Sir,
I would like to add to the article ‘What dose of aspirin should be used in the initial treatment of Kawasaki disease?’ by Luke Guo Yang Ho and Nigel Curtis (Archives, 2017, 102, 1180-1182). Fifteen months have passed since this article concluded that low-dose aspirin is not inferior to higher doses in reducing the risk of coronary artery abnormalities in acute Kawasaki disease. Since then, it is worth considering what and if anything has changed in the field. A recent study not included in the review is a retrospective cohort study by Huang et al1 (2018), where 910 patients followed up for 2 years, which showed that there was no significant difference between 3 groups in terms of anti-inflammation or prevention of coronary artery abnormalities. This paper concluded that the role of aspirin in the treatment of the acute phase of Kawasaki disease should be questioned, as a definite benefit has not been shown. Therefore, in concordance with the conclusion of the review, this rapid response poses that current data remains unchanged with regards to the role and effects of administration of higher doses of aspirin on coronary outcome in acute Kawasaki disease. In the absence of evidence to support higher doses in prevention of coronary artery abnormalities, low-dose aspirin (3–5 mg/kg) may be the safest, most rational approach until better evidence becomes available.
There are currently three prospective randomised control trials in process to continue this inv...
Sir,
I would like to add to the article ‘What dose of aspirin should be used in the initial treatment of Kawasaki disease?’ by Luke Guo Yang Ho and Nigel Curtis (Archives, 2017, 102, 1180-1182). Fifteen months have passed since this article concluded that low-dose aspirin is not inferior to higher doses in reducing the risk of coronary artery abnormalities in acute Kawasaki disease. Since then, it is worth considering what and if anything has changed in the field. A recent study not included in the review is a retrospective cohort study by Huang et al1 (2018), where 910 patients followed up for 2 years, which showed that there was no significant difference between 3 groups in terms of anti-inflammation or prevention of coronary artery abnormalities. This paper concluded that the role of aspirin in the treatment of the acute phase of Kawasaki disease should be questioned, as a definite benefit has not been shown. Therefore, in concordance with the conclusion of the review, this rapid response poses that current data remains unchanged with regards to the role and effects of administration of higher doses of aspirin on coronary outcome in acute Kawasaki disease. In the absence of evidence to support higher doses in prevention of coronary artery abnormalities, low-dose aspirin (3–5 mg/kg) may be the safest, most rational approach until better evidence becomes available.
There are currently three prospective randomised control trials in process to continue this investigation2-4, it would be interesting to review this on their completion.
1. Huang, X. et al. Is aspirin necessary in the acute phase of Kawasaki disease? J. Paediatr. Child Health 54, 661–664 (2018).
2. NCT02951234. A Multi-center, Randomized to Compare the Efficacy of IVIG Alone and IVIG Plus High-dose Aspirin in Kawasaki Disease. Https://clinicaltrials.gov/show/nct02951234 doi:10.1002/CENTRAL/CN-01559692
3. NCT02359643. Multi-center Prospective Randomized Control Trail of High Dose Aspirin in Acute Stage of Kawasaki Disease. Https://clinicaltrials.gov/show/nct02359643 (2015). doi:10.1002/CENTRAL/CN-01582768
4. Kuo, H.-C., Guo, M. M.-H., Lo, M.-H., Hsieh, K.-S. & Huang, Y.-H. Effectiveness of intravenous immunoglobulin alone and intravenous immunoglobulin combined with high-dose aspirin in the acute stage of Kawasaki disease: study protocol for a randomized controlled trial. BMC Pediatr. 18, 200 (2018).
Many thanks for your response to the editorial ‘What are you looking at?’, which highlights some important principles for this extensively studied research area (despite being a relatively new field in healthcare) [1]
Despite the emergence of new methods to analyse gaze behaviour terminology has not been revised to reflect scientific advances. A recent article by Hessels et al. outlined significant inconsistencies in the definitions of fixations and saccades held by eye movement researchers and highlighted the conceptual confusion surrounding these terms.[2]
The term saccade is derived from the French for ‘jerk’. The phrase appears to have been coined by Emile Javal, a French ophthalmologist, in the 1800’s.[3] By 1916 it had been accepted into the English literature.[4]
Saccades are frequently defined in the literature as rapid, ballistic movements of the eyes that abruptly change the point of fixation.5 Definitions have included;
‘Rapid eye movements used to voluntarily move gaze from one target of interest to another.’[6]
‘Ballistic movements, 20-150ms long, reaching a velocity up to 800°/s. They direct the eye so that external visual objects are projected onto the fovea.’[7]
‘Rapid eye movements used in repositioning the fovea to a new location in the visual environment.’[8]
The term ballistic refers to the fact that the saccade-generating system cannot respond to subsequent changes in the position of a target during th...
Many thanks for your response to the editorial ‘What are you looking at?’, which highlights some important principles for this extensively studied research area (despite being a relatively new field in healthcare) [1]
Despite the emergence of new methods to analyse gaze behaviour terminology has not been revised to reflect scientific advances. A recent article by Hessels et al. outlined significant inconsistencies in the definitions of fixations and saccades held by eye movement researchers and highlighted the conceptual confusion surrounding these terms.[2]
The term saccade is derived from the French for ‘jerk’. The phrase appears to have been coined by Emile Javal, a French ophthalmologist, in the 1800’s.[3] By 1916 it had been accepted into the English literature.[4]
Saccades are frequently defined in the literature as rapid, ballistic movements of the eyes that abruptly change the point of fixation.5 Definitions have included;
‘Rapid eye movements used to voluntarily move gaze from one target of interest to another.’[6]
‘Ballistic movements, 20-150ms long, reaching a velocity up to 800°/s. They direct the eye so that external visual objects are projected onto the fovea.’[7]
‘Rapid eye movements used in repositioning the fovea to a new location in the visual environment.’[8]
The term ballistic refers to the fact that the saccade-generating system cannot respond to subsequent changes in the position of a target during the course of an eye movement. If the target was to move a second saccade would be required to correct the error. Acceptance of such definitions suggests that the primary function of saccades is to bring objects of interest onto or near the fovea. The fovea operates at high resolution and, although it only provides 1-2 degrees of vision, it plays a central role in resolving objects. Whilst saccades assist vision by moving the eyes rapidly to various objects of interest so that parts of a scene can be seen in greater resolution, there is probably little or no meaningful information absorbed during the saccadic movements.
However, other papers have been more liberal in their definitions defining a saccade as the inter-fixation interval.[9,10] These definitions imply that a saccade is any movement outside of periods of fixation. This definition will therefore also capture smooth pursuit movements (slower tracking movements), vestibulo-ocular movements (stabilise eyes relative to external world) and visual scanning movements. Consequentially during saccades defined in this manner visual information may be absorbed both consciously and/or subconsciously including, for example, the presence or absence of pathology, as outlined in your letter.
As the field of eye tracking research in healthcare expands it is imperative that authors explicitly define their key measurements, including fixations, dwell time and saccades, to allow accurate interpretation and comparison of results and to minimise ambiguity. Without this it will be difficult to examine the links between visual scanning patterns and decision making. For example it may be hypothesised that subconscious visual scanning behaviours may be a clue to understanding the concept of gut feeling, whereby a particular clinician sees things perhaps others do not.
We certainly agree greater understanding of saccade pathways should undoubtedly be an area for future research in eye tracking studies in healthcare.
References:
1. Roland D. What are you looking at? Arch Dis Child 2018; 103: 1098-1099.
2. Hessels RS, Niehorster DC, Nyström M, Andersson R, Hooge IT. Is the eye-movement field confused about fixations and saccades? A survey among 124 researchers. Royal Society open science. 2018 Aug 29;5(8):180502.
3. Javal E. Essai sur la physiologie de la lecture. Annales d'Ocilistique. 1878;80:61-73.
4. Wade NJ. Scanning the seen: Vision and the origins of eye-movement research. In Eye Movements 2007 (pp. 31-63).
5. Purves D, Augustine GJ, Fitzpatrick D, Katz LC, LaMantia AS, McNamara JO, Williams SM. Neuroscience 2nd Edition. Sunderland (MA) Sinauer Associates.
6. Ramat S, Leigh RJ, Zee DS, Optican LM. What clinical disorders tell us about the neural control of saccadic eye movements. Brain. 2006 Nov 21;130(1):10-35.
7. Falkmer T, Dahlman J, Dukic T, Bjällmark A, Larsson M. Fixation identification in centroid versus start-point modes using eye-tracking data. Perceptual and motor skills. 2008 Jun;106(3):710-24.
8. Duchowski AT. Eye tracking methodology. Theory and practice. 2007;328.
9. Holmqvist K, Nyström M, Andersson R, Dewhurst R, Jarodzka H, Van de Weijer J. Eye tracking: A comprehensive guide to methods and measures. OUP Oxford; 2011 Sep 22.
10. Larsson L, Nyström M, Andersson R, Stridh M. Detection of fixations and smooth pursuit movements in high-speed eye-tracking data. Biomedical Signal Processing and Control. 2015 Apr 1;18:145-52.
As a final year medical student, I read with great interest this article highlighting the pedagogical value of gaze study. Whilst the article raises many poignant features of this new medium of data collection, I believe the definition of saccade in your article may be slightly incomplete.
The article states that “Saccades...are movements of the eyes between fixations in which information is not meaningfully acquired or absorbed.” However, I would suggest that whilst the primary purpose of saccades may be to move between fixation points, there is subconscious information acquisition completed by these movements-- the subconscious identification of a lack of pathology.
If one does not take certain regions of an image as fixation points, it suggests that they are not looking for pathology in those regions. This is reinforced by one study analysing gaze study in mammogram analysis which reported that “long saccades often missed the target but were followed by corrective saccades”. (1-Kundel H, Nodine C, Conant E et al. Holistic component of image perception in mammogram interpretation: gaze-tracking study. Radiology 2007;242(2):396-402.) This highlights that within a saccade is also inert analysis of a lack of pathology rather than just transformational eye movement.
Another study analysing a gaze study of virtual histopathology slides between trained pathologists, residents and medical students reported that “fully trained pathologists h...
As a final year medical student, I read with great interest this article highlighting the pedagogical value of gaze study. Whilst the article raises many poignant features of this new medium of data collection, I believe the definition of saccade in your article may be slightly incomplete.
The article states that “Saccades...are movements of the eyes between fixations in which information is not meaningfully acquired or absorbed.” However, I would suggest that whilst the primary purpose of saccades may be to move between fixation points, there is subconscious information acquisition completed by these movements-- the subconscious identification of a lack of pathology.
If one does not take certain regions of an image as fixation points, it suggests that they are not looking for pathology in those regions. This is reinforced by one study analysing gaze study in mammogram analysis which reported that “long saccades often missed the target but were followed by corrective saccades”. (1-Kundel H, Nodine C, Conant E et al. Holistic component of image perception in mammogram interpretation: gaze-tracking study. Radiology 2007;242(2):396-402.) This highlights that within a saccade is also inert analysis of a lack of pathology rather than just transformational eye movement.
Another study analysing a gaze study of virtual histopathology slides between trained pathologists, residents and medical students reported that “fully trained pathologists had prolonged saccadic movement and lower saccadic velocity [compared to residents and medical students]”. (2-Krupinski E, Tillack A, Richter L et al. Eye-movement study and human performance using telepathology virtual slides. Implications for medical education and differences with experience. Hum Pathol 2006;37(12):1543-56.) This suggests that experts do not need to have greater fixation points as they were aware of a lack of pathology through subconscious processing which led to a lower saccade velocity.
Through greater understanding about saccade pathways, we may be able to both add to our knowledge of how participants are analysing the data they are being given as well as position ourselves to better analyse where participants are also missing pathology.
It is with great interest that we read ‘Why do babies cry?” in which Dr. Robert Scott-Jupp have provided a concise evaluation of the research pertaining to non-pathologic crying in infants.
Crying is a normal variant in the day 2 newborn examination however it can pose a significant source of stress and anxiety for parents. To add to the body of evidence detailed in this article we posed the question; What proportion of babies cry during the day 2 newborn examination?
A convenience sample of data was collected on well babies during the standard day 2 physical examination on the postnatal ward in a tertiary maternity hospital. All babies on the postnatal ward were eligible for inclusion. Gestation, birth weight, gender, mode of delivery and duration of examination were recorded. The presence or absence of crying during examination was documented. The data was analysed using SPSS .
One hundred and fifty three babies (n=153) were included in the study. There were 82 male infants (53%) and 71 female infants (47%). Mean birth weight was 3589g (range 2590g -5160g) with a mean gestation of 39+4 (Range 36+3 - 42+1). Mean duration of examination was 7 minutes. Eighty-one babies (52.9%) delivered by spontaneous vaginal delivery, 22 (14.4%) by ventouse, 26 (16.9%) by elective caesarean section, 20 (13.1%) by emergency caesarean section and 4(2.6%) by forceps. Overall, 118 (77.1%) babies were observed to cry during the physical examination (78%...
It is with great interest that we read ‘Why do babies cry?” in which Dr. Robert Scott-Jupp have provided a concise evaluation of the research pertaining to non-pathologic crying in infants.
Crying is a normal variant in the day 2 newborn examination however it can pose a significant source of stress and anxiety for parents. To add to the body of evidence detailed in this article we posed the question; What proportion of babies cry during the day 2 newborn examination?
A convenience sample of data was collected on well babies during the standard day 2 physical examination on the postnatal ward in a tertiary maternity hospital. All babies on the postnatal ward were eligible for inclusion. Gestation, birth weight, gender, mode of delivery and duration of examination were recorded. The presence or absence of crying during examination was documented. The data was analysed using SPSS .
One hundred and fifty three babies (n=153) were included in the study. There were 82 male infants (53%) and 71 female infants (47%). Mean birth weight was 3589g (range 2590g -5160g) with a mean gestation of 39+4 (Range 36+3 - 42+1). Mean duration of examination was 7 minutes. Eighty-one babies (52.9%) delivered by spontaneous vaginal delivery, 22 (14.4%) by ventouse, 26 (16.9%) by elective caesarean section, 20 (13.1%) by emergency caesarean section and 4(2.6%) by forceps. Overall, 118 (77.1%) babies were observed to cry during the physical examination (78% male vs 76% female). There was no difference in incidence of crying when compared for gestation. Eighty eight percent of babies born by instrumental delivery cried during examination while only 74% of those born by spontaneous vaginal delivery and 76% of those born by emergency section cried. Babies with a birth weight of 4001g – 4500g were more likely to cry than any other birth weight category (90.4%).
To conclude, crying is a normal variant in the newborn examination. Communicating these statistics to parents could play a role in reducing stress and anxiety. This is the first study to document the frequency of crying on the day 2 examination. It was also observed that babies of a higher birth weight, as well as those delivered instrumentally, were more likely to cry than others.
Thank you to the authors for bringing the concept of ACPs and their importance to the forefront for consideration in practice. Thankfully, I have never had to utilise one in my professional practice, but having recently been encouraged to use an antenatal ACP for our daughter, I would offer personal support to the intentions that they should be used in practice, when appropriate. Our daughter was given a terminal diagnosis antenatally, and the decisions that followed to prepare for her birth and her death would have been overwhelming and emotionally charged in the immediate aftermath and I can only assume that our journey would have looked very different without one. Instead, the decisions and plans were considered, they were controlled and they were based on our true wishes for our daughter and our family. As the authors relate too in their article, without the ACP there would have been significant likelihood that the decisions we made for our daughter would have been made ad-hoc, under emotional pressure, and the outcome of her peaceful and comfortable death, surrounded by her family and in our arms, would likely have not been as achievable. Furthermore, the authors comment that it guides healthcare providers and parents, in a structured manner to ensure needs and wishes are met and I could not agree more. I think much of the conversations that took place, would have taken place without the ACP document, but the concept as a whole encouraged timely discussions, e...
Thank you to the authors for bringing the concept of ACPs and their importance to the forefront for consideration in practice. Thankfully, I have never had to utilise one in my professional practice, but having recently been encouraged to use an antenatal ACP for our daughter, I would offer personal support to the intentions that they should be used in practice, when appropriate. Our daughter was given a terminal diagnosis antenatally, and the decisions that followed to prepare for her birth and her death would have been overwhelming and emotionally charged in the immediate aftermath and I can only assume that our journey would have looked very different without one. Instead, the decisions and plans were considered, they were controlled and they were based on our true wishes for our daughter and our family. As the authors relate too in their article, without the ACP there would have been significant likelihood that the decisions we made for our daughter would have been made ad-hoc, under emotional pressure, and the outcome of her peaceful and comfortable death, surrounded by her family and in our arms, would likely have not been as achievable. Furthermore, the authors comment that it guides healthcare providers and parents, in a structured manner to ensure needs and wishes are met and I could not agree more. I think much of the conversations that took place, would have taken place without the ACP document, but the concept as a whole encouraged timely discussions, ensured all parties were included, and offered a prompt that the conversations we would be having would be difficult, but that they were incredibly important. I, obviously can not be sure of how our team of professionals found the logistical use of our ACP at the time, but I can only assume it was of benefit, as they provided our daughters care, as requested, without any additional need for questions or decisions at an incredibly difficult time. From a parents viewpoint, the conversations that occurred whilst completing the ACP with our team, ensured that we had considered all aspects of her care, that we understood options and that everyone in the team, including us as parents, were all in agreement around ceiling of care. Our healthcare team knew her name from before she was born and therefore referred to her as such from the minute she arrived; they knew we wished for her sibling to join us as soon as possible to meet her, and they arranged this to prevent us wasting our fleeting moments together with texts and phone-calls or battling to allow relatives access to the busy the ward; they knew we wished to have photos taken and as such they did not fear snapping every moment for us (as a result we have the most beautiful and natural photos that we will cherish forever); they knew we wanted time alone so did not feel awkward at leaving us to just be together, and they knew that we wanted her not to leave our side, and that was never questioned. The ACP (and all the staff who made it happen!) brought us a beautiful short life for our daughter and a calm and peaceful death, which is really all you can hope for in such tragic circumstances.
I welcome Himmelmann’s editorial concerning the prevention of respiratory problems for individuals with cerebral palsy1. As a speech and language therapist working within a multi-disciplinary nutrition team, I recognise the need to increase our understanding of the complex interactions between risk factors through collaboration across stakeholders. It is of particular concern that solids or liquids in the lungs or windpipe have been identified as the cause of death for almost a quarter of people with cerebral palsy2.
With this in mind, we developed the Eating and Drinking Ability Classification System (EDACS) for people with cerebral palsy from age 3 years. EDACS classifies limitations to eating and drinking ability in 1 of 5 levels, replacing frequently used terms “mild”, “moderate” and “severe” which lack shared definition. Key features of “safety” and “efficiency” are used to determine 5 distinct levels of ability: from Level I Eats and drinks safely and efficiently through to Level V Unable to eat or drink safely – tube feeding may be considered to provide nutrition. EDACS demonstrated strong content validity and excellent inter-observer reliability when used by speech and language therapists3. EDACS is free to download from www.edacs.org along with sixteen completed translations. Ten other language translations are currently in process.
Himmelmann1 points out associations between limitations to gross motor function and...
I welcome Himmelmann’s editorial concerning the prevention of respiratory problems for individuals with cerebral palsy1. As a speech and language therapist working within a multi-disciplinary nutrition team, I recognise the need to increase our understanding of the complex interactions between risk factors through collaboration across stakeholders. It is of particular concern that solids or liquids in the lungs or windpipe have been identified as the cause of death for almost a quarter of people with cerebral palsy2.
With this in mind, we developed the Eating and Drinking Ability Classification System (EDACS) for people with cerebral palsy from age 3 years. EDACS classifies limitations to eating and drinking ability in 1 of 5 levels, replacing frequently used terms “mild”, “moderate” and “severe” which lack shared definition. Key features of “safety” and “efficiency” are used to determine 5 distinct levels of ability: from Level I Eats and drinks safely and efficiently through to Level V Unable to eat or drink safely – tube feeding may be considered to provide nutrition. EDACS demonstrated strong content validity and excellent inter-observer reliability when used by speech and language therapists3. EDACS is free to download from www.edacs.org along with sixteen completed translations. Ten other language translations are currently in process.
Himmelmann1 points out associations between limitations to gross motor function and someone’s eating and drinking abilities. We found that there was a statistically significant but only moderate positive correlation between EDACS and the widely used GMFCS4 for a group of children with CP (n=128 Kendall’s tau 0.5)3. The clinical relevance of this is that some children with limited gross motor function will show greater ability when eating and drinking; conversely, other children who walk with or without assistance may eat and drink with increased risk of choking or aspiration.
Someone’s eating and drinking ability is not readily observed in most clinical contexts. Whilst video-fluoroscopic swallowing examinations will support identification of “silent aspiration”, it provides a useful but partial view of the overall clinical picture. Some health professionals may rely on parent or carer report. Parents were involved in the development of EDACS and found it easy to use to describe their children’s eating and drinking abilities. However, questions remain about parents’ use of EDACS to describe their children’s eating and drinking abilities. Direct comparisons of parents' and speech and language therapists’ classifications using EDACS revealed more disagreements than between pairs of speech and language therapists, although these were consistent: parents either agreed with speech and language therapists or parents systematically rated their children as more able than speech and language therapists, by one level3.
EDACS provides a framework which makes explicit the extent of the disagreement between parents and professionals including implications for safety and efficiency of children's eating/drinking. There is uncertainty whether children experience adverse health outcomes because of these disagreements. Disagreements between parents and healthcare teams regularly occur in this emotionally charged area of function. It can be challenging for the multi-disciplinary team to provide children with cerebral palsy and their parents with person-centred healthcare with consequent negative impacts on the well-being and quality of life of their child and family5.
EDACS provides a framework with potential to support person-centred healthcare. Further work needs to be carried out to implement use of EDACS across community and acute healthcare settings to fully realise its preventative potential.
References:
1. Himmelmann K. Putting prevention into practice for the benefit of children and young people with cerebral palsy Archives of Disease in Childhood Published Online First: 18 July 2018. doi: 10.1136/archdischild-2018-315134
2. Glover G and Ayub M (2010). How people with learning disabilities die. Published by Improving Health and Lives: Learning Disabilities Observatory. http://www.improvinghealthandlives.org.uk/uploads/doc/vid_9033_IHAL2010-... accessed 21 September 2013.
3. Sellers D, Mandy A, Pennington L, Hankins M and Morris C (2014). Development and reliability of a system to classify the eating and drinking ability of people with cerebral palsy. Developmental Medicine & Child Neurology 56(3):245-251
4. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E and Galuppi B (1997). Development and Reliability of a System to Classify Gross Motor Function of Children with Cerebral Palsy. Developmental Medicine &Child Neurology 39:214 -223.
5. Cowpe E, Hanson B and Smith C (2014). What do parents of children with dysphagia think about their MDT? A qualitative study. BMJ Open 4 e005934.
Having just read this article I am concerned about the terminology used as I am not sure it truly reflects the clinical problem posed. The article refers to "maintenance" fluids but the question asked relates more to “resuscitation” fluids.
It is important to be clear as to the aim of treatment in the individual patient when prescribing fluids rather than just following a guideline. The paper debates the relative merits of 0.9% sodium chloride and balanced fluids as “maintenance” fluids. To my mind “maintenance” fluids are administered to patients who have a replete extracellular fluid (ECF) volume. If ECF volume is low then “resuscitation” fluids are required. “Maintenance” and “resuscitation” fluids have different roles and therefore might be expected to have different characteristics.
As the article refers to “maintenance” fluids I will deal with these first. This fluid is needed to replicate the fluid that the patient would normally be drinking but for a variety of reasons may not be able to ingest. It should be differentiated in turn from "replacement" fluid which is the fluid given on top of the "maintenance" fluid when patients have fluid losses in excess of those normally anticipated. This includes diarrhoea, vomiting and fluid from surgical drains. The fluid used for "replacement" needs to match the composition and volume of the fluid being lost. Once "resuscitation" and "replacement" fluid...
Having just read this article I am concerned about the terminology used as I am not sure it truly reflects the clinical problem posed. The article refers to "maintenance" fluids but the question asked relates more to “resuscitation” fluids.
It is important to be clear as to the aim of treatment in the individual patient when prescribing fluids rather than just following a guideline. The paper debates the relative merits of 0.9% sodium chloride and balanced fluids as “maintenance” fluids. To my mind “maintenance” fluids are administered to patients who have a replete extracellular fluid (ECF) volume. If ECF volume is low then “resuscitation” fluids are required. “Maintenance” and “resuscitation” fluids have different roles and therefore might be expected to have different characteristics.
As the article refers to “maintenance” fluids I will deal with these first. This fluid is needed to replicate the fluid that the patient would normally be drinking but for a variety of reasons may not be able to ingest. It should be differentiated in turn from "replacement" fluid which is the fluid given on top of the "maintenance" fluid when patients have fluid losses in excess of those normally anticipated. This includes diarrhoea, vomiting and fluid from surgical drains. The fluid used for "replacement" needs to match the composition and volume of the fluid being lost. Once "resuscitation" and "replacement" fluids have been taken care of and the ECF compartment is full, "maintenance" fluid needs to be prescribed. This equates to insensible water losses and urine output and will be the same as the fluid and electrolytes we take in orally each day. Current guidelines propose the use of a fluid containing 154 mmol/l of sodium. This article questions whether this should be accompanied by chloride or a mix of chloride and potential bicarbonate. However none of us would dream of drinking such a fluid and the recommended sodium intake for infants is around 3 mmol/kg/day which for a 10 kg child given the standard 1 litre of maintenance fluid equates to a solution containing 30 mmol/l or 0.18% sodium chloride. This is the sodium concentration you will find in total parenteral nutrition (TPN). Using 0.9% sodium chloride gives 154 mmol of sodium or 15.4 mmol/kg! The concern about using hypotonic solutions as “maintenance” fluid centres around the notion that the syndrome of inappropriate anti-diuretic hormone secretion (SIADH) is a common phenomenon and administration of hypotonic solutions will cause hyponatraemia. However SIADH is overdiagnosed and when ADH levels are raised it is almost always appropriate i.e. ADH is being produced in response to ECF volume contraction. In that situation an isotonic solution is required. Once ECF volume has been restored ADH production will almost always be switched off and continuing use of isotonic solutions will risk causing hypernatraemia.
The question that should have been asked was which fluid was more appropriate for “resuscitation” purposes? In the scenario described it is the administration of a 20ml/kg bolus of 0.9% sodium chloride that has led to a hyperchloraemic metabolic acidosis. We have recently had this discussion in our department and as in this article, have had to look primarily at evidence from adult studies. At this meeting the use of isotonic crystalloid as "maintenance" fluid was questioned and subsequently we have seen three cases of hypernatraemia as a result of 0.9% sodium chloride “maintenance” therapy.
"Resuscitation" fluid is given to restore ECF volume. To achieve this it would make sense to use a fluid that matches the composition of ECF and unfortunately 0.9% saline only goes part of the way to achieving this. ECF contains 140 mmol/l of sodium, 4 mmol/l of potassium, 113 mmol/l of chloride and 26 mmol/l of bicarbonate and as a result, when using 0.9% sodium chloride to correct a deficit there is an excess of chloride and a lack of bicarbonate. This creates a metabolic acidosis. It therefore makes sense to use balanced fluids containing potential bicarbonate. The studies quoted in this article are primarily related to severely ill patients many with sepsis in whom ongoing problems with ECF volume will be an issue and cannot be extrapolated to children on a general paediatric ward.
In summary, prescription of intravenous fluids should only be made after a careful assessment of the patient, in particular their ECF volume status. If that is reduced an isotonic solution should be administered. A balanced solution makes more sense physiologically but the evidence supporting its use over 0.9% saline is limited, particularly in the paediatric population. If there are ongoing losses they should be replaced by a solution best matching the fluid being lost. If it is not possible to establish the electrolyte content of the fluid losses an isotonic solution is advised. Once ECF volume is replete then a hypotonic solution should be given and on our ward we would use 0.45% saline + 2.5% dextrose. This is still providing more sodium than is normally recommended if giving fluids orally or in TPN. Unfortunately ECF volume status is notoriously difficult to assess and if there is doubt isotonic solutions will be safer. However if 0.9% sodium chloride continues to be administered as "maintenance" fluid we will see more cases of hypernatraemia. Whatever strategy is adopted it is essential to monitor serum electrolytes at least daily in children receiving a significant (>50%) proportion of their fluids intravenously.
I have not mentioned the ongoing debate about the volume of "maintenance" fluid we should be giving children. Currently this is based on recommendations made by Holliday and Segar in the 1950’s, matching fluid requirement to energy expenditure. It is now recognised that these do not reflect the fluid requirements of unwell children lying in bed and as a result “maintenance” fluid volume prescriptions may be twice what they should be. The prescription of more water than is needed is potentially a contributing factor to hypotonic solutions producing hyponatraemia - the prescribing of too much water rather than too little sodium. It is also likely that the cases of hyponatraemia reported in the literature were the result of the prescribing of hypotonic solutions to patients who were deplete of ECF in which case isotonic solutions should have been given.
We are writing to respond with our data, that, in the same region (Lazio), indicate a different pattern.
We have focused on the patients that were previously eligible for palivizumab treatment (only preterm infants, with gestational age>29 weeks), in three different hospitals located in Rome.
Please consider that the time frame is the year before and the year after of the AIFA reimbursement limitations, the same years where in Figure 1 of your manuscript you show higher hospitalizations before and lower hospitalizations after AIFA limitations.
At the NICU Casilino Hospital (ref.A) we have noticed an increase in the number of bronchiolitis from the year before (6 bronchiolitis/35 children with 30-32WGA; 17%) to the year after limitations (12/47; 26%).
At the Sapienza University of Rome we have registered an increase in hospitalizations for bronchiolitis in children with 30-36 WGA from 14 out of 165 hospitalizations (8.5%) during the 2015/16 season to 21/141 hospitalizations in the subsequent season (14.9%, p =0.05). Of them, respectively 8 (14%) and 13 (18.3%) were due to RSV, although the difference is not statistically significant. The total number of VRS+ increased significantly in the second year (ref.B).
At the OPBG we have analysed only the data from the 2016/17 season and we have noticed a higher incidence of bronchiolitis in the late preterm (13 VRS+/27 children 30-37WGA, not treated with palivizuma...
We are writing to respond with our data, that, in the same region (Lazio), indicate a different pattern.
We have focused on the patients that were previously eligible for palivizumab treatment (only preterm infants, with gestational age>29 weeks), in three different hospitals located in Rome.
Please consider that the time frame is the year before and the year after of the AIFA reimbursement limitations, the same years where in Figure 1 of your manuscript you show higher hospitalizations before and lower hospitalizations after AIFA limitations.
At the NICU Casilino Hospital (ref.A) we have noticed an increase in the number of bronchiolitis from the year before (6 bronchiolitis/35 children with 30-32WGA; 17%) to the year after limitations (12/47; 26%).
At the Sapienza University of Rome we have registered an increase in hospitalizations for bronchiolitis in children with 30-36 WGA from 14 out of 165 hospitalizations (8.5%) during the 2015/16 season to 21/141 hospitalizations in the subsequent season (14.9%, p =0.05). Of them, respectively 8 (14%) and 13 (18.3%) were due to RSV, although the difference is not statistically significant. The total number of VRS+ increased significantly in the second year (ref.B).
At the OPBG we have analysed only the data from the 2016/17 season and we have noticed a higher incidence of bronchiolitis in the late preterm (13 VRS+/27 children 30-37WGA, not treated with palivizumab; 48.2%), while in the 5 children ≤37WGA treated with prophylaxis, there was only 1 VRS+ (20%, ref.C).
Our data from the clinical point of view indicate an opposite trend with respect to your paper, with higher hospitalizations and higher RSV+ infections after AIFA limitations. Furthermore, we have analysed the population of interest, and not an administrative databases, where is possible to have the general hospitalitation data for bronchiolitis but not the correct number of at risk infants, therefore we believe they provide a more cautious picture of real world data.
References:
A. Picone, S., Fabiano, A., Roma, D., & Paolillo, P. (2018). Comparing of two different epidemic seasons of bronchiolitis. Italian journal of pediatrics, 44(1), 11.
B. Di Mattia G, Nenna R, Petrarca L, Frassanito A, Di Martino M, Cascio M and Midulla F. Ruolo della profilassi con Palivizumab nella prevenzione della bronchiolite nei bambini “late pre-term”. XXI congresso SIMRI, Napoli 12-14 Dicembre 2017
C. Vittucci AC, Di Camillo C, Rotondi Aufiero L, Marchili MR, and Villani A. VRS nei lattanti: un nemico ancora da combattere. XXIII Congresso Nazionale della Società Italiana di Neonatologia, Milano, 25-28 September 2017 (P188, page 99)
We are kindly observing that the study on hospitalizations for infection due to respiratory syncytial virus should be conducted on infants aged <1 year old [1], and not on infants aged <2 years old. Such a choice is motivated by medical literature and since the prescription of palivizumab on the general population of preterm infants is up to 1 year of age. Moreover, the study does not tightly classify the hospitalization depending on the gestational age, a lack of information that exclude the possibility of a punctual statistical analysis on the infants whose gestational age is between 29-35 weeks, population matter of the analysis, impacted by the AIFA reimbursement limitations.
In the study infants aged <2 years old have been considered, the same subjects are statistically contributing to two consecutive seasons with different ages. The algebraic sum of the season 2014-2015 / 2015-2016 perpetuate the complexity of analysis of hospitalization for a specific season, if the infant is hospitalized in the season of his/her birth or next year.
As reported by Medici et al. [2], respiratory syncytial virus infection has a 2-years evolution, with a less critical year following a year with more abundant virus diffusion. By algebraically summing the data from two consecutive years the seasonality, so the stochasticity, is lost. Eventually the season 2016-2017 appear to be the less critical season. Environmental and patient conditions such...
We are kindly observing that the study on hospitalizations for infection due to respiratory syncytial virus should be conducted on infants aged <1 year old [1], and not on infants aged <2 years old. Such a choice is motivated by medical literature and since the prescription of palivizumab on the general population of preterm infants is up to 1 year of age. Moreover, the study does not tightly classify the hospitalization depending on the gestational age, a lack of information that exclude the possibility of a punctual statistical analysis on the infants whose gestational age is between 29-35 weeks, population matter of the analysis, impacted by the AIFA reimbursement limitations.
In the study infants aged <2 years old have been considered, the same subjects are statistically contributing to two consecutive seasons with different ages. The algebraic sum of the season 2014-2015 / 2015-2016 perpetuate the complexity of analysis of hospitalization for a specific season, if the infant is hospitalized in the season of his/her birth or next year.
As reported by Medici et al. [2], respiratory syncytial virus infection has a 2-years evolution, with a less critical year following a year with more abundant virus diffusion. By algebraically summing the data from two consecutive years the seasonality, so the stochasticity, is lost. Eventually the season 2016-2017 appear to be the less critical season. Environmental and patient conditions such as: birth order, birth weight, gestational age, age at onset of the RSV season, passive smoke [3-4]; these have not been taken into account in the study.
Administrative databases, e.g. CEDAP, Drug Claims Registry and Hospital Information System, may hide some more detail information offered instead by clinical studies.
1. Lanari, M., Giovannini, M., Giuffre, L., Marini, A., Rondini, G., Rossi, G. A., ... & Salvioli, G. P. (2002). Prevalence of respiratory syncytial virus infection in Italian infants hospitalized for acute lower respiratory tract infections, and association between respiratory syncytial virus infection risk factors and disease severity. Pediatric pulmonology, 33(6), 458-465.
2. Medici, M. C., Arcangeletti, M. C., Rossi, G. A., Lanari, M., Merolla, R., Di Luzio Paparatti, U., & Chezzi, C. (2006). Four year incidence of respiratory syncytial virus infection in infants and young children referred to emergency departments for lower respiratory tract diseases in Italy: the" Osservatorio VRS" study (2000-2004). MICROBIOLOGICA-BOLOGNA-, 29(1), 35.
3. Rossi, G. A., Medici, M. C., Arcangeletti, M. C., Lanari, M., Merolla, R., Paparatti, U. D. L., ... & Osservatorio RSV Study Group. (2007). Risk factors for severe RSV-induced lower respiratory tract infection over four consecutive epidemics. European journal of pediatrics, 166(12), 1267-1272.
4. Lanari, M., Giovannini, M., Giuffre, L., Marini, A., Rondini, G., Rossi, G. A., ... & Salvioli, G. P. (2002). Prevalence of respiratory syncytial virus infection in Italian infants hospitalized for acute lower respiratory tract infections, and association between respiratory syncytial virus infection risk factors and disease severity. Pediatric pulmonology, 33(6), 458-465.
Dr Smith makes relevant and interesting points regarding the terminology used for fluids, which can be used for both “resuscitation” purposes and “maintenance” therapy, and we thank him for his interest and response.
The purpose of this clinical question was to review the current evidence for paediatric patients in relation to “ balanced fluids”, a term emerging in the medical literature. NICE recommends using any isotonic crystalloid, which covers a wide range of sodium concentration from 130 to 154mmol/L (reference 1 in the article).
The loss of electrolytes, either from the gut or as a result of renal impairment, needs regular clinical review. We observe that repeated bicarbonate measurements are not regularly undertaken after initial assessment or following admission and it is important to remind trainees to consider these losses, hence our recommendation of daily monitoring of electrolytes. By following this approach, appropriate individualised adjustments can be made to the fluid prescription of patients as necessary.
Our conclusion from this question highlighted that research needs to be undertaken in the paediatric population of bicarbonate/ lactate containing fluids to determine whether this may affect acute kidney injury and other specific clinical outcomes. We agree attention to detail is always necessary when caring for infants and children receiving intrav...
Dr Smith makes relevant and interesting points regarding the terminology used for fluids, which can be used for both “resuscitation” purposes and “maintenance” therapy, and we thank him for his interest and response.
The purpose of this clinical question was to review the current evidence for paediatric patients in relation to “ balanced fluids”, a term emerging in the medical literature. NICE recommends using any isotonic crystalloid, which covers a wide range of sodium concentration from 130 to 154mmol/L (reference 1 in the article).
The loss of electrolytes, either from the gut or as a result of renal impairment, needs regular clinical review. We observe that repeated bicarbonate measurements are not regularly undertaken after initial assessment or following admission and it is important to remind trainees to consider these losses, hence our recommendation of daily monitoring of electrolytes. By following this approach, appropriate individualised adjustments can be made to the fluid prescription of patients as necessary.
Our conclusion from this question highlighted that research needs to be undertaken in the paediatric population of bicarbonate/ lactate containing fluids to determine whether this may affect acute kidney injury and other specific clinical outcomes. We agree attention to detail is always necessary when caring for infants and children receiving intravenous fluids of any type.
Sir,
I would like to add to the article ‘What dose of aspirin should be used in the initial treatment of Kawasaki disease?’ by Luke Guo Yang Ho and Nigel Curtis (Archives, 2017, 102, 1180-1182). Fifteen months have passed since this article concluded that low-dose aspirin is not inferior to higher doses in reducing the risk of coronary artery abnormalities in acute Kawasaki disease. Since then, it is worth considering what and if anything has changed in the field. A recent study not included in the review is a retrospective cohort study by Huang et al1 (2018), where 910 patients followed up for 2 years, which showed that there was no significant difference between 3 groups in terms of anti-inflammation or prevention of coronary artery abnormalities. This paper concluded that the role of aspirin in the treatment of the acute phase of Kawasaki disease should be questioned, as a definite benefit has not been shown. Therefore, in concordance with the conclusion of the review, this rapid response poses that current data remains unchanged with regards to the role and effects of administration of higher doses of aspirin on coronary outcome in acute Kawasaki disease. In the absence of evidence to support higher doses in prevention of coronary artery abnormalities, low-dose aspirin (3–5 mg/kg) may be the safest, most rational approach until better evidence becomes available.
There are currently three prospective randomised control trials in process to continue this inv...
Show MoreMany thanks for your response to the editorial ‘What are you looking at?’, which highlights some important principles for this extensively studied research area (despite being a relatively new field in healthcare) [1]
Despite the emergence of new methods to analyse gaze behaviour terminology has not been revised to reflect scientific advances. A recent article by Hessels et al. outlined significant inconsistencies in the definitions of fixations and saccades held by eye movement researchers and highlighted the conceptual confusion surrounding these terms.[2]
The term saccade is derived from the French for ‘jerk’. The phrase appears to have been coined by Emile Javal, a French ophthalmologist, in the 1800’s.[3] By 1916 it had been accepted into the English literature.[4]
Saccades are frequently defined in the literature as rapid, ballistic movements of the eyes that abruptly change the point of fixation.5 Definitions have included;
‘Rapid eye movements used to voluntarily move gaze from one target of interest to another.’[6]
‘Ballistic movements, 20-150ms long, reaching a velocity up to 800°/s. They direct the eye so that external visual objects are projected onto the fovea.’[7]
‘Rapid eye movements used in repositioning the fovea to a new location in the visual environment.’[8]
The term ballistic refers to the fact that the saccade-generating system cannot respond to subsequent changes in the position of a target during th...
Show MoreDear Sir,
As a final year medical student, I read with great interest this article highlighting the pedagogical value of gaze study. Whilst the article raises many poignant features of this new medium of data collection, I believe the definition of saccade in your article may be slightly incomplete.
The article states that “Saccades...are movements of the eyes between fixations in which information is not meaningfully acquired or absorbed.” However, I would suggest that whilst the primary purpose of saccades may be to move between fixation points, there is subconscious information acquisition completed by these movements-- the subconscious identification of a lack of pathology.
If one does not take certain regions of an image as fixation points, it suggests that they are not looking for pathology in those regions. This is reinforced by one study analysing gaze study in mammogram analysis which reported that “long saccades often missed the target but were followed by corrective saccades”. (1-Kundel H, Nodine C, Conant E et al. Holistic component of image perception in mammogram interpretation: gaze-tracking study. Radiology 2007;242(2):396-402.) This highlights that within a saccade is also inert analysis of a lack of pathology rather than just transformational eye movement.
Show MoreAnother study analysing a gaze study of virtual histopathology slides between trained pathologists, residents and medical students reported that “fully trained pathologists h...
Dear Sir,
It is with great interest that we read ‘Why do babies cry?” in which Dr. Robert Scott-Jupp have provided a concise evaluation of the research pertaining to non-pathologic crying in infants.
Crying is a normal variant in the day 2 newborn examination however it can pose a significant source of stress and anxiety for parents. To add to the body of evidence detailed in this article we posed the question; What proportion of babies cry during the day 2 newborn examination?
A convenience sample of data was collected on well babies during the standard day 2 physical examination on the postnatal ward in a tertiary maternity hospital. All babies on the postnatal ward were eligible for inclusion. Gestation, birth weight, gender, mode of delivery and duration of examination were recorded. The presence or absence of crying during examination was documented. The data was analysed using SPSS .
One hundred and fifty three babies (n=153) were included in the study. There were 82 male infants (53%) and 71 female infants (47%). Mean birth weight was 3589g (range 2590g -5160g) with a mean gestation of 39+4 (Range 36+3 - 42+1). Mean duration of examination was 7 minutes. Eighty-one babies (52.9%) delivered by spontaneous vaginal delivery, 22 (14.4%) by ventouse, 26 (16.9%) by elective caesarean section, 20 (13.1%) by emergency caesarean section and 4(2.6%) by forceps. Overall, 118 (77.1%) babies were observed to cry during the physical examination (78%...
Show MoreThank you to the authors for bringing the concept of ACPs and their importance to the forefront for consideration in practice. Thankfully, I have never had to utilise one in my professional practice, but having recently been encouraged to use an antenatal ACP for our daughter, I would offer personal support to the intentions that they should be used in practice, when appropriate. Our daughter was given a terminal diagnosis antenatally, and the decisions that followed to prepare for her birth and her death would have been overwhelming and emotionally charged in the immediate aftermath and I can only assume that our journey would have looked very different without one. Instead, the decisions and plans were considered, they were controlled and they were based on our true wishes for our daughter and our family. As the authors relate too in their article, without the ACP there would have been significant likelihood that the decisions we made for our daughter would have been made ad-hoc, under emotional pressure, and the outcome of her peaceful and comfortable death, surrounded by her family and in our arms, would likely have not been as achievable. Furthermore, the authors comment that it guides healthcare providers and parents, in a structured manner to ensure needs and wishes are met and I could not agree more. I think much of the conversations that took place, would have taken place without the ACP document, but the concept as a whole encouraged timely discussions, e...
Show MoreI welcome Himmelmann’s editorial concerning the prevention of respiratory problems for individuals with cerebral palsy1. As a speech and language therapist working within a multi-disciplinary nutrition team, I recognise the need to increase our understanding of the complex interactions between risk factors through collaboration across stakeholders. It is of particular concern that solids or liquids in the lungs or windpipe have been identified as the cause of death for almost a quarter of people with cerebral palsy2.
With this in mind, we developed the Eating and Drinking Ability Classification System (EDACS) for people with cerebral palsy from age 3 years. EDACS classifies limitations to eating and drinking ability in 1 of 5 levels, replacing frequently used terms “mild”, “moderate” and “severe” which lack shared definition. Key features of “safety” and “efficiency” are used to determine 5 distinct levels of ability: from Level I Eats and drinks safely and efficiently through to Level V Unable to eat or drink safely – tube feeding may be considered to provide nutrition. EDACS demonstrated strong content validity and excellent inter-observer reliability when used by speech and language therapists3. EDACS is free to download from www.edacs.org along with sixteen completed translations. Ten other language translations are currently in process.
Himmelmann1 points out associations between limitations to gross motor function and...
Show MoreHaving just read this article I am concerned about the terminology used as I am not sure it truly reflects the clinical problem posed. The article refers to "maintenance" fluids but the question asked relates more to “resuscitation” fluids.
It is important to be clear as to the aim of treatment in the individual patient when prescribing fluids rather than just following a guideline. The paper debates the relative merits of 0.9% sodium chloride and balanced fluids as “maintenance” fluids. To my mind “maintenance” fluids are administered to patients who have a replete extracellular fluid (ECF) volume. If ECF volume is low then “resuscitation” fluids are required. “Maintenance” and “resuscitation” fluids have different roles and therefore might be expected to have different characteristics.
As the article refers to “maintenance” fluids I will deal with these first. This fluid is needed to replicate the fluid that the patient would normally be drinking but for a variety of reasons may not be able to ingest. It should be differentiated in turn from "replacement" fluid which is the fluid given on top of the "maintenance" fluid when patients have fluid losses in excess of those normally anticipated. This includes diarrhoea, vomiting and fluid from surgical drains. The fluid used for "replacement" needs to match the composition and volume of the fluid being lost. Once "resuscitation" and "replacement" fluid...
Show MoreDear authors, dear editors,
We are writing to respond with our data, that, in the same region (Lazio), indicate a different pattern.
Show MoreWe have focused on the patients that were previously eligible for palivizumab treatment (only preterm infants, with gestational age>29 weeks), in three different hospitals located in Rome.
Please consider that the time frame is the year before and the year after of the AIFA reimbursement limitations, the same years where in Figure 1 of your manuscript you show higher hospitalizations before and lower hospitalizations after AIFA limitations.
At the NICU Casilino Hospital (ref.A) we have noticed an increase in the number of bronchiolitis from the year before (6 bronchiolitis/35 children with 30-32WGA; 17%) to the year after limitations (12/47; 26%).
At the Sapienza University of Rome we have registered an increase in hospitalizations for bronchiolitis in children with 30-36 WGA from 14 out of 165 hospitalizations (8.5%) during the 2015/16 season to 21/141 hospitalizations in the subsequent season (14.9%, p =0.05). Of them, respectively 8 (14%) and 13 (18.3%) were due to RSV, although the difference is not statistically significant. The total number of VRS+ increased significantly in the second year (ref.B).
At the OPBG we have analysed only the data from the 2016/17 season and we have noticed a higher incidence of bronchiolitis in the late preterm (13 VRS+/27 children 30-37WGA, not treated with palivizuma...
Dear authors,
We are kindly observing that the study on hospitalizations for infection due to respiratory syncytial virus should be conducted on infants aged <1 year old [1], and not on infants aged <2 years old. Such a choice is motivated by medical literature and since the prescription of palivizumab on the general population of preterm infants is up to 1 year of age. Moreover, the study does not tightly classify the hospitalization depending on the gestational age, a lack of information that exclude the possibility of a punctual statistical analysis on the infants whose gestational age is between 29-35 weeks, population matter of the analysis, impacted by the AIFA reimbursement limitations.
Show MoreIn the study infants aged <2 years old have been considered, the same subjects are statistically contributing to two consecutive seasons with different ages. The algebraic sum of the season 2014-2015 / 2015-2016 perpetuate the complexity of analysis of hospitalization for a specific season, if the infant is hospitalized in the season of his/her birth or next year.
As reported by Medici et al. [2], respiratory syncytial virus infection has a 2-years evolution, with a less critical year following a year with more abundant virus diffusion. By algebraically summing the data from two consecutive years the seasonality, so the stochasticity, is lost. Eventually the season 2016-2017 appear to be the less critical season. Environmental and patient conditions such...
Dear Sir/ Editor,
Dr Smith makes relevant and interesting points regarding the terminology used for fluids, which can be used for both “resuscitation” purposes and “maintenance” therapy, and we thank him for his interest and response.
The purpose of this clinical question was to review the current evidence for paediatric patients in relation to “ balanced fluids”, a term emerging in the medical literature. NICE recommends using any isotonic crystalloid, which covers a wide range of sodium concentration from 130 to 154mmol/L (reference 1 in the article).
The loss of electrolytes, either from the gut or as a result of renal impairment, needs regular clinical review. We observe that repeated bicarbonate measurements are not regularly undertaken after initial assessment or following admission and it is important to remind trainees to consider these losses, hence our recommendation of daily monitoring of electrolytes. By following this approach, appropriate individualised adjustments can be made to the fluid prescription of patients as necessary.
Our conclusion from this question highlighted that research needs to be undertaken in the paediatric population of bicarbonate/ lactate containing fluids to determine whether this may affect acute kidney injury and other specific clinical outcomes. We agree attention to detail is always necessary when caring for infants and children receiving intrav...
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