes have included a standardised threshold for
referral (when attendance falls to 80%), agreed minimum information sets
on referrals, agreed time frames for assessments and production of
correspondence, holistic assessment, onward referrals, investigations and
reintegration programmes to aide full return to school.
Over the last academic year 251 new referrals were received form the
Education Social Work department (previously 55 a year). There were two
peaks of referral (December 51, April 40). There were 120 referrals from
primary schools and 131 for secondary schools. Referrals included 122 boys
and 129 girls. Referrals to the service from 18 individual education
social workers varied from 1 - 41 (median 14). The main causes of school
absence were asthma, recurrent URTI, headache, sore throat, menstruation
problems, chronic fatigue, skin problems, emotional and behavioural
problems and inadequate provision for special needs within school. A
variety of onward referrals were made including ENT, community
paediatrics, dietetics, Young Carers, social care, occupational care,
physiotherapy, CAMHs and two admissions to hospital. Support packages of
care have been initiated for some together with supported reintegration
plans to enable the young person to return to regular school attendance.
Pathways are being devised for young people identified with ‘school
phobia’ (jointly with CAMHs) and also a menstruation pathway for girls
presenting with complex menstrual history.
In all cases of non attendance it is essential that preventative and
early intervention should be seen as the cornerstone of multiagency
working in order to ensure pupils right to education and to protect their
health and well being. The redesigned service in Bolton has made good
progress towards achieving these aims.
Reference
1.Jones R, Hoare P, Elton R, Dunhill Z, Sharpe M. Frequent medical
absences in secondary school students: survey and case control study. Arch
Dis Child 2009;94:763-767
We read with interest the publication by Ladomenou et al entitled
"Protective effect of exclusive breastfeeding against infections during
infancy" (1). The authors conclude that exclusive breastfeeding protects
infants against common infections and lessens the frequency and severity
of infectious episodes. This study, however, failed to reach a conclusion
about the potential protective role of breastfeeding on the sever...
We read with interest the publication by Ladomenou et al entitled
"Protective effect of exclusive breastfeeding against infections during
infancy" (1). The authors conclude that exclusive breastfeeding protects
infants against common infections and lessens the frequency and severity
of infectious episodes. This study, however, failed to reach a conclusion
about the potential protective role of breastfeeding on the severity of a
Urinary Tract Infection (UTI). We recently published our results (2)
concerning the role of breastfeeding on the development of renal lesions
in infants with UTI. Our conclusions, which show a protective effect of
breastfeeding in certain infants, may contribute to the study of
Ladomenou et al. We correlated the frequency of acute pyelonephritis (APN)
with the duration of breastfeeding in infants who experienced their first
episode of UTI. Findings of APN on Technetium-99m-dimercaptosuccinic acid
(DMSA) scintigraphy were documented in 45% of infants who were still on
breastfeeding during the infection, in 56% of infants who were being
breastfed in the past for different periods of time and in 70% of infants,
who had never been breastfed (p=ns). Among boys, APN was detected in 52%,
48% and 56% of infants with ongoing breastfeeding, different duration of
breastfeeding and no breastfeeding respectively (p=ns) whereas among girls
the corresponding values were 29%, 62.5% and 79% (p=0.008). Consequently,
a protective role of breastfeeding against the development of APN lesions
on DMSA scan was noted for girls with UTI. A possible explanation for our
failure to detect the same protective role in boys may be attributed to
mother's milk action on the intestinal flora in combination with the
anatomical differences in the lower urinary tract between the genders (3).
It is also well known that infant boys with first episode of UTI are
younger than girls (4) and consequently the protective role of
breastfeeding may be less obvious for them. Nevertheless, APN changes on
DMSA scan during a UTI is a multifactorial event and further prospective
studies are needed in order to clarify the role of breastfeeding.
LITERATURE
1. Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E.
Protective effect of exclusive breastfeeding against infections during
infancy: a prospective study. Arch Dis Child. 2010;95:1004-8
2. Doganis D, Delis D, Mavrikou M, Issaris G, Martirosova A, Stamoyiannou
L, Siafas K. The protective role of breastfeeding against pyelonephritis
in infants with urinary tract infection. Paediatriki. 2011;74:43-47.
3. Hanson LA. Protective effects of breastfeeding against urinary tract
infection. Acta Paediatr. 2004;93:154-6.
4. American Academy of Pediatrics. Committee on Quality Improvement.
Subcommittee on Urinary Tract Infection. Practice Parameter: the
diagnosis, treatment and evaluation of the Initial urinary tract infection
in febrile infants and young children. Pediatrics. 1999;103:843-52.
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 signific...
Dear Sir:
We read with interest Marko Kerac's excellent article on wasting amongst under 6-month old infants in developing countries (1). There is a considerable amount of excellent research on how to identify malnutrition. We also have comprehensive, effective, evidence on how to manage malnutrition and reduce mortality (2). However, we and others have audited the identification of malnutrition in children...
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 exclusivel...
We thank Professor Hall for drawing our attention to this issue. At present there are no relevant published recommendations in the UK but we would agree that both vaccination against VZV and influenza should be offered and recommended to children receiving long term aspirin.
Conflict of Interest:
None declared
We feel Dr Markovitch (1) was over critical of Hilton et al (2). Although we agree that there was a paucity of evidence to allow them to rebut Dr Wakefield’s suggestion that MMR could in some children cause autism, we believe that they still could have been clearer in reporting the full situation. The suggestion that the MMR vaccine should be given as its separate components came, not from a scientific paper, but as an a...
We welcome Dr Rees' October review as it highlights the need for a radical re-think in safeguarding training if the paediatrician is to start to contribute to the protection of children in the way she suggests. Most maltreated children are seen by paediatric trainees and traditional training has not equipped them or their seniors to view their role in the way suggested. As well as recognition and response, training should...
Dear Editor
Griffiths et al have studied conditional weight gain from birth to the age of 3 years in babies from the Millennium Cohort Study and drawn conclusions concerning the effect of breastfeeding on this weight gain.1
However there are potential confounding factors that they have not accounted for.
Weight must be clearly related to height. The authors report weight (z score) at age 3 co...
Dr Kemp and her colleagues have done us a great service over the years in collating and analysing the evidence base related to safeguarding.
I wonder however how they themselves translate their work into practice. Consistently they report the likelihood that an abused child will have such and such an injury. But in practice we must travel the other direction. We must ask: in a child with such and such an inju...
We were interested to read the paper by Jones at al1 on âFrequent medical absences in secondary school studentsâ. They conclude that âthis study should prompt education departments and their NHS partners to look more critically at the problem ⦠and to establish a system that provides more comprehensive assessment and treatment.â
Within Bolton PCT such a sy...
We read with interest the publication by Ladomenou et al entitled "Protective effect of exclusive breastfeeding against infections during infancy" (1). The authors conclude that exclusive breastfeeding protects infants against common infections and lessens the frequency and severity of infectious episodes. This study, however, failed to reach a conclusion about the potential protective role of breastfeeding on the sever...
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