We welcome your interest in our paper(1) and in general agree with
your comments. However, in our paper we wanted to emphasise the actions,
which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood
tests for those with paracetamol level below the treatment line at 4 hours
post overdose and an overdose <150 mg/kg. However, t...
We welcome your interest in our paper(1) and in general agree with
your comments. However, in our paper we wanted to emphasise the actions,
which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood
tests for those with paracetamol level below the treatment line at 4 hours
post overdose and an overdose <150 mg/kg. However, the time of
ingestion is not always clear and paracetamol toxicity may follow multiple
doses or chronic use(2). If there is any doubt about either of these and
especially in younger children with viral infection receiving multiple
doses we suggest that it is sensible to repeat liver function tests after
24 hours.
We agree that in children who have taken paracetamol deliberatively
should undergo a psychosocial review prior to discharge, so repeating
liver function tests may not necessarily increase the hospital stay.
Should it be appropriate that they be discharged within 24 hours, than a
clinical judgement should be made on the need for repeat blood tests.
It is correct that blood tests may be repeated at the end of NAC
infusion.. But in those with the most severe illness especially where the
INR is above 2, an early blood test at 12 hours may guide further
management. This helps the team to contact a specialist liver centre for
advice and referral and in severe cases, facilitates continuation of NAC
without interruption.
S B K Mahadevan
P J McKiernan
D A Kelly
The Liver Unit
Birmingham Children’s Hospital
Steelhouse Lane
Birmingham B4 6NH
References:
1) S B K Mahadevan, P J McKiernan, P Davies, and D A Kelly
Paracetamol induced hepatotoxicity. Arch Dis Child 2006; 91:598-603.
2) Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with
acetaminophen: hepatoxicity after multiple doses in children. J Pediatr.
1998;132(1):22-7.
I have read with interest the article by Beattie et al on
inflammatory bowel disease (IBD) in children (1). In addition to the
standard treatment methods outlined in the article, many patients try
complementary and alternative medicines (CAM) (2). McCann et al has shown
that children with chronic disease were greater than three times more
likely to use complementary and alternative medicine, usually wi...
I have read with interest the article by Beattie et al on
inflammatory bowel disease (IBD) in children (1). In addition to the
standard treatment methods outlined in the article, many patients try
complementary and alternative medicines (CAM) (2). McCann et al has shown
that children with chronic disease were greater than three times more
likely to use complementary and alternative medicine, usually without a
paediatrician’s knowledge (3). In a multi centre study done by Heuschkel
et al, over 40% of children with chronic inflammatory bowel disease used
complementary medicine in addition to conventional therapies (4). Parental
CAM usage and the number of adverse effects from conventional therapies
were the only independent predictors of CAM use in that study.
Recently interest has been shown on the effect of omega-3 fatty acid
supplementation in inflammatory bowel disease. Meister et al had shown
that IBD tissues, after incubation with an elemental diet modified in its
fatty acid composition with fish oil, show an increase in IL-1ra/IL-1beta
cytokine ratio (5). They concluded that the effect of omega-3 fatty acid
modulation was significantly more marked in ulcerative colitis (UC)
compared with Crohn’s disease (CD) and suggested that dietary treatment of
UC may be possible. A recent double blind randomised placebo controlled
study done by Romano et al showed that enteric coated omega-3 fatty acids
in addition to treatment with 5-ASA were effective in maintaining
remission of paediatric CD (6). Tenikoff et al have investigated the
effect of pre treatment with Lyprinol (Pharmalink international), the
stabilised lipid extract of the New Zealand green-lipped mussel, currently
used to relieve symptoms of arthritis, on experimentally induced IBD in
mice (7). They had shown that Lyprinol treatment significantly reduced
body weight loss, disease activity index scores, crypt area losses and
caecum and colon weights compared with fish oil treatment. They conclude
that Lyprinol may be potentially useful in the treatment of IBD and the
benefit is unlikely to be due to the omega-3 fatty acid content.
In summary, practitioners caring for children and adolescents with
IBD need to be aware of the new research and developments in this field
and should adopt an open attitude, if the patients are using alternative
therapies.
Dr.R.Muhammed Specialist Registrar in Paediatrics University
Hospital of North Durham Durham
Competing interests declared: none
References:
1.. R M Beattie, N M Croft, J M Fell, N A Afzal, and R B Heuschkel
Inflammatory bowel disease Arch Dis Child 2006; 91: 426-432.
2. Day AS, Whitten KE, Bohane TD. Use of complementary and
alternative medicines by children and adolescents with inflammatory bowel
disease. J Paediatr Child Health 2004 Dec; 40(12): 681-4.
3.McCann LJ, Newell SJ. Survey of paediatric complementary and
alternative medicine use in health and chronic illnesses Arch Dis
Child.2006; 91: 173-174
4.Heuschkel R, Afzal N, Wuerth A, Zurakowski D, Leichtner A, Kemper
K, Tolia V, Bousvaros A Complementary medicine use in children and young
adults with inflammatory bowel disease Am J Gastroenterol. 2002 Feb;
97(2): 382-8.
5. Meister D, Ghosh S. Effect of fish oil enriched enteral diet on
inflammatory bowel disease tissues in organ culture: differential effects
on ulcerative colitis and Crohn's disease. World J Gastroenterol. 2005 Dec
21; 11(47): 7466-72.
6. Romano C, Cucchiara S, Barabino A, Annese V, Sferlazzas C
Usefulness of omega-3 fatty acid supplementation in addition to mesalazine
in maintaining remi.ssion in pediatric Crohn's disease: a double-blind,
randomized, placebo-controlled study. World J Gastroenterol. 2005 Dec 7;
11(45): 7118-21.
7. Tenikoff D, Murphy KJ, Le M, Howe PR, Howarth GS. Lyprinol
(stabilised lipid extract of New Zealand green-lipped mussel): a potential
preventative treatment modality for inflammatory bowel disease. J
Gastroenterol. 2005 Apr; 40(4): 361-5.
Drs Thakur and Pocha present an interesting case of spontaneous
primary pneumothorax. It is not unusual for such cases to present late. In
fact in nearly half the cases medical opinion is sought after 2 days or
more. The uncertainty about the management of primary and secondary
pneumothoraces appears to have been resolved by the revised guidelines
published by the British Thoracic Society (BTS) in 2003....
Drs Thakur and Pocha present an interesting case of spontaneous
primary pneumothorax. It is not unusual for such cases to present late. In
fact in nearly half the cases medical opinion is sought after 2 days or
more. The uncertainty about the management of primary and secondary
pneumothoraces appears to have been resolved by the revised guidelines
published by the British Thoracic Society (BTS) in 2003.
This case provides the right opportunity to highlight certain key
issues. Firstly pneumothoraces appear deceptively small on a 2-dimensional
AP chest radiograph. A pneumothorax measuring 2 cm on a chest x-ray where
the hemi thoracic diameter is 10 cm represents a loss of nearly 50% of the
lung volume. This is much larger than what x-ray appearance might suggest.
The new BTS guidelines have emphasized this by classifying pneumothoraces
into two groups, large (>/= 2 cm) and small (< 2 cm). The x-ray
shown suggests that the case presented perhaps had a large pneumothorax by
definition. The recommended management of such a patient as per the BTS
algorithm would probably be needle aspiration rather than simple
observation.
Secondly it is important to remember that in general the resolution
of spontaneous pneumothoraces is a slow process occurring at a rate of
1.25% to 1.8% of the hemithorax volume per day. A 50% pneumothorax would
therefore take approximately 4 weeks to resolve. Consequently frequent x-
rays are unwarranted. The process of resolution can be speeded up to four
times by the use of supplemental high flow (10 litres/minute) oxygen, and
this should be offered to any patient who is observed in the hospital.
Spontaneous pneumothorax is not an every day problem encountered by
paediatricians. The new BTS guidelines are a great asset in tackling this
problem.
Reference:
1. Henry M, Arnold T, Harvey J. BTS guidelines for management of
spontaneous pneumothorax. Thorax 2003;58:ii39.
The study conducted by Erlewy-Lajeunesse et al. is welcomed and
addresses the validity of a radicated clinical practice unsupported by
clear evidence.
In the discussion the authors clearly state that the study only
examined the short term (at one hour) impact of the combined therapy and
that longer measurement periods might present different results.
The study conducted by Erlewy-Lajeunesse et al. is welcomed and
addresses the validity of a radicated clinical practice unsupported by
clear evidence.
In the discussion the authors clearly state that the study only
examined the short term (at one hour) impact of the combined therapy and
that longer measurement periods might present different results.
However, the authors' final statement that the measured effect does
not "warrant routine use for rapid fever reduction" goes beyond the
findings of the study.
Further studies are needed to ascertain the impact of the combined
therapy on long term impact (> 4 hours) measuring not only the drop in
temperature but also estimating the number of repeat doses required to
control the pyrexia under each intervention.
It should also be noted that 15 mg/kg of paracetamol were
administered during the study while a lower dosage of 10 mg/kg is commonly
used in the hospital and GP practice setting. This could have had an
impact on the difference between combination therapy versus paracetamol
alone measured in the study.
We read the paper by Jimenez et al with interest regarding the
potential role of limited slice high resolution CT (HRCT) in children with
cystic fibrosis (1). Studies such as this utilising fewer CT sections at
greater intervals in children with diffuse lung disease warrant further
evaluation. We certainly agree with the authors’ assertion that CT should
be used judiciously in children and that tec...
We read the paper by Jimenez et al with interest regarding the
potential role of limited slice high resolution CT (HRCT) in children with
cystic fibrosis (1). Studies such as this utilising fewer CT sections at
greater intervals in children with diffuse lung disease warrant further
evaluation. We certainly agree with the authors’ assertion that CT should
be used judiciously in children and that technical parameters must be
modified in accordance with the size of the child.
We believe however that Jimenez et al have not fully addressed the
issues of radiation burden reduction in children. They have examined their
patients with different CT scanners but in all patients used ‘100-130mA,
with exposure times between 1 and 3 seconds, resulting in 100-300mAs’.
Exposure times can be machine dependent, but are now much faster with
newer multidetector CT scanners which should be widely available. The mA
they have used on their patient group is unnecessarily high in our
opinion. [The mA (milliAmperage) used is the major determinant of CT dose,
together with, albeit to a lesser degree, the kV (kilovoltage) setting of
the machine. Of note, mA multiplied by time, in seconds, equals mAs].
Examples of truly low dose HRCT techniques have been in use for some
time with authors stating that acceptable image quality can be obtained
using only 10 or 20mA, which is a fraction of the dose used by Jimenez et
al in their study (2-5). Whilst such extremely low dose techniques may not
be widely utilised, it is fair to state that lower mA studies are possible
in every day practice even with older single slice helical CT scanners.
There is a balance between diagnostic image quality [with sufficient
signal] and image noise when extremely low mA doses are used. If the dose
is too low the images may become too ‘noisy’ thus impairing the overall
acceptability of the images, and rendering them non-diagnostic. We
currently perform HRCT sections at a maximum of 30mAs in children of less
than 35kg, and use no more than 55mAs in children weighing 35-54kg in our
routine practice. To keep the radiation burden to a minimum the mA, and
thus mAs also, should be set as low as reasonably achievable (ALARA
principle) whilst maintaining diagnostic image quality.
Kieran McHugh, FRCR
Catherine Owens, FRCR.
Consultant Paediatric Radiologists
Great Ormond Street Hospital for Children
London WC1N 3JH
References:
1. Jimenez S, Jimenez JR, Crespo M, et al. Computed tomography in children
with cystic fibrosis: a new way to reduce the radiation dose. Arch Dis
Child 2006;91:388-390.
2. Zwirewich CV, Mayo JR, Muller NL. Low-dose high-resolution CT of
lung parenchyma. Radiology 1991;180:413-417.
3. Naidich DP, Marshall CH, Gribbin C, et al. Low-dose CT of the
lungs: preliminary observations. Radiology 1990;175:729-731.
4. Ambrosino MM, Genieser NB, Roche KJ, et al. Feasibility of high-
resolution low-dose chest CT in evaluating the pediatric chest. Pediatr
Radiol 1994;24:6-10.
5. Lucaya J, Piqueras J, Garcia-Pena P, et al. Low-dose high-
resolution CT of the chest in children and young adults: dose co-
operation, artifact incidence, and image quality. AJR Am J Roentgenol
2000;175:985-992.
We are very interested in the debate recently published on your Journal regarding the relationships between paediatricians and infant formula milk companies (1,2). In 1998 our association, whose main aims are providing continuing medical education, promoting primary care research, and protecting children, launched an initiative to develop a code on competing interests (3). This was based on the principles of...
We are very interested in the debate recently published on your Journal regarding the relationships between paediatricians and infant formula milk companies (1,2). In 1998 our association, whose main aims are providing continuing medical education, promoting primary care research, and protecting children, launched an initiative to develop a code on competing interests (3). This was based on the principles of the code of the International Pharmaceutical Manufacturers' Association and the international code for the marketing of breast milk substitutes. The code was intended as a list of recommendations for members without any intention to punish violations. Since then our Journal (Quaderni Acp) and our national Congress are free of sponsor of infant formula milk companies.
We think that the relationship with manufacturers must obviously continue, but it must be based on the ethical principles of transparency and independence, keeping in mind that the most important beneficiary is the patient.
For The Task Force on breastfeeding of the
Associazione Culturale Pediatri (Italy)
Sergio Conti Nibali MD serconti@glauco.it
References:
1) Wright C.M., Waterston A.J.R. Relationships between paediatricians and infant formula milk companies. Arch Dis Child Fetal Neonatal 2006;91:383–385.
2) Weaver L.T. Relationships between paediatricians and infant milk formula companies. Arch Dis Child Fetal Neonatal 2006;91:383–385.
It is impossible to disagree with the results of this study. However,
in practice I think the use of both drugs separately every few hours is
very useful in treating childhood pyrexia where the temperature is rising
again before it is considered safe to administer a second dose of either
drug. Alternating them allows more frequent safe anti-pyretic effects.
We have interest in the case of pulmonary hypertension (PHT) with B.
pertussis infection, described in paper of Casano et al.[1] We think the Bordetella heat-labile toxin (HLT) or dermonecrotic toxin may
have a role of the PHT. The toxin causes contraction of various smooth
muscles.[2,3] Endoh et al. suggested that an increase of the perfusion
pressure was induced in perfused lung of guinea p...
We have interest in the case of pulmonary hypertension (PHT) with B.
pertussis infection, described in paper of Casano et al.[1] We think the Bordetella heat-labile toxin (HLT) or dermonecrotic toxin may
have a role of the PHT. The toxin causes contraction of various smooth
muscles.[2,3] Endoh et al. suggested that an increase of the perfusion
pressure was induced in perfused lung of guinea pigs by HLT.[4] The data
was similar to the case described by Casano et al. [1] It may be necessary
to study HLT for prevention of PHT.
References
(1) Casano P, Pons Odena M, Cambra FJ et al. Bordetella pertussis infection
causing pulmonary hypertension. Arch Dis Child 2002;86:453.
(2) Endoh M, Nagai M, Nakase Y. Contractile action of heat-labile toxin of
Bordetella parapertussis on aortic smooth muscles of pigs. Microbiol
Immunol 1988;35:755-767.
(3) Endoh M, Nakase Y. Mechanism of action of Bordetella heat-labile toxin
on vascular smooth muscle strips and cells. Tokai J Exp Clin Med
1988;13 Suppl l:193-202.
(4) Endoh M, Nagai M, Nakase Y. Effect of Bordetella heat-labile toxin on
perfused lung preparations of guinea pigs. Microbiol Immunol 1986;30:1239-1246.
We read with interest the article by Oddie et al. titled ‘Hypernatraemic
Dehydration and Breast Feeding: a population Study’ in your journal (Arch
Dis Child 2001;85:318-320).
We followed 16 breast-fed newborns with hypernatraemic dehydration in our
NICU between 1994-1999. The mean age of the babies was 5.3 (3-16) days on
admission and all but one were term. Gestational age of one baby was 34.5
week...
We read with interest the article by Oddie et al. titled ‘Hypernatraemic
Dehydration and Breast Feeding: a population Study’ in your journal (Arch
Dis Child 2001;85:318-320).
We followed 16 breast-fed newborns with hypernatraemic dehydration in our
NICU between 1994-1999. The mean age of the babies was 5.3 (3-16) days on
admission and all but one were term. Gestational age of one baby was 34.5
weeks. Main complaints were fever in 7 cases, poor feeding in 5 cases and
jaundice in 4 cases. Mean weight loss compared to birth weight was 13% (6.3- 30%) in the babies, above 15% in 6 of them.
Serum sodium levels were 150-210 mEq/L and elevated BUN levels existed in
6 babies. One baby with sodium concentration of 187 mEq/L had convulsion
and one died from sepsis with sodium level of 154 mEq/L.
Although poor interaction between baby and breast was main problem in
these babies, elevated breast milk sodium concentration was noted in two
cases (12.5%). Our findings suggest that high sodium concentrations in
the breast milk may be an important cause for hypernatremia in newborn
infants and must be taken account in evaluation of these patients.
Füsun Kitapçý UYSAL, MD
E.Esra ÖNAL, MD
Uður DÝLMEN, MD
I.Safa KAYA, MD
Department of Neonatology
Fatih University Medical School
Alparslan Türkeþ cad. No:57 06510 Ankara, TURKEY
Oddie et al [1]suggest that neonatal hypernatraemic dehydration is
uncommon, occuring with an incidence of "at least 2.5 per 10,000 live
births". We recently described 5 infants re-admitted with hypernatraemic
dehydration secondary to failure of lactation and its support [2]. During
the six months of our study a pair of 36 week gestation twins were also
readmitted with hypernatraemic dehydration seconda...
Oddie et al [1]suggest that neonatal hypernatraemic dehydration is
uncommon, occuring with an incidence of "at least 2.5 per 10,000 live
births". We recently described 5 infants re-admitted with hypernatraemic
dehydration secondary to failure of lactation and its support [2]. During
the six months of our study a pair of 36 week gestation twins were also
readmitted with hypernatraemic dehydration secondary to failure of breast
feeding, but were excluded because of prematurity.
We estimate the incidence of documented hypernatraemic dehydration
secondary to the failure of lactation is much higher in Bristol (1.7 per
1,000 live births) than that described by Oddie et al [1] in the Northern
Region (2.5 per 10,000 live births). Although our estimate could also be
an underestimate as our study looked only at infants readmitted within 10
days (Oddie et al looked at infants readmitted up to one month of age). In
addition only 50% of infants readmitted with weight loss of >10% in
Bristol during this time had a plasma sodium concentration measured. The
true incidence of hypernatraemic dehydration secondary to lactation
problems in Bristol could thus be as high 3.4 per 1000 live births!
Furthermore, during 2000, of a total of 15 infants readmitted to Southmead
Hospital Neonatal Intensive Care Unit from home, 5 babies (33%) were
readmitted with hypernatraemic dehydration.
We continue to see one infant a month with hypernatramic dehydration;
these have included one infant who had seizures, one case which unmasked a
metabolic disorder but presented with apnoea followed by respiratory
arrest resulting in hypoxic brain damage and one infant with pre-renal
failure which resolved.
We agree with Oddie et al that hypernatraemic dehydration secondary
to lacation failure is not a negligible problem and leads to preventable
morbidity. Excessive neonatal weight loss may allow early identification
and enable appropriate breast feeding support to be instituted. Due to
midwifery shortages, postnatal wards are short staffed and many women are
discharged within a few hours of delivering. The vast majority of
mother/baby dyads establish breast feeding successfully. However it
appears difficult to recognise when this is failing. None of the cases
that we have seen have been recognised to have a feeding problem and
therefore had no increased support or advice. We remain unconvinced that
weighing neonates within the first week of life is harmful and may be
beneficial.
David Harding
Lecturer
Pamela Cairns
Consultant Neonatologist
Department of Child Health
St Michael's Hospital, Bristol
References
(1) Hypernatraemic dehydration and breast feeding: a population study.
Oddie S, Richmond S, Coulthard M. Arch Dis Child. 2001;85:318-20.
(2) Hypernatraemia: why bother weighing breast fed babies? Harding D,
Cairns P, Gupta S, Cowan F. Arch Dis Child Foetal Neonatal Ed. 2001; 85:
F145.
Dear Editor,
We welcome your interest in our paper(1) and in general agree with your comments. However, in our paper we wanted to emphasise the actions, which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood tests for those with paracetamol level below the treatment line at 4 hours post overdose and an overdose <150 mg/kg. However, t...
Dear Editor,
I have read with interest the article by Beattie et al on inflammatory bowel disease (IBD) in children (1). In addition to the standard treatment methods outlined in the article, many patients try complementary and alternative medicines (CAM) (2). McCann et al has shown that children with chronic disease were greater than three times more likely to use complementary and alternative medicine, usually wi...
Dear Editor,
Drs Thakur and Pocha present an interesting case of spontaneous primary pneumothorax. It is not unusual for such cases to present late. In fact in nearly half the cases medical opinion is sought after 2 days or more. The uncertainty about the management of primary and secondary pneumothoraces appears to have been resolved by the revised guidelines published by the British Thoracic Society (BTS) in 2003....
Dear Editor,
The study conducted by Erlewy-Lajeunesse et al. is welcomed and addresses the validity of a radicated clinical practice unsupported by clear evidence.
In the discussion the authors clearly state that the study only examined the short term (at one hour) impact of the combined therapy and that longer measurement periods might present different results.
However, the authors' final stat...
Dear Editor,
We read the paper by Jimenez et al with interest regarding the potential role of limited slice high resolution CT (HRCT) in children with cystic fibrosis (1). Studies such as this utilising fewer CT sections at greater intervals in children with diffuse lung disease warrant further evaluation. We certainly agree with the authors’ assertion that CT should be used judiciously in children and that tec...
Dear Editor,
We are very interested in the debate recently published on your Journal regarding the relationships between paediatricians and infant formula milk companies (1,2). In 1998 our association, whose main aims are providing continuing medical education, promoting primary care research, and protecting children, launched an initiative to develop a code on competing interests (3). This was based on the principles of...
Dear Editor,
It is impossible to disagree with the results of this study. However, in practice I think the use of both drugs separately every few hours is very useful in treating childhood pyrexia where the temperature is rising again before it is considered safe to administer a second dose of either drug. Alternating them allows more frequent safe anti-pyretic effects.
Dear Editor
We have interest in the case of pulmonary hypertension (PHT) with B. pertussis infection, described in paper of Casano et al.[1] We think the Bordetella heat-labile toxin (HLT) or dermonecrotic toxin may have a role of the PHT. The toxin causes contraction of various smooth muscles.[2,3] Endoh et al. suggested that an increase of the perfusion pressure was induced in perfused lung of guinea p...
We read with interest the article by Oddie et al. titled ‘Hypernatraemic Dehydration and Breast Feeding: a population Study’ in your journal (Arch Dis Child 2001;85:318-320).
We followed 16 breast-fed newborns with hypernatraemic dehydration in our NICU between 1994-1999. The mean age of the babies was 5.3 (3-16) days on admission and all but one were term. Gestational age of one baby was 34.5 week...
Dear Editor
Oddie et al [1]suggest that neonatal hypernatraemic dehydration is uncommon, occuring with an incidence of "at least 2.5 per 10,000 live births". We recently described 5 infants re-admitted with hypernatraemic dehydration secondary to failure of lactation and its support [2]. During the six months of our study a pair of 36 week gestation twins were also readmitted with hypernatraemic dehydration seconda...
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