1531 e-Letters

  • Authors' reply:

    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]


    Show More
  • CRP first? : Less is better for education

    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...

    Show More
  • Population-based study of cognitive outcomes in congenital heart defects: Novel Information about a not so uncommon entity

    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.

  • Response to Seizures, safety and submersion: sense and sensibility

    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 More
  • Testing in relation to timing of illness needs to be considered

    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.

    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&amp;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 More
  • Nevere X ray

    Dear 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

    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


    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

    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


    1. Goldwater PN. SIDS, infection, prone sleep position & Vagal neuroimmunology. Front Pediatr 2017; doi:10.3389/fped.2017.00223

    Conflict of interest

    None declared.

  • Community paediatrics in Israel - spotlight on terminology

    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...

    Show More
  • Ryanodine Receptor mutation

    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.