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 a...
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.
Our Paediatric Consultant Advisory Service (PCAS) was set up in 2010 as communication between Oxfordshire General Practitioners and General Paediatricians to provide a cost-saving means of reducing the numbers of outpatient face-to-face attendees. Twelve General Paediatrician Consultants rostered for Resident-oncall night duty (21.00h-09.00h) respond to email queries from Oxfordshire GPs, aiming for a standard response within 24h period. Thirty-six GP surgeries utilised this email service and Resident Paediatric Consultants responded as part of Night activity a mean of 9 emails (median 8, range 3-20) during night hours. This confirmed that between 2011-2013 there was a five fold increase of number of GP advice-seeking emails (Annual Total for [2011-2012] was 156; for [2012-2013] was 780); between 2013-2016 emails have now doubled to 1800 emails per year (5,400 emails); there were only 2 Complaints, 15 Compliments to advisory service; the complexity of questions has emerged from 1-2 line questions in 2010-2011, to paragraphs, now seeking response to a range clinical questions entailing 10-12 lines and attached clinic consultation letters.
Quality anlaysis of a 3 month period of audit (1st September – 30th November 2013), 122 email questions arrived: of these 81 (66%) were responded to within <24hours (set standard); 15 ( 12.3%) in 24-48h; 26 (21.3%) > 48hours. 6 did not have adequate patient details so did not receive first advice response; )
Prev...
Our Paediatric Consultant Advisory Service (PCAS) was set up in 2010 as communication between Oxfordshire General Practitioners and General Paediatricians to provide a cost-saving means of reducing the numbers of outpatient face-to-face attendees. Twelve General Paediatrician Consultants rostered for Resident-oncall night duty (21.00h-09.00h) respond to email queries from Oxfordshire GPs, aiming for a standard response within 24h period. Thirty-six GP surgeries utilised this email service and Resident Paediatric Consultants responded as part of Night activity a mean of 9 emails (median 8, range 3-20) during night hours. This confirmed that between 2011-2013 there was a five fold increase of number of GP advice-seeking emails (Annual Total for [2011-2012] was 156; for [2012-2013] was 780); between 2013-2016 emails have now doubled to 1800 emails per year (5,400 emails); there were only 2 Complaints, 15 Compliments to advisory service; the complexity of questions has emerged from 1-2 line questions in 2010-2011, to paragraphs, now seeking response to a range clinical questions entailing 10-12 lines and attached clinic consultation letters.
Quality anlaysis of a 3 month period of audit (1st September – 30th November 2013), 122 email questions arrived: of these 81 (66%) were responded to within <24hours (set standard); 15 ( 12.3%) in 24-48h; 26 (21.3%) > 48hours. 6 did not have adequate patient details so did not receive first advice response; )
Previous 2013 audit of 116 responses were analysed: 72 (62%) email advice sufficed, 11 (9.4%) referred to General Paediatric Clinic; 22 (18.9%) required specialist referral or other consultant; 11 (9.5%) deemed inappropriate for PCAS advice; none required emergency care within 7 day period.
Of 105 enquiries, clinical conditions were grouped as new concern (<14days: 4), persisting symptoms (2-12 weeks: 35) or longstanding concern (>3months; 62); 4 responses excluded where original query unavailable. Recurring clinical themes of email questions occurred requiring development of FAQ section.
We conclude that Oxfordshire General Practitioners are utilising the PCAS email service regularly. 62% of email referrals receive adequate Paediatric advice to prevent outpatient face-to-face attendance – saving time and finance for GPs and families; however just over a quarter of referrals (28.3%) still required a specialist or General Paediatric OP review.
Electronic communications are now longer with accompanying detailed referral letters similar to the face-to-face consultation. This trend of increasing complex range of conditions, may not be resolved by electronic communication and face-to-face consultation are still needed to ensure medico-legal pitfalls do not occur.
The paper by Yang et al1 provided an interesting epidemiological picture regarding the healthcare use in the year before correct diagnoses are confirmed for childhood cancer, type 1 diabetes mellitus (T1DM) and other immune diseases. Despite the presence of known clinical presentations associated with these diseases, diagnoses are not usually made until after couples of medical visits, except in cases with T1DM. Nearly two thirds of newly diagnosed T1DM patients presented emergent diabetic ketoacidosis. This rate was similar to that reported in a single-center Taiwanese study2 but still much higher than those in the US and Europe.3,4 This finding raised a question whether diabetic ketoacidosis at diagnosis of T1DM was a result of missed recognition for diabetic symptoms. In this regard, I am surprised that common urological symptoms, such as proteinuria and polydipsia2, found in Taiwanese T1DM patients were not included in the ICD-9 codes grouped for the urogenital problems, although the data showed an increase in urogenital problems shortly before the diagnosis of T1DM.1 From a clinical perspective, it is also crucial to know how the access to healthcare before diagnosis differ between those with and without diabetic ketoacidosis.3 If the analysis can be stratified by this factor, we may better evaluate the performance and impact of pre-diagnostic outpatient visits on subsequent healthcare for T1DM. There is always room for improvement in terms of increasing awareness of...
The paper by Yang et al1 provided an interesting epidemiological picture regarding the healthcare use in the year before correct diagnoses are confirmed for childhood cancer, type 1 diabetes mellitus (T1DM) and other immune diseases. Despite the presence of known clinical presentations associated with these diseases, diagnoses are not usually made until after couples of medical visits, except in cases with T1DM. Nearly two thirds of newly diagnosed T1DM patients presented emergent diabetic ketoacidosis. This rate was similar to that reported in a single-center Taiwanese study2 but still much higher than those in the US and Europe.3,4 This finding raised a question whether diabetic ketoacidosis at diagnosis of T1DM was a result of missed recognition for diabetic symptoms. In this regard, I am surprised that common urological symptoms, such as proteinuria and polydipsia2, found in Taiwanese T1DM patients were not included in the ICD-9 codes grouped for the urogenital problems, although the data showed an increase in urogenital problems shortly before the diagnosis of T1DM.1 From a clinical perspective, it is also crucial to know how the access to healthcare before diagnosis differ between those with and without diabetic ketoacidosis.3 If the analysis can be stratified by this factor, we may better evaluate the performance and impact of pre-diagnostic outpatient visits on subsequent healthcare for T1DM. There is always room for improvement in terms of increasing awareness of T1DM symptoms, ensuring early diagnosis, and preventing complications among healthcare sectors and affected families.
References
1. Yang TO, Huang W, Chen M, et al. Childhood cancer, type 1 diabetes and other immune diseases: healthcare visits in the year before diagnosis in Taiwan Archives of Disease in Childhood Published Online First: 08 February 2017. doi: 10.1136/archdischild-2016-311762
2. Chen YC, Tung YC, Liu SY, et al. Clinical characteristics of type 1 diabetes mellitus in Taiwanese children aged younger than 6 years: A single-center experience.
J Formos Med Assoc. 2016 Aug 9. doi: 10.1016/j.jfma.2016.07.005. [Epub ahead of print]
3. Baldelli L, Flitter B, Pyle L, et al. A survey of youth with new onset type 1 diabetes: Opportunities to reduce diabetic ketoacidosis. Pediatr Diabetes. 2016 Oct 11. doi: 10.1111/pedi.12455.
4. Cherubini V, Skrami E, Ferrito L, et al. High frequency of diabetic ketoacidosis at diagnosis of type 1 diabetes in Italian children: a nationwide longitudinal study, 2004-2013. Sci Rep. 2016 Dec 19;6:38844. doi: 10.1038/srep38844.
We have read with great interest the investigation by Ivanovska et al in which they compared the antibiotic formulations included on the WHO Essencial Medicines List for Children (EMLc) versus four pertinent International Formularies (-1- ). As a result, they identified nine clinically relevant additional formulations on the comparator lists which were not listed on the WHO EMLc.
We would like to mention another relevant formulation of great interest, which was not studied by the authors as it was not included on the lists they selected for the comparison study.
They found only one vancomycin formulation on the WHO EMLc (250mg powder for injection) and two additional formulations on the comparator lists (125mg and 250mg oral capsules). Neither the WHO EMLc nor the comparator lists had any reference about oral liquid formulations of vancomycin; they are commercially available only in a few countries. However, they are necessary to simplify and facilitate the proper oral administration of the drug to infants and young children to treat Clostridium Difficile (CD) Infection (CDI) disease in accordance with therapeutic guidelines.
CD has become the most common cause of health care-associated infections in US hospitals (-2- ). Since the discovery of CDI there has been an alarming increase in the incidence, severity, recurrence rate of the disease and mortality. The emergence of an epidemic hypervirulent strain of toxin –producing CD in r...
We have read with great interest the investigation by Ivanovska et al in which they compared the antibiotic formulations included on the WHO Essencial Medicines List for Children (EMLc) versus four pertinent International Formularies (-1- ). As a result, they identified nine clinically relevant additional formulations on the comparator lists which were not listed on the WHO EMLc.
We would like to mention another relevant formulation of great interest, which was not studied by the authors as it was not included on the lists they selected for the comparison study.
They found only one vancomycin formulation on the WHO EMLc (250mg powder for injection) and two additional formulations on the comparator lists (125mg and 250mg oral capsules). Neither the WHO EMLc nor the comparator lists had any reference about oral liquid formulations of vancomycin; they are commercially available only in a few countries. However, they are necessary to simplify and facilitate the proper oral administration of the drug to infants and young children to treat Clostridium Difficile (CD) Infection (CDI) disease in accordance with therapeutic guidelines.
CD has become the most common cause of health care-associated infections in US hospitals (-2- ). Since the discovery of CDI there has been an alarming increase in the incidence, severity, recurrence rate of the disease and mortality. The emergence of an epidemic hypervirulent strain of toxin –producing CD in recent years is a matter of major concern due to it has been described as causing more severe disease. The US CDC estimated that almost half a million CD infections occurred in USA in 2011 and that they were associated with death in 29.000 patients that year (-2- ). In Europe, 175.000 cases were estimated in the same year (-3- ).
CDI is less common in children than in adults, but it is increasing (-4- ). According to international recommendations (-5- ) (-6- ), metronidazole is the initial recommended therapy for mild and moderate cases. For severe – severe complicated cases and recurrent episodes vancomycin is the drug of choice: 40mg/Kg/day divided in four doses (10mg/kg/dose). The use of oral metronidazole in severe CDI or life-threatening disease is strongly discouraged (-6- ). Fidaxomicin is a novel alternative antibiotic used for CDI treatment in adults (-7 - ).
Although oral vancomycin (in capsules) has potential contradictions with WHO rules, vancomycin is the recommended and preferred agent for severe disease and recurrent episodes, and it is the only drug approved by US FDA for CDI treatment in children (-5 - ).
In most countries there are no pharmaceutical products available on the market with oral liquid formulations to administer low amounts of vancomycin to infants (e.g. 55mg, 70mg) so every time we need to start a treatment we have to use compounded formulations usually prepared by the hospital pharmacy for each patient; or nurses have to obtain each dose by taking the intravenous injectable vial as a basis, from the dilution and fractionation of the existing injectable medicines for adults (500 mg/vial or 1000 mg/vial).
The WHO EMLc and International Formularies are used as a Model List by national Health Authorities for the selection and procurement of medicines, and they are especially taken into account in low and middle income countries to improve the availability of medicines.
Vancomycin oral liquid formulations (e.g. powder for oral liquid) simplify the dosing of low amounts of the drug, reduce medication errors and decrease the waste of medicines. They should be considered for evaluation to be listed, or somehow mentioned, on the WHO EMLc and International Formularies. These references will have an important influence to promote public (or private) pharmaceutical production, especially in low and middle income countries, with low cost, so that suitable formulations for infants and young children may be available to treat the severe and sometimes life threatening CDI cases.
Last month, on March 29th, the WHO launched a Global Initiative to reduce avoidable medication-associated harm in all countries by 50% over the next 5 years (- 8 - ).
A greater availability of age –appropriate formulations for neonates, infants and young children in all countries will help to achieve the goal globally.
Jorge Pisapia - Matías Lucero - Leonardo Giunta.
Clínica y Maternidad Suizo Argentina.
Department of Pharmacy.
SWISS MEDICAL GROUP. Buenos Aires. Argentina.
REFERENCES
1 – Ivanovska V., Leufkens HG., Rademaker CMA. et al. Are age-appropriate antibiotic formulations missing from the WHO list of essential medicines for children? A comparison study. Arch Dis Child 2017; 102:352-356.
2 – Lessa FC., Mu Y., Bamberg WM., et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015; 372(9):
825–834.
4. - Nylund CM., Goudie A., Garza JM. et al. Clostridium difficile Infection in hospitalized children in the United States. Arch Pediatr Adolesc Med 2011; 165(5):451-457.
5. - Schutze GE., Willoughby RE. Committee on Infectious Diseases. American Academy of Pediatrics. Clostridium difficile Infection in Infants and Children. Pediatrics 2013; 131(1):196-200.
6. - Debast SB., Bauer MP., Kuijper EJ. et al. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): update of the treatment guidance document for Clostridium difficile infection (CDI). Clin Microbiol Infect 2014; 20 (Suppl 2):1-26.
I would like to thank Professor Taylor for his response, and apologise if my second response seems rude. I thought the first one had been overlooked.
We do indeed agree that there is a large unmet need due to the under-recognition of ADHD and, I would suggest, other developmental disorders with a supposed genetic aetiology which seem to be more common than they were. The question of aetiology is, of course, pertinent to the epidemiology and the service needs assessment. Urgent too, if children's community services are not to be overwhelmed.
Berrington and Ward Platt recently summarized current advances in the management of preterm infants born < 1000 g, so called extremely low birth weight (ELBW) infants (1). In this thoroughly done review, the authors highlighted the findings of the 2014 Cochrane review showing probiotics to reduce all-cause mortality and NEC in preterm infants, but not in the subgroup of ELBW infants (2). They hypothesized the lacking protective effect in this extremely vulnerable population to be attributable to their general immaturity, the timing of probiotic exposure or the small sample size of only 575 ELBW infants analyzed. Another recent meta-analysis did not show a significant beneficial effect of probiotics on sepsis in 771 ELBW infants included (3). This demands further studies with adequate power on the use of probiotics in infants born < 1000 g. Almost at the same time, we published a multi-center time series analysis supporting the beneficial effects of dual-strain probiotics on NEC, overall-mortality and nosocomial bloodstream infections (BSI) in preterm infants (4). Beyond that, we performed a subgroup analyses with 4683 ELBW infants. Routine use of dual-strain probiotics significantly reduced the risk of NEC (HR 0.48, 95 % CI 0.36 – 0.64), overall mortality (HR 0.59, 95 % CI 0.41 – 0.84) and nosocomial BSI (HR 0.83, 95 % CI 0.74 – 0.94) in this cohort. Further, probiotics also protected ELBW infants from mortality following NEC (HR 0.40, 95 % CI 0.19 – 0.85). Up to dat...
Berrington and Ward Platt recently summarized current advances in the management of preterm infants born < 1000 g, so called extremely low birth weight (ELBW) infants (1). In this thoroughly done review, the authors highlighted the findings of the 2014 Cochrane review showing probiotics to reduce all-cause mortality and NEC in preterm infants, but not in the subgroup of ELBW infants (2). They hypothesized the lacking protective effect in this extremely vulnerable population to be attributable to their general immaturity, the timing of probiotic exposure or the small sample size of only 575 ELBW infants analyzed. Another recent meta-analysis did not show a significant beneficial effect of probiotics on sepsis in 771 ELBW infants included (3). This demands further studies with adequate power on the use of probiotics in infants born < 1000 g. Almost at the same time, we published a multi-center time series analysis supporting the beneficial effects of dual-strain probiotics on NEC, overall-mortality and nosocomial bloodstream infections (BSI) in preterm infants (4). Beyond that, we performed a subgroup analyses with 4683 ELBW infants. Routine use of dual-strain probiotics significantly reduced the risk of NEC (HR 0.48, 95 % CI 0.36 – 0.64), overall mortality (HR 0.59, 95 % CI 0.41 – 0.84) and nosocomial BSI (HR 0.83, 95 % CI 0.74 – 0.94) in this cohort. Further, probiotics also protected ELBW infants from mortality following NEC (HR 0.40, 95 % CI 0.19 – 0.85). Up to date, this is the largest study on probiotics in ELBW infants. Our findings suggest the routine use of dual-strain probiotics in standard neonatal care of infants born < 1000 g.
References
1. Berrington J, Ward Platt M. Recent advances in the management of infants born <1000 g. Archives of disease in childhood. 2016; doi: 10.1136/archdischild-2015-309583 [published Online First: 2016/05/12].
2. AlFaleh K, Anabrees J. Probiotics for prevention of necrotizing enterocolitis in preterm infants. The Cochrane database of systematic reviews. 2014;4:Cd005496 doi: 10.1002/14651858.CD005496.pub4 [published Online First: 2014/04/12].
3. Zhang GQ, Hu HJ, Liu CY, Shakya S, Li ZY. Probiotics for Preventing Late-Onset Sepsis in Preterm Neonates: A PRISMA-Compliant Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine. 2016;95:e2581 doi: 10.1097/md.0000000000002581 [published Online First: 2016/03/05].
4. Denkel LA, Schwab F, Garten L, Geffers C, Gastmeier P, Piening B. Protective Effect of Dual-Strain Probiotics in Preterm Infants: A Multi-Center Time Series Analysis. PloS one. 2016;11:e0158136 doi: 10.1371/journal.pone.0158136 [published Online First: 2016/06/23].
In your paper [1], you did not mention a previous prospective study performed by our group [2], on 148 otherwise healthy children referred to a Sleep Center for suspected OSA. In our study, pulse oximetry metrics were similar on the two consecutive nights. The McGill Oximery Score (MOS) on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive. We highlighted that the findings may not apply to younger infants, to adolescents, or to children with complex comorbidities.
Our conclusions were different from yours for at least two main reasons.
Firstly, you accepted oximetry recording lasting ≥ 4 hrs. On our opinion, this cut off is too low and it cannot be sufficiently representative of an overnight study. In our study [2], we accepted recordings lasting ≥ 6 hrs according to the ATS guidelines for sleep study.
Secondly, you used a Nonin 9600 Pulse Oximeter with Nellcor neonatal-adult SpO2 sensor. In our study [2], we used a motion-resistant Radical 5 Masimo Pulse Oximeter. Previous studies [3,4], demonstrated the superiority of the Radical Masimo technology.
We believe that your study was performed using suboptimal technology and the criteria for minimum acceptable recording time didn’t respect the ATS guidelines. Therefore, your results should be considered with caution.
Convincing data already exist on pulse oximetry and the analysis of MOS as a useful tool for...
In your paper [1], you did not mention a previous prospective study performed by our group [2], on 148 otherwise healthy children referred to a Sleep Center for suspected OSA. In our study, pulse oximetry metrics were similar on the two consecutive nights. The McGill Oximery Score (MOS) on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive. We highlighted that the findings may not apply to younger infants, to adolescents, or to children with complex comorbidities.
Our conclusions were different from yours for at least two main reasons.
Firstly, you accepted oximetry recording lasting ≥ 4 hrs. On our opinion, this cut off is too low and it cannot be sufficiently representative of an overnight study. In our study [2], we accepted recordings lasting ≥ 6 hrs according to the ATS guidelines for sleep study.
Secondly, you used a Nonin 9600 Pulse Oximeter with Nellcor neonatal-adult SpO2 sensor. In our study [2], we used a motion-resistant Radical 5 Masimo Pulse Oximeter. Previous studies [3,4], demonstrated the superiority of the Radical Masimo technology.
We believe that your study was performed using suboptimal technology and the criteria for minimum acceptable recording time didn’t respect the ATS guidelines. Therefore, your results should be considered with caution.
Convincing data already exist on pulse oximetry and the analysis of MOS as a useful tool for detecting and grading severity of paediatric OSA, to prioritize the most severely affected children for expeditious adenotonsillectomy, to predict the likelihood of having adverse peri-operative respiratory events.
We reinforce the concept that pulse oximetry is useful when performed with appropriate motion-resistant technology, interpreted by expert physicians, and targeted to otherwise healthy children.
Children with complex pathologies deserve a different approach as suggested by ERS Guidelines and poly(somno)graphy should be performed.
References
1) Burke RM, Maxwell B, Hunter C, et al. Night-to-night variation of pulse oximetry in children with sleep disordered breathing. Arch Dis Child 2016;101:1095–9.
2) Pavone M, Cutrera R, Verrillo E, et al Night-to-night consistency of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatr Pulmonol. 2013 Aug; 48(8):754-60.
3) Trang H, Boureghda S, Leske V. Sleep desaturation: comparison of two oximeters. Pediatr Pulmonol. 2004 Jan;37(1):76-80”.
4) Brouillette RT, Lavergne J, Leimanis A, et al. “Differences in pulse oximetry technology can affect detection of sleep-disorderd breathing in children. Anesth Analg. 2002 Jan;94(1 Suppl):S47-53”
Dear Editor,
We woud like to respond to one of the issues raised in the audit of high
flow nasal cannula (HHFNC) recently published (1). As the authors observed, although evidence for efficacy is lacking,
clinical pactice has rapidly expanded the indications for respiratory
support on the ward using HHFNC. We have observed a number of cases
where commencement of HHFNC may have delayed referral to the PICU
service, and are concerned that this may have affected the level of
respiratory support required on subsequent admission to PICU. Humidified high flow nasal cannula (HHFNC) provides heated and
humidified air/oxygen flow to support respiratory function in sick
infants and children. Flow rates may be up to 60L/min, and are usually
titrated at 1-3L/kg depending on clinical work of breathing (WOB). The
concentration of oxygen may be adjusted to maintain oxygen saturations
within the normal range for each child. Pediatric units providing this
therapy, usually do so within agreed guidelines. Some units mandate
admission to the Pediatric Intensive Care Unit (PICU), and some
administer HHFNC on the ward. There is some evidence that the use of
HHFNC may reduce the need for PICU admission and more advanced
respiratory support (2). However, studies to date have not stratified
infants further, into categories of risk of failure of therapy (3). Yet
infants with significan...
Dear Editor,
We woud like to respond to one of the issues raised in the audit of high
flow nasal cannula (HHFNC) recently published (1). As the authors observed, although evidence for efficacy is lacking,
clinical pactice has rapidly expanded the indications for respiratory
support on the ward using HHFNC. We have observed a number of cases
where commencement of HHFNC may have delayed referral to the PICU
service, and are concerned that this may have affected the level of
respiratory support required on subsequent admission to PICU. Humidified high flow nasal cannula (HHFNC) provides heated and
humidified air/oxygen flow to support respiratory function in sick
infants and children. Flow rates may be up to 60L/min, and are usually
titrated at 1-3L/kg depending on clinical work of breathing (WOB). The
concentration of oxygen may be adjusted to maintain oxygen saturations
within the normal range for each child. Pediatric units providing this
therapy, usually do so within agreed guidelines. Some units mandate
admission to the Pediatric Intensive Care Unit (PICU), and some
administer HHFNC on the ward. There is some evidence that the use of
HHFNC may reduce the need for PICU admission and more advanced
respiratory support (2). However, studies to date have not stratified
infants further, into categories of risk of failure of therapy (3). Yet
infants with significant comorbidities may present to the emergency
department of the district general hospital (DGH), and receive HHFNC
therapy (1).
We have retrospectively audited admissions of infants to PICU with a
diagnosis of bronchiolitis over the past 24 months to assess the impact
of HHFNC, Synagis administration and standard PICU care on outcome. As
part of this quality audit we have observed a number of cases which
suggest the HHFNC may have increased the requirement for sedation and
intubation, and increased the duration of ventilatory support required.
We present three cases from this audit, and suggest changes to practice
which may improve outcome when utilizing HHFNC in very young infants.
Ethics approval was waived as an audit of existing practice. Case 1
12 day old ex-premature infant, born at 34+5, 2.4kg. Home for 5 days,
presented to the emergency department with occasional cough, brief
apneas and cyanosis. First SpO2 81% on room air. Commenced HHFNC 2L/kg
50% oxygen. RSV positive. 16 hours after admission had prolonged apnea
with bradycardia. Lifeless in parents arms, resuscitated and transferred
to PICU. Intubated and ventilated for 6 days.
Case 2
4 week old infant post-operative hypoplastic left ventricle, stage I
palliation, norwood. Had received Synagis before discharge home. Poor
feeding and cough for 24 hours. Presented to ED and admitted to Cardiac
ward on HHFNC 2L/kg, FiO2 0.25. Marked WOB and cold peripheries. Oxygen
saturations dipping into the 60's, oxygen titrated up overnight. Kept
fasting and commenced intravenous fluids. Significant WOB continued,
flow increased to 3L/kg, 40% oxygen. Cold peripheries. Infant
increasingly lethargic. Arterial blood gas 28 hours after admission
showed pH 7.17 pO2 3.4, pCO2 10.7, BE -17, lactate 8. Admitted to PICU,
sedated and intubated after fluid administration. Transfused 20ml/kg red
cells, ventilated for 8 days. RSV positive.
Case 3
9 week old 3.2kg infant post-operative tracheoesophageal fistula repair,
VACTERL syndrome. Presented to ED with cough, profuse nasal secretions
and significant work of breathing (WOB). HHFNC 2L/kg and nasogastric
feeds commenced with initial improvement of WOB. 50 hours later, infant
still had increased WOB. Coughing spells provoked vomiting at the end of
each feed. Venous blood gas showed pH 7.1, PO2 5.1, PCO2 11.0, BE -12,
lactate 4. He was reviewed by PICU team who noted respiratory rate of 16
breaths per minute. Transferred to PICU and intubated immediately.
Ventilated for 7 days, followed by 2 days of non-invasive ventilation.
From the above cases, and other infants reviewed during our audit of
bronchiolitis admissions to PICU, we concur with Jones et al that
further study of HHFNC in some groups of infants and children is
required (1). The patients we have particular concerns about are:
-Infants less than 48 weeks post-conceptual age (PCA).
-Ex-premature infants who are <48 weeks PCA
-Infants post cardiac surgery
-Young infants post major surgery
-Young infants who present with increased PCO2 on their first blood gas
analysis.
-Young infants who present with a significant oxygen requirement >
50%
Implementation of following measures may be considered to increase the
safety and efficacy of ward-based HHFNC in these infants:
-Increased level of monitoring for the first 2 hours after starting
HHFNC. If no clinical improvement, admit to PICU.
-If PCO2 is increased at presentation, admit to PICU for non-invasive
PS/CPAP (BIPAP).
-If HHFNC is still required after 24 hours of support, admit to PICU.
Until we have robust evidence to support the widespread use of HHFNC on
the infant wards and in the DGH, we should aim to reduce inappropriate
and prolonged use of HHFNC in very young infants, especially those with
co-morbidity, by ensuring that locally agreed clinical guidelines are
being adhered to - we also need to consider the possiblity that HHFNC
may not be a panacea for all patients (4).
References:
1. Jones AJ, Mathew S, Wong SW, Patel M, Equi A, Sukhani S, Mambiar S,
Ramnarayan P. A regional audit of high-flow nasal cannula therpay use
for bronchiolitis in London district general hospitals. Rch Dis Child
online Jan 24 2017. http://adc.bmj.com/content/early/2017/01/24/archdischild-2016-312462
2.Beggs SI, Wong ZH, Kaul S, Ogden KJ, Walters JA. High flow nasal
cannula therapy for infants with bronchiolitis. Cochrane Database Syst
Rev 2014 Jan 20;(1):CD009609
3.Riese J, Fierce J, Riese A, Alverson BK. Effect of a hospital-wide
hgh-flow cannula protocol on clinical outcomes and resource utilization
of bronchiolitis patients admitted to PICU. Hosp Pediatrics
2015;5(12):613-8
4.Kang BJ, Koh Y, Lim CM et al. Failure of high-flow nasal cannula
therapy may delay intubation and increase mortality. Intensive Care
Medicine 2015;41:623-32
Professor Taylor, quoting a sound meta-analysis by Polanczyk et al
published 16 years previously, declares that the prevalence of ADHD is
around 5%. He appears convinced that the prevalence has not changed and
does not change, and he explains that rates which differ from around 5%
are either due to over-diagnosis or under-diagnosis.
I hope I am not being impudent in suggesting that the professor has a
rather in...
Professor Taylor, quoting a sound meta-analysis by Polanczyk et al
published 16 years previously, declares that the prevalence of ADHD is
around 5%. He appears convinced that the prevalence has not changed and
does not change, and he explains that rates which differ from around 5%
are either due to over-diagnosis or under-diagnosis.
I hope I am not being impudent in suggesting that the professor has a
rather inflexible view on the epidemiology of ADHD. As ADHD is not an
aetiological diagnosis, might it not vary considerably by place and over
time? We are invited to adjust our view of normality such that a magic 5%
fall beyond threshold, regardless of how many children are swinging from
the chandeliers.
Thanks to Dr Colvin for his interest. I should like to clarify that
an "unspoken assumption" of genetic determinism did not underlie my
review. I agree with his points on the aetiology: the balance of genetic
and environmental influences and their interaction deserve much more
study. The aetiology, however, is an issue rather separate from
prevalence. Even if countries did differ in their actual rates (rather
than just...
Thanks to Dr Colvin for his interest. I should like to clarify that
an "unspoken assumption" of genetic determinism did not underlie my
review. I agree with his points on the aetiology: the balance of genetic
and environmental influences and their interaction deserve much more
study. The aetiology, however, is an issue rather separate from
prevalence. Even if countries did differ in their actual rates (rather
than just the rates of diagnosis in practice), the explanation could
equally be in genetic or environmental diversity. The suggestion, that
the actual rate of ADHD is broadly similar across countries, did not
derive from theories of cause, but from the cited metaanalyses of
epidemiological research. Those meta-analyses conclude that geographical
location plays only a small and limited role in the variability of
prevalence (eg as between estimates from North America on one hand and
Africa and the Middle East on the other). That conclusion is provisional
in the presence of uncertainties about case identification and the strong
influences of methodology on prevalence results.
I hope the questions raised will not distract readers from the key
argument that there is substantial and avoidable under-recognition and
under-treatment of ADHD in the UK. I am glad that Dr Colvin agrees and
indeed regards it as obvious. I hope other readers will do the same and
convey their concern to commissioners and providers of services in health
and education.
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 a...
Show MoreOur Paediatric Consultant Advisory Service (PCAS) was set up in 2010 as communication between Oxfordshire General Practitioners and General Paediatricians to provide a cost-saving means of reducing the numbers of outpatient face-to-face attendees. Twelve General Paediatrician Consultants rostered for Resident-oncall night duty (21.00h-09.00h) respond to email queries from Oxfordshire GPs, aiming for a standard response within 24h period. Thirty-six GP surgeries utilised this email service and Resident Paediatric Consultants responded as part of Night activity a mean of 9 emails (median 8, range 3-20) during night hours. This confirmed that between 2011-2013 there was a five fold increase of number of GP advice-seeking emails (Annual Total for [2011-2012] was 156; for [2012-2013] was 780); between 2013-2016 emails have now doubled to 1800 emails per year (5,400 emails); there were only 2 Complaints, 15 Compliments to advisory service; the complexity of questions has emerged from 1-2 line questions in 2010-2011, to paragraphs, now seeking response to a range clinical questions entailing 10-12 lines and attached clinic consultation letters.
Show MoreQuality anlaysis of a 3 month period of audit (1st September – 30th November 2013), 122 email questions arrived: of these 81 (66%) were responded to within <24hours (set standard); 15 ( 12.3%) in 24-48h; 26 (21.3%) > 48hours. 6 did not have adequate patient details so did not receive first advice response; )
Prev...
The paper by Yang et al1 provided an interesting epidemiological picture regarding the healthcare use in the year before correct diagnoses are confirmed for childhood cancer, type 1 diabetes mellitus (T1DM) and other immune diseases. Despite the presence of known clinical presentations associated with these diseases, diagnoses are not usually made until after couples of medical visits, except in cases with T1DM. Nearly two thirds of newly diagnosed T1DM patients presented emergent diabetic ketoacidosis. This rate was similar to that reported in a single-center Taiwanese study2 but still much higher than those in the US and Europe.3,4 This finding raised a question whether diabetic ketoacidosis at diagnosis of T1DM was a result of missed recognition for diabetic symptoms. In this regard, I am surprised that common urological symptoms, such as proteinuria and polydipsia2, found in Taiwanese T1DM patients were not included in the ICD-9 codes grouped for the urogenital problems, although the data showed an increase in urogenital problems shortly before the diagnosis of T1DM.1 From a clinical perspective, it is also crucial to know how the access to healthcare before diagnosis differ between those with and without diabetic ketoacidosis.3 If the analysis can be stratified by this factor, we may better evaluate the performance and impact of pre-diagnostic outpatient visits on subsequent healthcare for T1DM. There is always room for improvement in terms of increasing awareness of...
Show MoreTo the editor:
We have read with great interest the investigation by Ivanovska et al in which they compared the antibiotic formulations included on the WHO Essencial Medicines List for Children (EMLc) versus four pertinent International Formularies (-1- ). As a result, they identified nine clinically relevant additional formulations on the comparator lists which were not listed on the WHO EMLc.
We would like to mention another relevant formulation of great interest, which was not studied by the authors as it was not included on the lists they selected for the comparison study.
They found only one vancomycin formulation on the WHO EMLc (250mg powder for injection) and two additional formulations on the comparator lists (125mg and 250mg oral capsules). Neither the WHO EMLc nor the comparator lists had any reference about oral liquid formulations of vancomycin; they are commercially available only in a few countries. However, they are necessary to simplify and facilitate the proper oral administration of the drug to infants and young children to treat Clostridium Difficile (CD) Infection (CDI) disease in accordance with therapeutic guidelines.
CD has become the most common cause of health care-associated infections in US hospitals (-2- ). Since the discovery of CDI there has been an alarming increase in the incidence, severity, recurrence rate of the disease and mortality. The emergence of an epidemic hypervirulent strain of toxin –producing CD in r...
Show MoreI would like to thank Professor Taylor for his response, and apologise if my second response seems rude. I thought the first one had been overlooked.
We do indeed agree that there is a large unmet need due to the under-recognition of ADHD and, I would suggest, other developmental disorders with a supposed genetic aetiology which seem to be more common than they were. The question of aetiology is, of course, pertinent to the epidemiology and the service needs assessment. Urgent too, if children's community services are not to be overwhelmed.
Berrington and Ward Platt recently summarized current advances in the management of preterm infants born < 1000 g, so called extremely low birth weight (ELBW) infants (1). In this thoroughly done review, the authors highlighted the findings of the 2014 Cochrane review showing probiotics to reduce all-cause mortality and NEC in preterm infants, but not in the subgroup of ELBW infants (2). They hypothesized the lacking protective effect in this extremely vulnerable population to be attributable to their general immaturity, the timing of probiotic exposure or the small sample size of only 575 ELBW infants analyzed. Another recent meta-analysis did not show a significant beneficial effect of probiotics on sepsis in 771 ELBW infants included (3). This demands further studies with adequate power on the use of probiotics in infants born < 1000 g. Almost at the same time, we published a multi-center time series analysis supporting the beneficial effects of dual-strain probiotics on NEC, overall-mortality and nosocomial bloodstream infections (BSI) in preterm infants (4). Beyond that, we performed a subgroup analyses with 4683 ELBW infants. Routine use of dual-strain probiotics significantly reduced the risk of NEC (HR 0.48, 95 % CI 0.36 – 0.64), overall mortality (HR 0.59, 95 % CI 0.41 – 0.84) and nosocomial BSI (HR 0.83, 95 % CI 0.74 – 0.94) in this cohort. Further, probiotics also protected ELBW infants from mortality following NEC (HR 0.40, 95 % CI 0.19 – 0.85). Up to dat...
Show MoreDear Authors.
In your paper [1], you did not mention a previous prospective study performed by our group [2], on 148 otherwise healthy children referred to a Sleep Center for suspected OSA. In our study, pulse oximetry metrics were similar on the two consecutive nights. The McGill Oximery Score (MOS) on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive. We highlighted that the findings may not apply to younger infants, to adolescents, or to children with complex comorbidities.
Our conclusions were different from yours for at least two main reasons.
Firstly, you accepted oximetry recording lasting ≥ 4 hrs. On our opinion, this cut off is too low and it cannot be sufficiently representative of an overnight study. In our study [2], we accepted recordings lasting ≥ 6 hrs according to the ATS guidelines for sleep study.
Secondly, you used a Nonin 9600 Pulse Oximeter with Nellcor neonatal-adult SpO2 sensor. In our study [2], we used a motion-resistant Radical 5 Masimo Pulse Oximeter. Previous studies [3,4], demonstrated the superiority of the Radical Masimo technology.
We believe that your study was performed using suboptimal technology and the criteria for minimum acceptable recording time didn’t respect the ATS guidelines. Therefore, your results should be considered with caution.
Convincing data already exist on pulse oximetry and the analysis of MOS as a useful tool for...
Show MoreDear Editor,
Show MoreWe woud like to respond to one of the issues raised in the audit of high
flow nasal cannula (HHFNC) recently published (1). As the authors observed, although evidence for efficacy is lacking,
clinical pactice has rapidly expanded the indications for respiratory
support on the ward using HHFNC. We have observed a number of cases
where commencement of HHFNC may have delayed referral to the PICU
service, and are concerned that this may have affected the level of
respiratory support required on subsequent admission to PICU. Humidified high flow nasal cannula (HHFNC) provides heated and
humidified air/oxygen flow to support respiratory function in sick
infants and children. Flow rates may be up to 60L/min, and are usually
titrated at 1-3L/kg depending on clinical work of breathing (WOB). The
concentration of oxygen may be adjusted to maintain oxygen saturations
within the normal range for each child. Pediatric units providing this
therapy, usually do so within agreed guidelines. Some units mandate
admission to the Pediatric Intensive Care Unit (PICU), and some
administer HHFNC on the ward. There is some evidence that the use of
HHFNC may reduce the need for PICU admission and more advanced
respiratory support (2). However, studies to date have not stratified
infants further, into categories of risk of failure of therapy (3). Yet
infants with significan...
Professor Taylor, quoting a sound meta-analysis by Polanczyk et al published 16 years previously, declares that the prevalence of ADHD is around 5%. He appears convinced that the prevalence has not changed and does not change, and he explains that rates which differ from around 5% are either due to over-diagnosis or under-diagnosis.
I hope I am not being impudent in suggesting that the professor has a rather in...
Thanks to Dr Colvin for his interest. I should like to clarify that an "unspoken assumption" of genetic determinism did not underlie my review. I agree with his points on the aetiology: the balance of genetic and environmental influences and their interaction deserve much more study. The aetiology, however, is an issue rather separate from prevalence. Even if countries did differ in their actual rates (rather than just...
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