We are pleased to see the interest shown in our article by Drs Cheung and Lachman, but cannot agree with their assertion that our research ‘misses the point’.
Despite widespread use, there remains limited research on the effectiveness of paediatric early warning systems (PEWS) in detecting deterioration in hospitalised children. Our paper sought to establish if there were statistically significance differences in performance between 18 published systems. Trigger systems were out-performed by scoring-systems in this relevant but narrow assessment. Our conclusion emphasizes that it is unclear what factors account for these differences in performance.
Dr Cheung and others feel this observation of statistical inferiority of trigger system is not merited and the observed differences may be influenced by the scoring threshold selected. Dr Cheung illustrates this by comparison to the threshold selection of the C-reactive protein test as an indicator of inflammation. We found this to be rather confusing. The outcomes of trigger-based systems are, by their very nature, dichotomous. Whilst there is always a trade-off between sensitivity and specificity for scoring-based systems, the same does not apply to trigger-based systems. The system is either triggered or not. We note that Dr Cheung does not offer data to support his preference for trigger systems.
We agree that managing deterioration in children is complex. However it is hard to imagine how this would be improved through the use of a tool with reduced ability to discriminate children ‘at risk’ of deterioration, even if staff used this optimally. Or how the use of a tool with an unknown performance would improve the situation. Dr Cheung states “One would not recommend a new drug be widely used, regardless of its efficacy, without also evaluating whether the means of administration was reliable and acceptable.” We respectfully suggest that understanding whether an intervention is efficacious is a fundamental first step. There is no sense in evaluating the reliability and acceptability of ineffective interventions. The real world clinical effectiveness does indeed depend on many factors including human behaviour. However, clinicians are unlikely to adopt a system enthusiastically that does a poor job of categorising patients as high or low risk of deterioration.
Dr Cheung is correct in stating that score-based systems are inherently more complex to use, however this can be over-come by adopting ‘smart’ technology to automatically calculate scores, as we have done in our institution. As technology continues to develop it may be time for healthcare to work ‘smarter’ by embracing technological solutions to problems rather than demanding staff work ‘harder’. Neither quality nor its improvement should be constrained by the systems within which processes occur. While quality can be optimized within a system, improvement can be stunted.
Our paper sought to establish if there were differences in performance between differing systems and whether these were significant. Our findings indicate that differences do indeed exist and as such, this may be an important consideration for centres using a PEWS. As the editorial by Lillitos and Maconochie emphasises – it is time to focus on the evidence.

Thank you for your letter and for sharing your very personal experience.
We agree with you that by the time the child who is choking is attended to by advanced medical practitioners the situation is often dire and that the best hope of a good outcome rests with prompt and effective attempts to dislodge the offending object.
However, knowing that partial airway obstruction may quickly become complete airway obstruction, that (as in the cases we describe) First Aid measures may fail, and that even if the obstruction is relieved the consequences may be significant; we would also advocate that emergency services were alerted as early as possible.
The Advanced Paediatric Life Support (APLS)1 guidance in the UK gives the clear advice with regard to first aid measures to be employed in the choking child.
• If the foreign body is easily visible then carefully try to remove it.
• If the child is coughing effectively and is conscious then encourage them to cough and monitor closely.
• If the child has an ineffective cough but is still conscious then proceed as follows:
o An infant should be laid horizontally with head down, supported with airway open (on the rescuer’s forearm or lap) and five sharp back blows delivered between the shoulder blades. If this fails then the infant is turned supine, still head down, and five chest thrusts (sharp and slower compressions using the same landmarks as for CPR) commenced.
The Heimlich manoeuvre (abdominal thrusts) is not recommended in this guidance for the under 1’s since it can cause injury. However, it is well known and in extremis it would seem appropriate.
o In an older child back blows can be attempted with the child standing and leaning forward, alternated with the more traditional abdominal thrust as described by Heimlich either from behind the patient or with the patient supine and the rescuer astride.
• If the child becomes unconscious then the airway should be opened and 5 rescue breaths attempted, followed by chest compressions. Though, clearly if the airway is completely occluded the breaths will be ineffectual.
In the 3 cases we describe in the paper, we tried to outline that all episodes were witnessed by adults, promptly identified and that First Aid attempts were made to dislodge the grape at the scene by lay people and by those with training. The exact nature, timing and order of the attempts were not clear but it would appear that all appropriate manoeuvres were tried in each case.
We note that you have a question regarding the outcome of the child in our article who survived. We described this in the article but he thankfully made an excellent and complete recovery.
In conclusion, we are all too aware that by the time a child with prolonged foreign body airway obstruction reaches the Emergency Department the situation can be terminal and thank you for highlighting the importance of the dissemination of these vital First Aid skills.
Jamie Cooper and Amy Lumsden
23rd June 2017
Ref.
1. Advanced Life Support Group 2016. The choking child (section 18.4). In: Samuels M. And Wieteska S. Eds. Advanced Paediatric Life Support: a practical approach to emergencies 6th edition. Chichester UK. Wiley, pp180-185.

The authors conclude here that when withdrawing treatment in PICU is considered parents' refusal
to consent can cause additional suffering as clinicians tend to extend burdensome treatment beyond
what they think is reasonable to allow parents time to reconsider. Moreover, both parents and
clinicians try to avoid approaching the courts for a decision.
On the basis of these findings the authors suggest that limiting parental authority by using the concept of parental assent instead of consent could lead to an expeditious resolution in cases of disagreement and should be the focus of further research.
This suggestion is not supported by the parental quotes used in this article. Indeed, one of the parent's objection to a court decision stems from his opinion that the decisions regarding withdrawal of treatment should be the domain of the parents. Limiting parental authority might therefore lead to increased adversarial relationships between the treating team and parents especially when parental views are overruled.
Some quotes in this article as well as other research show that parents at the end of their child's life need time to
often extensively research alternative treatments 'because you just need to have looked and
exhausted every avenue'. Rather than limiting parental authority, it may thus be better to start the
discussion regarding end of life care, including withholding treatment earlier.
This would allow parents time to explore the presence or absence of other treatment options whilst
their child is still relatively well. Given that the majority of children that die in PICU due to
withholding treatment suffer from a chronic illness(1) and referral to palliative care services
reduces the number of children dying in hospital(2), I would argue that earlier referral to paediatric palliative care services might well prevent the conundrum during PICU admissions described in this article.

1. Burns JP, Sellers DE, Meyer EC, Lewis-Newby M, Truog RD. Epidemiology of death in the
PICU at five U.S. teaching hospitals*. Crit Care Med. 2014 Sep;42(9):2101–8.
2. Fraser LK, Miller M, Draper ES, McKinney PA, Parslow RC, on behalf of the Paediatric
Intensive Care Audit Network. Place of death and palliative care following discharge from
paediatric intensive care units. Arch Dis Child. 2011 Dec 1;96(12):1195–8.

I am a paediatric cardiothoracic surgeon who came across the article in a public account of Wechat (a popular Chinese social network app). With great interest, I tried to find and have read the full text of this paper. The reason why I am so interested in this topic is that I myself, as a father of two, experienced the same event happening to the younger sister of my children and so fortunately, I managed to have expelled the whole grape with Heimlich manoeuvre and saved her. It was an evening one year ago when my girl was 6 and a half months old. When I was having a shower in the bathroom at home, my wife suddenly screamed and cried to ask me out immediately. Her voice sounded so urgent that I could hardly have time to put on my underwear to rush out. The baby was then already drowsy, presenting with lip cyanosis and spit bubbles in the mouth. It would seem to be useless if I call medical emergency service. I had no time to think about but tried to perform Heimlich manoeuvre with hands pushing down and cephalad in her stomach, the first sets of pushes didn’t work. I rushed her to living room to check her response and did the second sets. Fortunately, the whole peel-off grape was expelled out of her mouth. Her face started to turn red and she fell asleep. The grape was peeled by my sister-in-law (as a babysitter). She intended to hold it to the baby to suck the juice. Unexpectedly, the grape was suddenly sucked deeply in by my girl! As of now, my girl is very healthy and active. I and my family would never forget this event.
I agree with the authors that choking hazards from fruits like grape and cherry tomatoes have not raised enough awareness in the public. And it is never too emphasised that parents and babysitters should pay much more attention to such fruits, which seem more dangerous than nuts because they are bigger and smoother and can block the airway completely. From the three cases the authors presented and my own experience, as emergent as an even like this is, help from medical professional often seems too late, resulting in the high mortality and morbidity. Though in all cases, professional medical method was used to dislodge grapes with the aid of some instruments, two of the three cases died, and the only surviving one suffered from cerebral and pulmonary edema. And yet it was uncertain if there was permanent damage of the brain. I noticed that in only one case Heimlich manoeuvre was mentioned. Yet in the other two, only obscure words “back blow”, etc., were used. Did they also use Heimlich manoeuvre on the rest two? Did they do it right on the surviving one? There was no detail of these. Even I myself, as a health professional, did not succeed until the second sets of pushes. Just like CPR, though Heimlich manoeuvre seems simple, is it really easy to do it effectively? While I agree prevention is better than cure, we have to admit such cases will always be there to happen. If such an unfortunate event does occur, the best hope is that a capable bystander is to use “effective” Heimlich manoeuvre to try to remove the foreign body as soon as possible. However we are reluctant to admit, if such an on-site first aid method fails, there is little hope that a victim can survive without sequalea after managed by health professionals that rush to help.