I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.
Previous research:
CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]
I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.
Previous research:
CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]
Practical issues:
At the time of study onset, reliable POC tests were available for CRP only, providing test results within 4 minutes.[3, 4] As mentioned by Professor Blair in his e-letter, other tests such as the Brahms PCT-Q, a semi-quantitative point-of-care procalcitonin test, was available at the time, but required additional manipulation of the sample (centrifugation needed to obtain serum or plasma), a sample volume of 200µL (which was 133 times the volume used in the CRP point-of-care test (merely 1.5 µL, roughly a small drop of blood, especially useful in children)) and an incubation period of at least 30 minutes, which would not be manageable within a single acute care consultation. Therefore, it was not deemed suitable for application in our trial.
Study characteristics & findings:
In the present study, we only included children who were not referred by their general practitioner. Taking into account the organization of healthcare services in Belgium, children and parents may present to A&E directly or a consultant paediatrician of their choice, without the need for a letter of referral. This might explain why some children presented at an early stage of their illness to A&E services, potentially reducing the difference in patient spectrum between GP and hospital paediatric settings.
Furthermore, we found that children with a CRP between 20-75mg/L, should be assessed on seven features, including fever duration <1 day, which reflects the effect of disease onset on the CRP level.
In this particular CRP range, children could still have a serious infection if fever was only present for 1 day.
Conclusion:
Procalcitonin has been introduced as an earlier and more accurate diagnostic markers than currently available tests, however evidence of superior clinical accuracy in diagnosing serious infection in children in ambulatory care is still lacking.
I agree with Professor Blair that further prospective studies are needed to compare the clinical effectiveness of using point-of-care CRP and procalcitonin to guide clinical assessment in acute paediatric care.
REFERENCES
1. Van den Bruel A, Thompson M, Haj-Hassan T, et al. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011;342:d3082
2. Verbakel JY, Lemiengre MB, De Burghgraeve T, et al. Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial. BMC Med. 2016;14(1):131 doi: 10.1186/s12916-016-0679-2published Online First: Epub Date]|.
3. Minnaard MC, van de Pol AC, Broekhuizen BD, et al. Analytical performance, agreement and user-friendliness of five C-reactive protein point-of-care tests. Scand. J. Clin. Lab. Invest. 2013;73(8):627-34 doi: 10.3109/00365513.2013.841985published Online First: Epub Date]|.
4. Verbakel JY, Aertgeerts B, Lemiengre MB, De Sutter A, Bullens DM, Buntinx F. Analytical accuracy and user-friendliness of the Afinion point-of-care CRP test. J. Clin. Pathol. 2014;67:83 - 86
With great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
The algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show traine...
With great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
The algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show trainees how they can assess the pre-test probability for SI in acutely ill children without resorting to pricking children’s fingers to obtain their “inorganic” CRP value.
I assume that the authors' algorithm will function as insurance for children with suspected SI; however, debriefing and reflection by trainees and attending physicians alike after each patient encounter is essential even after implementing this technique.
References:
1. Verbakel JY, Lemiengre MB, DeBurghgraeve T, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-312384.
2. Williams HS and Zenel JA. Commentary: When Doing Less Is Best. Pediatr Rev. 2013;34;423-8.
3. Cornfield DN. Bronchiolitis: Doing Less and Still Getting Better. Pediatrics. 2014;133: e213-4.
4. Taylor JA. Oral rehydration: in pediatrics, less is often better. Arch Pediatr Adolesc Med. 2004;158:420-1.
I read the article with interest and wish to congratulate the authors for their genuine work on a little known subject.
However there are certain points which require elaboration:
(a) It is likely that there are independent genetic factors that are responsible for a baby being born SGA and the same factors may be playing a role in affecting cognitive outcomes.These factors have not been addressed in the study.
(b) Cognitive outcome of a child is the result of certain internal and certain extraneous factors (eg environmental stimulation).The extraneous factors may confound the results of the above study.
(c) Open heart surgery per se may be detrimental to the cognitive development of a child .But there are certain factors such as Bypass time,duration of mechanical ventilation,exposure to hypotensive milieu,etc that need to be explored in order to get an indepth insight into the subject.
To summarize, the article is a praiseworthy effort into a novel field which opens up potentials of further avenues of research.
I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders...
I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders that affect adults and children, the latter with a markedly heterogeneous range of seizure types, syndromes, causes, treatments and outcomes, all of which can be used to provide an individualised care plan. Failure to do so in certain situations might constitute discrimination against children with an epilepsy.
The authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.
References
1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
S. Rainbow, R. Wall and M. Blair
Is procalcitonin a discriminant marker of early
invasive bacterial infection in children?
Current Paediatrics (2003) 13, 399
2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from:...
The authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.
References
1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
S. Rainbow, R. Wall and M. Blair
Is procalcitonin a discriminant marker of early
invasive bacterial infection in children?
Current Paediatrics (2003) 13, 399
2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from: http://adc.bmj.com/lookup/doi/10.1136/archdischild-2016-310863.232
We appreciated the paper by McCrossan and others but we believe that the diagnosis of pneumonia in children should be made on a clinical ground and that chest X-rays should be considered only in case of a diagnostic doubt or to rule out a complication such as pleural effusion.[1] A X-ray control after a round pneumonia in adults is prescribed with the aim of ruling out an undelying cancer but this is an extremely rare condition in children. Considering this, rather than discussing the opportunity of a radiologic follow up we should consider the opportunity of adapting international guidelines to children.
1. McCrossan P, McNaughten B, Shields M et al. Is follow up chest X-ray required in children with round pneumonia? Arch Dis Child 2017;102:1182-1183
I thank Mr O’Hagan for his insightful comments. Indeed it is implicit in the ideas put forward in my paper that a specific infection is not the “cause” of SIDS but, rather, it is the immunological response to the infection (bacterial or viral) in the predisposed infant that results in SIDS as proposed by Dr Korsch with his suggested “immunological burst.”
As mentioned in my response to Dr Korsch, I have extended the infection paradigm to take into account the as yet unexplained risk factor of prone sleep position. (See my paper accepted for publication in Frontiers in Pediatrics.1) The presence of infection is a requirement for the effect of prone sleep position to prevail and suggests a role for the Vagus in unfavourably tipping the homeostatic balance through neuroimmunological pathways.
Paul N. Goldwater
Reference:
1. Goldwater PN. SIDS, infection, prone sleep position & Vagal neuroimmunology. Front Pediatr 2017; doi:10.3389/fped.2017.00223
Response to Dr Eckhard Korsch’s letter: SIDS as the consequence of an immunological burst
I thank Dr Korsch for his supportive and helpful comments with which I fully concur. I remain concerned by the general lack of appreciation by mainstream SIDS researchers of the essential requirement of congruency between risk factors (male gender, prone sleep position, contaminated sleeping surfaces, smoke exposure, lack of breast feeding, high birth order, etc.) and various staining findings of brainstem nuclei or other pathological findings such as intrathoracic petechiae. The silence from the mainstream sector in relation to my ideas is also of concern. Funding of mainstream SIDS research will continue unimpeded as long as facts set out in my papers are not publicised and addressed. Such funding is an unconscionable waste.
In a new paper accepted for publication in Frontiers in Pediatrics1 I have extended the infection paradigm to take into account the as yet unexplained risk factor of prone sleep position. It seems that only in the presence of infection does prone sleep position achieve significance. My thinking suggests a role for the Vagus in unfavourably tipping the homeostatic balance through neuroimmunological pathways.
Paul N. Goldwater
Reference:
1. Goldwater PN. SIDS, infection, prone sleep position & Vagal neuroimmunology. Front Pediatr 2017; doi:10.3389/fped.2017.00223
Confusion may arise in the minds of UK-based readers of this article due to the terminology used in this article, which differs slightly from the notion of “community paediatrics” in the UK.
Whereas in the UK all children receive primary care from a General Practitioner (GP), who then makes referrals to secondary and tertiary level specialists as required, the Israeli “community paediatrician” referred to in this article is actually a primary care paediatrician, who delivers all aspects of medical care to the infant and child, much as the GP in the UK does for both adults and children.
The majority of children and young people in Israel receive primary medical care from a fully qualified paediatrician who has achieved consultant (or specialist) status with a minimum of 4.5-5 years of general paediatric training. Only a minority of children and young people in Israel receive primary medical care from a Family Physician (equivalent to the UK “GP”). Paediatricians in Israel can work either in primary care or as paediatricians with an additional sub-specialty in hospitals, or can work in both settings in parallel (often working part or full time in hospital and moonlighting in primary care).
In the UK, the “community paediatrician” is a second tier specialist who deals in specific medical areas , and accepts referrals from the primary medical carer (GP), via a selective referral system. Community paediatricians in the UK usually provide neuro-development...
Confusion may arise in the minds of UK-based readers of this article due to the terminology used in this article, which differs slightly from the notion of “community paediatrics” in the UK.
Whereas in the UK all children receive primary care from a General Practitioner (GP), who then makes referrals to secondary and tertiary level specialists as required, the Israeli “community paediatrician” referred to in this article is actually a primary care paediatrician, who delivers all aspects of medical care to the infant and child, much as the GP in the UK does for both adults and children.
The majority of children and young people in Israel receive primary medical care from a fully qualified paediatrician who has achieved consultant (or specialist) status with a minimum of 4.5-5 years of general paediatric training. Only a minority of children and young people in Israel receive primary medical care from a Family Physician (equivalent to the UK “GP”). Paediatricians in Israel can work either in primary care or as paediatricians with an additional sub-specialty in hospitals, or can work in both settings in parallel (often working part or full time in hospital and moonlighting in primary care).
In the UK, the “community paediatrician” is a second tier specialist who deals in specific medical areas , and accepts referrals from the primary medical carer (GP), via a selective referral system. Community paediatricians in the UK usually provide neuro-development and neuro-disability assessments, including autism, but also provide medical services related to child protection and child abuse; children in care of the state (“looked after children”), adoption panels, child death inquiries, statutory advice for children with special educational needs (currently Education and Health Care Plan), special schools and other specialist areas which are developed locally. The UK community paediatrician cannot be accessed on demand and at short notice in the same way as a UK GP or an Israeli primary paediatrician are.
Therefore, the title of the article “Community paediatrics in Israel” actually refers to a system of primary care for children and young people, with on-demand access for parents or children, rather than to a specialist second-tier service. However the changes described in the article refer to expansion of the existing training to incorporate additional expertise in topics such as mental health, behaviour and ADHD, which are increasing in prevalence and demand for service (in Israel as in the UK).
Another term in the article which might cause confusion is “resident” or residency, which in the UK would be equivalent to “registrar”.
The first paragraph in the article ends in a statement that “management of paediatric problems in the community (Israel) is done by paediatricians who had not completed subspecialty training”. This actually means that they are fully trained consultant paediatricians, but are not necessarily certified in a subspecialty, such as paediatric respiratory, neonatology, neurology or haematology, etc.
Whereas in the UK not all paediatricians are at consultant (specialist) grade (i.e. “non career grade paediatricians”), in Israel the only non-consultant grade paediatricians working in hospitals or primary care are those who are in paediatric training (registrars by UK terminology , or “residents” in USA terminology), which culminates in achieving status of specialist /consultant.
Paediatricians in the UK are usually either “community, “acute” (hospital general paediatricians), or specialist in paediatric sub-specialities (mostly based in tertiary level hospital settings).
In Israel many paediatric subspecialties are available both in hospitals and in the community, some of which require a referral from the primary paediatrician, but others can be accessed directly by parent initiative (for example paediatric orthopaedic surgeons or neurologists).
All people permanently residing in Israeli (I have avoided the word “resident” here) are covered by national health insurance, however, as opposed to the single system (NHS) operating in the UK, in Israel four competing public health organisations (Health Funds) operate, delivering a basic universal “basket of services” , and competing with each other by offering increasing levels of excellence or diversity of additional services.
This comment will, I hope, clarify some of the information presented in the article by Porter et al.
Dr Naomi Gerson-Sofer
Consultant Community Paediatrician
Oxleas Foundation Trust
(Formerly Director of Child Development Centre in the Western Galilee Hospital, Israel)
Hello,
After reviewing some cases presenting to Bristol with Rhabdomyolysis I wondered if this child had genetics sent for Ryanodine Receptor gene (RYR gene). This can cause malignant hyperthermia and in our case the boy resented with muscle pain on exertion and recurrent rhabdomyolysis. The article below is useful.
Chan EK, Kornberg AJ, Ryan MM, A diagnostic approach to recurrent myalgia and rhabdomyolysis in children. Archives of Disease in Childhood 2015;100:793-797.
I would like to thank Professor Mitch Blair for his valuable input and bringing up the issue of considering symptoms onset when interpreting point-of-care test results in acute care settings. Recognizing serious infection in children can be challenging, especially at disease onset when the severity of the infection is unclear. Although the choice of biomarker is pivotal in the risk assessment of acutely ill children guided by the point-of-care test result, we had very good rationale to choose C-reactive protein (CRP) as our preferred test.
Previous research:
CRP and procalcitonin were identified as the best inflammatory markers for serious infections in children to date in a systematic review, which only identified studies from hospital settings.[1] A CRP <20mg/L and procalcitonin <0.5ng/mL significantly reduce the risk of missing a serious infection in children. Our recent study on point-of-care (POC) CRP in primary care found an even lower threshold of 5mg/L to rule out serious infection in those children, probably due to the early presentation in primary care, when the inflammatory response is still developing, which indeed confirms the importance of setting.[2]
However, as shown in Figure 6 of the paper by Van den Bruel et al., C-reactive protein and procalcitonin had comparable diagnostic accuracy in the systematic review, as the shape of the curves was roughly similar and the confidence intervals were largely overlapping.[1]
Practical...
Show MoreWith great interest, I read a recent study by Verakel et al (1). illustrating the utility of a newly developed algorithm for excluding serious infections (SI) in acutely ill children. Their algorithm stratifies patients into three risk groups based on the values of point-of-care C reactive protein (POC CRP) and is meant to assist the decision making of physicians, especially trainees. This method demonstrated excellent diagnostic performance and enabled physicians to rule out 36% of SI in children visiting outpatient clinics and emergency departments. However, their proposed method does raise some concerns about potential negative consequences in the educational context.
Show MoreThe algorithm requires physicians to perform the POC CRP test for all patients regardless of their pre-test probability of SIs. In addition, their model may lead young physicians to draw conclusions about the patients’ clinical features only after estimating the risk of SI based on the POC CRP value and may cause them to neglect the importance of history taking and physical examinations.
As the authors state, the POC CRP is an innovative tool in pediatric acute care; a POC sample can be obtained by a simple finger prick and the test results can be obtained within several minutes. Nevertheless, in pediatric practice sometimes “doing nothing” is better than “doing something”. This may well be one of the most important principles in pediatrics (2-4). Our role as senior physicians is to show traine...
I read the article with interest and wish to congratulate the authors for their genuine work on a little known subject.
However there are certain points which require elaboration:
(a) It is likely that there are independent genetic factors that are responsible for a baby being born SGA and the same factors may be playing a role in affecting cognitive outcomes.These factors have not been addressed in the study.
(b) Cognitive outcome of a child is the result of certain internal and certain extraneous factors (eg environmental stimulation).The extraneous factors may confound the results of the above study.
(c) Open heart surgery per se may be detrimental to the cognitive development of a child .But there are certain factors such as Bypass time,duration of mechanical ventilation,exposure to hypotensive milieu,etc that need to be explored in order to get an indepth insight into the subject.
To summarize, the article is a praiseworthy effort into a novel field which opens up potentials of further avenues of research.
I am grateful for the clarification of one specific point made in the original paper published in Archives of Disease in Childhood by Richard Franklin, John Pearn and Amy Peden (Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of Disease in Childhood 2017; 102:888-93). This relates to their recommendations on swimming safely that reflected both their collective experiential opinion, as well as the recommendations of authorities such as the ‘Royal Life Saving Society – Australia’ and other Australian water safety organisations. Understandably, these authorities will have a significant adult bias and one could – and reasonably should – question some of their criteria, both in terms of ‘seizures’ (i.e. what type of 'seizure') and seizure-frequency. I would challenge the comment made by the International Life Saving Federation in which they state: “Epilepsy submersion and drowning risk is greatest in an identified high-risk group that includes: those with frequent (more than one per year) seizures….”; the majority of paediatricians and paediatric neurologists and probably adult physicians that treat people with epilepsy would not define “frequent” as more than one seizure per year; by definition this would include two seizures per year. My point remains that doctors, and the many different authorities to which they provide expert advice, should no longer consider and cite epilepsy as a single disorder but as a group of disorders...
Show MoreThe authors have added an interesting opportunity to refine our clinical decision making with the addition of a point of care test (POC) . However I would argue that choice of POC test might be a critical factor here and very much dependent on initial onset of symptoms. Some years ago published data on the then relatively new POC test for Procalcitonin (PCT-Q) indicated that children presenting within 24 h, PCT performed significantly better (AUC 0.96, SE 0.05) than CRP (0.74, 0.12).(1) This could well explain the differences the authors found in the primary care arm of their study. Setting for these tests becomes increasingly important as we see a shift of more children being seen in GP run Urgent Care Centres with a possibly a different spectrum of illness severity.(2) Prospective studies in different settings comparing both of these biomarkers as POCs would be worth further cosideration.
References
1 K. Brent, S .M. Hughes, S .Kumar, A. Gupta, A. Trewick,
S. Rainbow, R. Wall and M. Blair
Is procalcitonin a discriminant marker of early
invasive bacterial infection in children?
Current Paediatrics (2003) 13, 399
2 . Gritz A, Sen A, Hiles S, Mackenzie G, Blair M. G241(P) More under-fives now seen in urgent care centre than A&E- should we shift our focus? Arch Dis Child [Internet]. 2016 Apr 27 [cited 2016 Aug 3];101(Suppl 1):A132.1-A132. Available from:...
Show MoreDear Editor,
We appreciated the paper by McCrossan and others but we believe that the diagnosis of pneumonia in children should be made on a clinical ground and that chest X-rays should be considered only in case of a diagnostic doubt or to rule out a complication such as pleural effusion.[1] A X-ray control after a round pneumonia in adults is prescribed with the aim of ruling out an undelying cancer but this is an extremely rare condition in children. Considering this, rather than discussing the opportunity of a radiologic follow up we should consider the opportunity of adapting international guidelines to children.
1. McCrossan P, McNaughten B, Shields M et al. Is follow up chest X-ray required in children with round pneumonia? Arch Dis Child 2017;102:1182-1183
Response to Edward J O’Hagan: Tertium non datur
I thank Mr O’Hagan for his insightful comments. Indeed it is implicit in the ideas put forward in my paper that a specific infection is not the “cause” of SIDS but, rather, it is the immunological response to the infection (bacterial or viral) in the predisposed infant that results in SIDS as proposed by Dr Korsch with his suggested “immunological burst.”
As mentioned in my response to Dr Korsch, I have extended the infection paradigm to take into account the as yet unexplained risk factor of prone sleep position. (See my paper accepted for publication in Frontiers in Pediatrics.1) The presence of infection is a requirement for the effect of prone sleep position to prevail and suggests a role for the Vagus in unfavourably tipping the homeostatic balance through neuroimmunological pathways.
Paul N. Goldwater
Reference:
1. Goldwater PN. SIDS, infection, prone sleep position & Vagal neuroimmunology. Front Pediatr 2017; doi:10.3389/fped.2017.00223
Conflict of interest
None declared.
Response to Dr Eckhard Korsch’s letter: SIDS as the consequence of an immunological burst
I thank Dr Korsch for his supportive and helpful comments with which I fully concur. I remain concerned by the general lack of appreciation by mainstream SIDS researchers of the essential requirement of congruency between risk factors (male gender, prone sleep position, contaminated sleeping surfaces, smoke exposure, lack of breast feeding, high birth order, etc.) and various staining findings of brainstem nuclei or other pathological findings such as intrathoracic petechiae. The silence from the mainstream sector in relation to my ideas is also of concern. Funding of mainstream SIDS research will continue unimpeded as long as facts set out in my papers are not publicised and addressed. Such funding is an unconscionable waste.
In a new paper accepted for publication in Frontiers in Pediatrics1 I have extended the infection paradigm to take into account the as yet unexplained risk factor of prone sleep position. It seems that only in the presence of infection does prone sleep position achieve significance. My thinking suggests a role for the Vagus in unfavourably tipping the homeostatic balance through neuroimmunological pathways.
Paul N. Goldwater
Reference:
1. Goldwater PN. SIDS, infection, prone sleep position & Vagal neuroimmunology. Front Pediatr 2017; doi:10.3389/fped.2017.00223
Conflict of interest
None declared.
Confusion may arise in the minds of UK-based readers of this article due to the terminology used in this article, which differs slightly from the notion of “community paediatrics” in the UK.
Whereas in the UK all children receive primary care from a General Practitioner (GP), who then makes referrals to secondary and tertiary level specialists as required, the Israeli “community paediatrician” referred to in this article is actually a primary care paediatrician, who delivers all aspects of medical care to the infant and child, much as the GP in the UK does for both adults and children.
The majority of children and young people in Israel receive primary medical care from a fully qualified paediatrician who has achieved consultant (or specialist) status with a minimum of 4.5-5 years of general paediatric training. Only a minority of children and young people in Israel receive primary medical care from a Family Physician (equivalent to the UK “GP”). Paediatricians in Israel can work either in primary care or as paediatricians with an additional sub-specialty in hospitals, or can work in both settings in parallel (often working part or full time in hospital and moonlighting in primary care).
In the UK, the “community paediatrician” is a second tier specialist who deals in specific medical areas , and accepts referrals from the primary medical carer (GP), via a selective referral system. Community paediatricians in the UK usually provide neuro-development...
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After reviewing some cases presenting to Bristol with Rhabdomyolysis I wondered if this child had genetics sent for Ryanodine Receptor gene (RYR gene). This can cause malignant hyperthermia and in our case the boy resented with muscle pain on exertion and recurrent rhabdomyolysis. The article below is useful.
Chan EK, Kornberg AJ, Ryan MM, A diagnostic approach to recurrent myalgia and rhabdomyolysis in children. Archives of Disease in Childhood 2015;100:793-797.
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