We thank Dr Di Mascio and his colleagues for their interest in our
study. In response we would like to point out that only a very small
proportion (5.8%) of the children admitted with NSAP were subsequently
hospitalised with bowel pathology (1). The increased relative risk of
being diagnosed with appendicitis in the first year following a diagnosis
of NSAP is clearly notable.
We thank Dr Di Mascio and his colleagues for their interest in our
study. In response we would like to point out that only a very small
proportion (5.8%) of the children admitted with NSAP were subsequently
hospitalised with bowel pathology (1). The increased relative risk of
being diagnosed with appendicitis in the first year following a diagnosis
of NSAP is clearly notable.
Further analysis of the data shows that, considering "acute and
unspecified appendicitis" (ICD10 K35 & K37) and "other appendicitis"
(K36) together, of the 268 623 NSAP cohort 6274 (2%) children were
admitted with appendicitis within the first year after their NSAP
admission. We excluded cases where appendicitis occurred on the same
admission record as the code for NSAP because this was a follow-up study
based on person-days at risk. Of the 6274 children who were admitted with
appendicitis within the first year following an admission with NSAP, 1926
(31% of the 6274) experienced the appendicitis admission within 1-3 days
and 2505 (40%) experienced the appendicitis admission within 1-7 days of
the admission with NSAP. This leaves an excess number of children who do
get admitted with appendicitis some considerable time after the initial
admission with NSAP, as the rate ratio remained significantly high even
after 10 years (1). The small single centre study, described by Dr Di
Mascio and colleagues, with just a short period of time studied between
NSAP and appendicitis, is not comparable with our huge cohort constructed
from linked English national hospital episode statistics with substantial
follow-up.
It is not known what pre-disposes individuals and protects others
from developing acute appendicitis. One can perhaps hypothesise that a
number of these children who were unwell enough to be admitted with NSAP
have appendicular colic as the cause of their pain and may have some
predisposition such as the luminal size or anatomical site of of their
appendicular orifice which may subsequently lead to clinical appendicitis.
Kind regards
1- Diagnostic outcomes following childhood non-specific abdominal
pain: a record-linkage study G C D Thornton, M J Goldacre, R Goldacre, L J
Howarth Arch. Dis. Child. 2016 101:305-309
We support any idea or initiative to try to better understand the
covariates of paracetamol PK in neonates, including the potential impact
of excipients (propylene glycol, mannitol or none) on paracetamol
clearance.
We have carefully read the e-letter of Pisapia et al., and support
the potential impact of mannitol co-administration on paracetamol
clearance, however, we do have some relevant additional comments...
We support any idea or initiative to try to better understand the
covariates of paracetamol PK in neonates, including the potential impact
of excipients (propylene glycol, mannitol or none) on paracetamol
clearance.
We have carefully read the e-letter of Pisapia et al., and support
the potential impact of mannitol co-administration on paracetamol
clearance, however, we do have some relevant additional comments.
First, in the initial versions of the paper, we have explored the
potential impact of the different study as an indicator for potential
differences, including excipients, but this turned out to be negative.
This is a common practice for pooled datasets. This does not mean that
there is no impact, but it did not reach sufficient impact to be
quantified in this cohort of 150 neonates or has been superimposed by
other variables;
Second, if mannitol stimulates diuresis, it is not very likely to
affect paracetamol clearance since urinary elimination of paracetamol is a
very minor route of elimination in neonates, while sulphation and
glucuronidation are the most important contributors (1,2). For drugs
eliminated by renal route, the impact may be more relevant.
Finally, and in order to correct the suggestions made, the estimates
should correct for the 'real doses' administered, commonly below 60
mg/kg/24h while the impact of paracetamol administration on hemodynamics
in both neonates and healthy adult volunteers have been quantified (3,4).
References
1) Allegaert K, de Hoon J, Verbesselt R, Vanhole C, Devlieger H,
Tibboel D. Intra- and interindividual variability of glucuronidation of
paracetamol during repeated administration of propacetamol in neonates.
Acta Paediatr 2005;94:1273-9.
2) Krekels EH, van Ham S, Allegaert K, et al. Developmental changes rather
than repeated administration drive paracetamol glucuronidation in neonates
and infants. Eur J Clin Pharmacol 2015;71:1075-82.
3) Allegaert K, Naulaers G. Haemodynamics of intravenous paracetamol in
neonates. Eur J Clin Pharmacol 2010;66:855-8.
4) Chiam E, Weinberg L, Bailey M, McNicol L, Bellomo R. The haemodynamic
effects of intravenous paracetamol (acetaminophen) in healthy volunteers:
a double-blind, randomized, triple crossover trial. Br J Clin Pharmacol
2016;81:605-12.
Dear editor,
In their study G C D Thornton and al (1) found a diagnosis of appendicitis
in 6065 children out of 268623, previously diagnosed as non specific
abdominal pain (NSAP) at the first access, who returned within one year.
According to their data, the RR to develop appendicitis in the first year
after discharge with a diagnosis of NSAP is 15.04 times higher than the
risk in the control cohort. Appendicitis is an a...
Dear editor,
In their study G C D Thornton and al (1) found a diagnosis of appendicitis
in 6065 children out of 268623, previously diagnosed as non specific
abdominal pain (NSAP) at the first access, who returned within one year.
According to their data, the RR to develop appendicitis in the first year
after discharge with a diagnosis of NSAP is 15.04 times higher than the
risk in the control cohort. Appendicitis is an acute disease with a rapid
development (2) and, as expected for an acute condition, the RR gets down
considerably after the first year (RR 3.26 at 1-4 years; 2.13 at 5-9
years).
We recently evaluated patients readmitted to our emergency department,
from March 2015 to September 2015, with a previous diagnosis of abdominal
pain without a defined cause: we had 37 patients hospitalized for
appendicitis, 23 of them were diagnosed at the first access, 6 returned
within 72 hours, other 7 cases were readmitted within 7 days, and only one
returned in more than a week.
It could be interesting to know how many patients with appendicitis in the
Thornton's series were readmitted in an acute setting (defined as
readmission within 72 hours) or in the first week after discharge. A high
number of early readmissions would strongly clarify this otherwise very
puzzling connection.
Bibliography
1- Diagnostic outcomes following childhood non-specific abdominal
pain: a record-linkage study G C D Thornton, M J Goldacre, R Goldacre, L J
Howarth Arch. Dis. Child. 2016 101:305-309
2- Appendicitis. Lewis SR, Mahony PJ, Simpson J. BMJ. 2011 Oct
6;343:d5976
Thyroid hormone is critical for normal growth and brain development,
and hypothyroidism in infancy is the leading cause of intellectual
impairment worldwide.
Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones
at birth.
Congenital hypothyroidism is very important clinically since severe cases
will lead to irreversible mental handicap without prompt treatment.
Thyroid hormone is critical for normal growth and brain development,
and hypothyroidism in infancy is the leading cause of intellectual
impairment worldwide.
Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones
at birth.
Congenital hypothyroidism is very important clinically since severe cases
will lead to irreversible mental handicap without prompt treatment.
The essential role of thyroid hormones in brain development during
the first 24-36 months of age is well established; thus prompt
normalization of thyroid hormone levels is essential .
The incidence of CH diagnosed by neonatal screening varies per population,
ranging from 1 in 2000 to 1 in 3000 births and is comparatively higher
than the reported incidence prior to the era of screening.
Following clinical assessment, a good venous blood sample for
measurement of free thyroxine (fT4) and TSH is mandatory, since the result
reflects the presence and severity of congenital hypothyroidism.
Compared to venous serum, the concentrations in skin puncture serum
were higher for thyroid stimulating hormone (TSH) (86.7%). Capillary TSH
dried blood spot testing on the 3rd-5th day is the most sensitive method.
In our setup we could use only venous blood TSH levels rather than
capillary blood samples reason may be having expert nursing care to
collect the blood samples but not having sufficient infrastructure and
personnel to implement the same.
In our experience 4 babies out of 1500 had transient elevated TSH
levels which on follow up normalized within 3 weeks after birth without
treatment. There was no proved case of congenital hypothyroidism was seen
probable reasons may be use of common salt fortified with iodine for
cooking and staple diet being mainly fish.
In countries that can afford newborn screening, treatment within the
first 28 days of life - so-called 'early treatment' - has transformed the
outlook for children with CH so that severe growth retardation with mental
handicap(congenital hypothyroidism) is no longer seen.
It is described as primary when the gland itself is affected and
central when the defect lies in the hypothalamo-pituitary axis;
compensated when the hypothalamo-pituitary-thyroid axis is jeopardised but
still manages to maintain normal thyroxine (T4) levels and decompensated
when normal thyroid hormone levels cannot be maintained.
Van der Sluijs Veer et al. studied 95 toddlers with CH in whom L-
thyroxine treatment had been started at a median age of 9 days, with
normalization of the serum free T4 concentration within 2.1 days and of
the serum TSH level within 18.6 days.
Cord FT4 identifies only infants with severe CH. Cord TSH is more
sensitive than cord FT4 screening. Capillary TSH dried blood spot testing
on the 3rd-5th day is the most sensitive method.
In our experience it was found that serum thyrotropin values at 2nd and
3rd day were useful in screening and early treatment of congenital
hypothyroidism.
References :
Nikolina Zdraveska, Violeta Anastasovska and Mirjana Kocova.
Frequency of thyroid status monitoring in the first year of life and
predictors for more frequent monitoring in infants with congenital
hypothyroidism. J Pediatr Endocrinol Metab 2016; aop
Ari J. Wassner and Rosalind S. Brown. Hypothyroidism in the Newborn
Period. Curr Opin Endocrinol Diabetes Obes. 2013 Oct; 20(5): 449-454. doi:
10.1097/01.med.0000433063.78799.c2
Deladoey J, Ruel J, Gigu?re Y, et al. Is the incidence of congenital
hypothyroidism really increasing? A 20-year retrospective population-based
study in Quebec. J Clin Endocrinol Metab 2011;96:2422-9.
Grosse SD, Van Vliet G. Prevention of intellectual disability through
screening for congenital hypothyroidism: how much and at what level? Arch
Dis Child 2011;96:374-9.
Corbetta C, Weber G, Cortinovis F, Calebiro D, Passoni A, Vigone MC
et al. A 7-year experience with low blood TSH cutoff levels for neonatal
screening reveals an unsuspected frequency of congenital hypothyroidism
(CH). Clin Endocrinol (Oxf). 2009 Nov;71(5):739-45. doi: 10.1111/j.1365-
2265.2009.03568.x. Epub 2009 Mar 28.
Hardy JD, Zayed R, Doss I, Dhatt GS. Cord blood thyroxine and thyroid
stimulating hormone screening for congenital hypothyroidism: how useful
are they? J Pediatr Endocrinol Metab. 2008 Mar;21(3):245-9.
Hardy JD1, Zayed R, Doss I, Dhatt GS. Cord blood thyroxine and
thyroid stimulating hormone screening for congenital hypothyroidism: how
useful are they? J Pediatr Endocrinol Metab. 2008 Mar;21(3):245-9.
Heyerdahl S. Long-term outcome in children with congenital
hypothyroidism. Acta Paediatr 2001;90:1220-2.
Falch DK. Clinical chemical analyses of serum obtained from capillary
versus venous blood, using Microtainers and Vacutainers. Scand J Clin Lab
Invest. 1981 Feb;41(1):59-62.
We have found very interesting the paper by Dr Allegaert et al. about
iv paracetamol pharmacokinetics (1) in which they referred that between-
subject variability (BSV) is explained by covariates such as size, weight,
disease characteristics or co-administration of drugs. They mentioned that
they found an unexplained variance in paracetamol clearance, and that it
remained high (39,1 per cent) even a...
We have found very interesting the paper by Dr Allegaert et al. about
iv paracetamol pharmacokinetics (1) in which they referred that between-
subject variability (BSV) is explained by covariates such as size, weight,
disease characteristics or co-administration of drugs. They mentioned that
they found an unexplained variance in paracetamol clearance, and that it
remained high (39,1 per cent) even after taking size, age and bilirubin
into account.
Regarding the co-administration of drugs as a covariate, an issue
that was not addressed in the paper, we would like to note that the
neonates included in the pooled analysis (n: 158) were from different
studies and had been administered three different iv paracetamol
formulations; one of them (Perfalgan) with a considerable amount of
mannitol (3,85g/100ml) as excipient. Thus, the
neonates in study 3 (n: 50) were administered every 6 hours a concomitant
mannitol dose of 58 mg/Kg with each paracetamol dose of 15 mg/Kg; they
received 232 mg/Kg/day of mannitol during 2 to 7 days.
The amount of mannitol included as excipient in pharmaceutical
products licensed for adults and children is considered a non-active
ingredient because it is far below the pharmacologically significant dose
for them. However, it could be enough to show an osmotic diuretic effect
in neonates, especially in low weight preterm infants. This enhanced
osmotic effect would be greater in the most immature neonates and would
decline logarithmically during the first few weeks of life(2). The osmotic
diuretic effect of the same dose of mannitol could be considerably
different in accordance with the maturation of the renal function.
In Argentina iv paracetamol is available only since last year, with
mannitol as excipient.
In 2006 we had seen that a low amount of mannitol could have some
influence on the less oliguria observed with ibuprofen compared to
indomethacin for PDA closure.(3)
Last year, a new investigation by Chiam et al. showed that the majority of
the formulations with 1g iv paracetamol also contain near 4g of mannitol
(38-39mg/ml). They explained that this low amount of mannitol was a
clinically relevant dose which might cause hypotension in critically ill
adults due to its diuretic nature even in low doses.(4)
The fact that only 1/3 of neonates (50/158) in Allegaert et als study
were co-administered a concomitant diuretic dose of mannitol should be
considered, as it could have contributed to the extensive variability and
the unexplained high variance they found in iv paracetamol clearance.
Further research is necessary to evaluate the effects of low doses of
mannitol in neonates, especially in low birth weight infants, and to
determine how iv paracetamol pharmacodynamics and pharmacokinetics are
influenced, if so, by the mannitol content of the medication.
Jorge Pisapia. Matias Lucero. Leonardo Giunta.
Clinica y Maternidad Suizo Argentina. Department of Pharmacy. SWISS
MEDICAL GROUP. Buenos Aires. Argentina.
REFERENCES
1- Allegaert K, Palmer GM, Anderson BJ. The pharmacokinetics of
intravenous paracetamol in neonates: size matters most. Arch Dis Child
2011; 96:575???580.
2- Kleinman LI, Disney TA. Renal osmotic in the neonatal and adult
dog. Am J Physiol Renal Physiol 1984; 247 Issue 3 F396-F402.
3- Pisapia J, Giunta L, Alonso MR. Mannitol influence on the less
renal side effects of ibuprofen vs indomethacin for PDA closure. Arch Dis
Child
2003;88:1135.adc.bmj.com/content/88/12/1134.full/reply#archdischild_el_1881
Jan 2006
4- Chiam E, Weinberg L, Bellomo R. Paracetamol: a review with
specific focus on the haemodynamic effects of intravenous administration.
Heart Lung Vessel 2015; 7(2):121-32.
The MCS research by Massion and colleagues on childhood obesity
should be read in the light of other recent cohort studies exploring the
impact of early life factors in the UK and the USA (1). Kimbro and
Augustine found that US children living in married two biological parent
households had a lower risk of obesity than those living in other family
types. In the presence of other controls, poverty was not a significant
r...
The MCS research by Massion and colleagues on childhood obesity
should be read in the light of other recent cohort studies exploring the
impact of early life factors in the UK and the USA (1). Kimbro and
Augustine found that US children living in married two biological parent
households had a lower risk of obesity than those living in other family
types. In the presence of other controls, poverty was not a significant
risk factor for childhood obesity (2).
The reported associations of childhood obesity with parents'
educational attainment and smoking status are certainly important. Goodman
and Greaves, using the MCS, found that the educational attainment of
mothers was the strongest predictor of cognitive and social development in
children born in two parent households. This attenuated a significant
effect of parental marriage. Early parental separation had a major impact
on cognitive and social development, and this was much more common among
unmarried couples (3). Also, unmarried adults are more likely to smoke
(4).
Conclusions about the impact of early life factors on health
inequalities for children cannot be made without controlling for family
structure. Some of the reported findings of this research might be
confounded by the marital status of parents and parental separation.
1. Massion S, Wickham S, Pearce A, Barr B, Law C, Taylor-Robinson D.
Exploring the impact of early life factors on inequalities in risk of
overweight in UK children: findings from the UK Millenium Cohort Study.
Arch Dis Child 2016
2. Augustine J, Kimbro R. Family Structure and Obesity among US
Children. Journal of Applied Research on Children 2013
3. Goodman A, Greaves E. Cohabitation, marriage and child outcomes.
IFS Commentary C114 2010
4. Adult Smoking Habits in Great Britain: 2014. ONS 2016
In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety
netting advice and its documentation...
In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety
netting advice and its documentation in the medical notes, the authors
propose the introduction of a checklist. However, at this moment the
effective components or the best way to perform this safety netting
management still remains unknown.
A systematic review of Neill et al. states that incomplete
information on the illness of their child leaves parents still in need for
help.(1) Moreover, irrelevant information reduces parents' trust in the
intervention.(1) We know that parental knowledge and satisfaction improved
more after video discharge instructions than after written discharge
instructions alone.(2) So to proceed we think the next step is to focus on
the parental role in the decision making process. One could think of
parental monitoring of alarming signs and symptoms of their febrile child.
A study on self-referred children with fever emphasized that many parents
properly judged and acted on their febrile child's severity of illness.(3)
In England every parent is trained to recognise petechial rash,(4) we
might enlarge this knowledge to other alarming or reassuring signs and
symptoms. This could be initiated for example for respiratory rate, a
useful marker of pneumonia, one of the most frequent serious illness at
the ED.(5) We are aware of current projects on this topic. A next step is
evaluating the impact of such strategies providing improved information on
patient (re)consultation.
In addition to the recognition of deterioration, an important gap in
safety netting literature is its time frame strategy. The development of
optimal safety netting management should include clinical signs and
symptoms, but also a disease specific time frame to inform parents when
they should seek help again. This combination of safety netting
determinants may establish new starting points for improvement of care.
References:
1. Neill S, Roland D, Jones CH, Thompson M, Lakhanpaul M, group ASs.
Information resources to aid parental decision-making on when to seek
medical care for their acutely sick child: a narrative systematic review.
BMJ Open. 2015;5:e008280 doi: 10.1136/bmjopen-2015-008280 [published
Online.
2. Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to
standard written instructions improved caregivers' understanding of their
child's emergency department visit, plan, and follow-up: a randomized
controlled trial. Pediatr Emerg Care. 2013;29:699-704 doi:
10.1097/PEC.0b013e3182955480 [published Online.
3. van Ierland Y, Seiger N, van Veen M, et al. Self-referral and serious
illness in children with fever. Pediatrics. 2012;129:e643-51 doi:
10.1542/peds.2011-1952 [published Online.
4. Acutely sick kid safety netting interventions for families.
http://asksniff.org.uk/
5. Taylor JA, Del Beccaro M, Done S, Winters W. Establishing clinically
relevant standards for tachypnea in febrile children younger than 2 years.
Arch Pediatr Adolesc Med. 1995;149:283-7 Online.
Bronchiolitis is on rise, both in prevalence and severity in our
country due to many social and life style factors. in our hospital we
adopted a protocol named: SuProNO INCLUDE:-
- PROVIDE VITAL SIGN ASSESSMENT and close monitoring
- PROVIDE O2 AS NEEDED
- Provide IV fluid/ NGT Feeds as appropriate
-provide Hypertonic (3%) saline nebulization
-provide nasal decongestant drops/ spray and suctioning as needed
- provide anti...
Bronchiolitis is on rise, both in prevalence and severity in our
country due to many social and life style factors. in our hospital we
adopted a protocol named: SuProNO INCLUDE:-
- PROVIDE VITAL SIGN ASSESSMENT and close monitoring
- PROVIDE O2 AS NEEDED
- Provide IV fluid/ NGT Feeds as appropriate
-provide Hypertonic (3%) saline nebulization
-provide nasal decongestant drops/ spray and suctioning as needed
- provide antipyretics if needed
-NO NO NO antibiotics
NO NO NO steroids.
with this protocol, the out come is excellent even for severe cases,
with short hospitalization, and no need for high facility respiratory
support like CPAP or ventilator.
Safety netting in the Emergency Department (ED) is key to the
practice of safe medicine. Following the article by de Vos-Kerkhof (1),
we present further evidence to suggest that there is a lack of
standardised safety netting. In addition, we found a disparity between
paediatric trainees' perception of their safety netting practice and what
they actually documented in the medical notes.
Safety netting in the Emergency Department (ED) is key to the
practice of safe medicine. Following the article by de Vos-Kerkhof (1),
we present further evidence to suggest that there is a lack of
standardised safety netting. In addition, we found a disparity between
paediatric trainees' perception of their safety netting practice and what
they actually documented in the medical notes.
In a retrospective case notes review of 100 consecutive ED
attendances to our hospital seen by the paediatric team and discharged
from ED, only 16% had documentation that the families had been told about
the existence of uncertainty around the diagnosis and the course of the
illness. This compares unfavourably with the fact that 73% of surveyed
paediatric trainees reported that they routinely mentioned this to
families. Furthermore, the signs and symptoms to look for had only been
documented in 27% of cases, though 88% of trainees reported discussing
this with the family. 39% of the notes reviewed had no specific safety
netting documentation of any kind.
It is clear that for non-consultant paediatricians, who are the
clinicians seeing most referred children in ED, a gap exists between the
safety netting that they report undertaking and what is documented. This
may be in part because they provided verbal safety netting advice without
documenting it but it also suggests that safety netting procedures are
poor, despite the clinical and medico-legal imperative for adequate safety
netting and documentation advocated by the National Institute for Health
and Care Excellence(2).
Clearly training for junior doctors on safety netting and its
documentation needs to improve. A safety netting checklist and more high
quality patient information leaflets may help clinicians to offer adequate
advice and information to families at the time of discharge.
(297 words)
1. de Vos-Kerkhof E, Geurts DH, Wiggers M, Moll HA and Oostenbrink R.
Tools for 'safety netting' in common paediatric illnesses: a systematic
review in emergency care. Archives of Disease in Childhood. 2016; 101: 131
-9.
2. Fields E, Chard J, Murphy MS and Richardson M. Assessment and
initial management of feverish illness in children younger than 5 years:
summary of updated NICE guidance. BMJ (Clinical Research Ed). 2013; 346:
f2866.
Khan et al. make a strong case for investment in point-of-care
lactate testing in low and middle income countries (LMICs) (1). They
believe that this would identify children at high risk of death, and would
save lives because these children could receive earlier resuscitation.
Unfortunately the optimal management of children with hyperlactataemia in
LMICs is far from clear. Although Khan et al. extrapolate from findings i...
Khan et al. make a strong case for investment in point-of-care
lactate testing in low and middle income countries (LMICs) (1). They
believe that this would identify children at high risk of death, and would
save lives because these children could receive earlier resuscitation.
Unfortunately the optimal management of children with hyperlactataemia in
LMICs is far from clear. Although Khan et al. extrapolate from findings in
well-resourced settings to suggest that early fluid resuscitation would be
beneficial, this is contrary to the findings of the FEAST study in which
bolus fluid resuscitation in African children with signs of shock produced
an increase in mortality (2). Of note, this effect was also observed in
the subgroup of children with hyperlactataemia.
Not only is hyperlactataemia a consequence of sepsis, but it is also
a defining feature of severe malaria which is a common cause of death in
many LMICs (3). Unlike the situation in sepsis, the pathophysiology of
hyperlactataemia in malaria is thought to involve microvascular
obstruction by parasitized red blood cells, microvascular dysfunction, and
anaemia (4,5). Aggressive fluid resuscitation is discouraged in severe
malaria, and detailed physiological studies in adults with severe malaria
showed that fluid resuscitation failed to reduce microvascular obstruction
and lactate concentrations (5). However, when hyperlactataemia is
associated with severe malarial anaemia, blood transfusion can be
lifesaving (3).
It is likely that point of care lactate testing in LMICs would
achieve the goal of identifying children at higher risk of death, but it
is far from certain whether this would be accompanied by the improved
outcomes that would be needed to justify the investment. Amongst children
with malaria it may identify the need for parenteral artesunate or blood
transfusion, but in children with sepsis further research is needed to
define the optimal management strategies when intensive care is limited or
unavailable.
1. Khan M, Brown N, Mian AI. Point-of-care lactate measurement in
resource-poor settings. Arch Dis Child 2016;101(4):297-8.
2. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in
African children with severe infection. N Engl J Med 2011;364(26):2483-95.
3. World Health Organization. Guidelines for the treatment of malaria.
Third edition, 2015.
4. Miller LH, Ackerman HC, Su XZ, et al. Malaria biology and disease
pathogenesis: insights for new treatments. Nature medicine 2013;19(2):156-
67.
5. Hanson JP, Lam SW, Mohanty S, et al. Fluid resuscitation of adults with
severe falciparum malaria: effects on Acid-base status, renal function,
and extravascular lung water. Crit Care Med 2013;41(4):972-81.
Dear Editor,
We thank Dr Di Mascio and his colleagues for their interest in our study. In response we would like to point out that only a very small proportion (5.8%) of the children admitted with NSAP were subsequently hospitalised with bowel pathology (1). The increased relative risk of being diagnosed with appendicitis in the first year following a diagnosis of NSAP is clearly notable.
Further anal...
We support any idea or initiative to try to better understand the covariates of paracetamol PK in neonates, including the potential impact of excipients (propylene glycol, mannitol or none) on paracetamol clearance.
We have carefully read the e-letter of Pisapia et al., and support the potential impact of mannitol co-administration on paracetamol clearance, however, we do have some relevant additional comments...
Dear editor, In their study G C D Thornton and al (1) found a diagnosis of appendicitis in 6065 children out of 268623, previously diagnosed as non specific abdominal pain (NSAP) at the first access, who returned within one year. According to their data, the RR to develop appendicitis in the first year after discharge with a diagnosis of NSAP is 15.04 times higher than the risk in the control cohort. Appendicitis is an a...
Thyroid hormone is critical for normal growth and brain development, and hypothyroidism in infancy is the leading cause of intellectual impairment worldwide. Congenital hypothyroidism (CH), defined as deficiency of thyroid hormones at birth. Congenital hypothyroidism is very important clinically since severe cases will lead to irreversible mental handicap without prompt treatment.
The essential role of thyroid...
To the editor:
We have found very interesting the paper by Dr Allegaert et al. about iv paracetamol pharmacokinetics (1) in which they referred that between- subject variability (BSV) is explained by covariates such as size, weight, disease characteristics or co-administration of drugs. They mentioned that they found an unexplained variance in paracetamol clearance, and that it remained high (39,1 per cent) even a...
The MCS research by Massion and colleagues on childhood obesity should be read in the light of other recent cohort studies exploring the impact of early life factors in the UK and the USA (1). Kimbro and Augustine found that US children living in married two biological parent households had a lower risk of obesity than those living in other family types. In the presence of other controls, poverty was not a significant r...
Dear editor,
In their letter, colleagues Jacob et al. raised further evidence of the lack of standardised safety netting. We thank them for their comments emphasizing the disparity between paediatric trainees' perception of their safety netting practice and their documentation in the medical notes.
To overcome the lack of information on the difference of given safety netting advice and its documentation...
Bronchiolitis is on rise, both in prevalence and severity in our country due to many social and life style factors. in our hospital we adopted a protocol named: SuProNO INCLUDE:- - PROVIDE VITAL SIGN ASSESSMENT and close monitoring - PROVIDE O2 AS NEEDED - Provide IV fluid/ NGT Feeds as appropriate -provide Hypertonic (3%) saline nebulization -provide nasal decongestant drops/ spray and suctioning as needed - provide anti...
Safety netting in the Emergency Department (ED) is key to the practice of safe medicine. Following the article by de Vos-Kerkhof (1), we present further evidence to suggest that there is a lack of standardised safety netting. In addition, we found a disparity between paediatric trainees' perception of their safety netting practice and what they actually documented in the medical notes.
In a retrospective case...
Khan et al. make a strong case for investment in point-of-care lactate testing in low and middle income countries (LMICs) (1). They believe that this would identify children at high risk of death, and would save lives because these children could receive earlier resuscitation. Unfortunately the optimal management of children with hyperlactataemia in LMICs is far from clear. Although Khan et al. extrapolate from findings i...
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