Chapman et al (1) present a valuable evaluation of the performance characteristics of 18 commonly used paediatric early warning systems. They observed that the performance of the 12 “scoring” systems (where cumulative component values for vital signs are used to identify thresholds for escalation of care) was superior to 6 “trigger” systems (where breaching set thresholds for one or more vital signs lead to escalation without the need for adding numerical scores), based on sensitivity, specificity and area under the operating curve (AUROC). Although they do not specifically claim that this finding should be extrapolated to suggest that all scoring systems outperform trigger systems, this is the implication both in the results and discussion section. Indeed, the associated editorial by Lillitos & Maconochie confirms this implied conclusion, when they state that “In conclusion…overall, PEWS perform better than Trigger systems.” (2)
We contend that this is an erroneous and misleading conclusion and far outstrips the scope and methodology of the study. Firstly, the findings are related to the performance of 16 specific tools and no comment can be made about whether it is the Trigger or the Score aspects which are responsible for this difference. Using the analogy of a therapeutic trial, there can be no basis to conclude that this is a “class effect” rather than specific to each tool. Secondly, the authors themselves recognise that it is the thresholds for escalation...
Chapman et al (1) present a valuable evaluation of the performance characteristics of 18 commonly used paediatric early warning systems. They observed that the performance of the 12 “scoring” systems (where cumulative component values for vital signs are used to identify thresholds for escalation of care) was superior to 6 “trigger” systems (where breaching set thresholds for one or more vital signs lead to escalation without the need for adding numerical scores), based on sensitivity, specificity and area under the operating curve (AUROC). Although they do not specifically claim that this finding should be extrapolated to suggest that all scoring systems outperform trigger systems, this is the implication both in the results and discussion section. Indeed, the associated editorial by Lillitos & Maconochie confirms this implied conclusion, when they state that “In conclusion…overall, PEWS perform better than Trigger systems.” (2)
We contend that this is an erroneous and misleading conclusion and far outstrips the scope and methodology of the study. Firstly, the findings are related to the performance of 16 specific tools and no comment can be made about whether it is the Trigger or the Score aspects which are responsible for this difference. Using the analogy of a therapeutic trial, there can be no basis to conclude that this is a “class effect” rather than specific to each tool. Secondly, the authors themselves recognise that it is the thresholds for escalation that are intrinsic to sensitivity and specificity measurements, and that changes in those thresholds might ameliorate the apparent difference in performance between all 18 tools. This is unrelated to whether each tool is a Trigger or Score systems. One would not judge C-reactive protein to be a uniformly poorly specific test of inflammation based on a threshold of <5 mg/L – rather, one would assess the threshold of significance.
Thirdly, and most importantly, the misleading implication that Score systems outperform Trigger tools based purely on test performance misses the point – that early warning systems are a multicomponent intervention and not just restricted to the scoring system in isolation. Chapman et al’s study assesses only the statistical performance in but not overall effectiveness. One would not recommend a new drug be widely used, regardless of its efficacy, without also evaluating whether the means of administration was reliable and acceptable. The recognition of deteriorating patients depends on correct recording, identification of when a threshold is reached, and not just whether the threshold is correct. There is evidence that Score-based tools are subject to significantly greater errors in completion and interpretation than Trigger tools, due to the complexity of calculations and human error. (3,4) These error rates are likely to be even more exaggerated in live clinical use than in controlled experimental settings. Future widespread implementation of electronic systems which automate the calculation process may eliminate this issue, but this is not yet widely available. Since the research was undertaken in 2011-12, there have been advances in the understanding on what is required to detect deterioration and that trigger tools are only one part of the intervention. There has also been more research on trigger and track systems and their implementation. The effectiveness of any of the tools will be dependent on the context in which the tool is used. (5,6)
Given the increasing recognition that human factors play a significant role in patient safety interventions and especially the recognition and escalation of deterioration, it is important to clarify the limitations of the findings from this study, to ensure they are not misinterpreted to imply that Score-based tools are inherently superior to Trigger systems, especially in “live” use. A recent review of PEWS concluded that “future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors.” (7) This should be the focus of research rather than concentrating on PEWS as a tool evaluated mainly by statistical performance. Neither the paper by Chapman et al (1) nor the accompanying editorial (2) appears to take this complexity into account.
References:
1. Chapman SM et al. ‘The Score Matters’: wide variations in predictive performance of 18 paediatric track and trigger systems. Arch Dis Child 2017; 102:487-95.
2. Lillitos PJ, Maconochie IK. Paediatric early warning systems (PEWS and Trigger systems) for the hospitalised child: time to focus on the evidence. Arch Dis Child 2017;102: 479-80
3. Christofidis MJ et al. A human factors approach to observation chart design can trump health professionals’ prior chart experience. Resuscitation 2013; 84: 657-665
4. Preece MHW et al. Supporting the detection of
patient deterioration: observation chart design affects the recognition of abnormal
vital signs. Resuscitation 2012;83:1111–8.
5. Brady et al,. Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events. Pediatrics, 2013. 131; e298-e308
6. Hughes C, Pain C, Braithwaite J, et al. ‘Between the flags’: implementing a rapid response system at scale
BMJ Qual Saf 2014;23:714-717.
7. Lambert V, Matthews A, MacDonell R, et al. Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review BMJ Open 2017;7:e014497. doi: 10.1136/bmjopen-2016-014497
The team from Evelina are to be commended for questioning the current
direction of travel of acute hospital practice, seeking to find "policy-
based evidence" supporting the drive for increasingly consultant-delivered
healthcare and their detailed report should help inform wider discussions,
not just in paediatrics but across the entire spectrum of acute hospital
medicine.
The team from Evelina are to be commended for questioning the current
direction of travel of acute hospital practice, seeking to find "policy-
based evidence" supporting the drive for increasingly consultant-delivered
healthcare and their detailed report should help inform wider discussions,
not just in paediatrics but across the entire spectrum of acute hospital
medicine.
Apart from two specific instances (very short-stay admissions and
acute gastroenteritis (AGE) - conditions which of themselves are not
mutually exclusive), earlier consultant review does not appear to
significantly impact on hospital length of stays.
Whilst the authors describe AGE as "one of the commonest reasons for
an acute paediatric admission" and report that, following the introduction
of earlier consultant review, children presenting with (AGE) were
discharged sooner in 2014-'15 when compared to 2012-'14, they failed to
highlight the dramatic effect Rotavirus (Rotarix?) vaccination, introduced
into the United Kingdom's Immunisation Programme in July 2013 (roughly
midpoint in the study), has subsequently had on disease prevalence, which
goes some way towards negating this reported benefit from earlier AGE
discharge.
In 2012-'14, AGE made up 6.5% (291 admissions) of Evelina London
Children's Hospital (ELCH)'s unplanned admissions, whereas in 2014-'15
only 3.5% (70 admissions) of admissions were due to AGE, a fall of almost
50% (Table 2), an effect that must surely be attributed to vaccination and
reflects national trends where acute, unplanned admissions from rotavirus
have fallen dramatically [1].
Pre-2013, there were 13,000 hospital admissions for rotavirus in
England and Wales but since then rotavirus admissions have fallen
significantly with laboratory reported rotavirus infections in England
2013/14 falling 67% when compared to the previous 10-season averages from
2003-'13. Epidemiological reports have confirmed that this decline in
cases has continued and been sustained, suggesting that rotavirus
vaccination has been extremely successful in reducing the burden of
disease rotavirus placed on our acute paediatric units [2].
There can be no doubt that vaccination success has produced a
dramatic and sustained decrease in paediatric presentations/admissions
with acute gastroenteritis which, considered in the context of this
study's findings and conclusions, must further question the need for
increasingly earlier consultant review, the position endorsed by
politicians and royal colleges alike [3].
[1] Does increased duration of consultant presence affect length of
hospital stay for unplanned admissions in acute paediatrics?: an
observational before-and-after analysis using administrative healthcare
data. Cromb, D et al. Arch Dis Child Published Online
First:10.1136/archdischild-2016-311318
[2] PHE Monthly National Norovirus and Rotavirus Report Summary of
surveillance of norovirus and rotavirus 12 June 2015. Page 8.
www.gov.uk/government/uploads/system/uploads/attachment_data/file/434768/GEZIreportTableNew12062015.pdf
[3] RCPCH "Facing the Future: Standards for Acute General Paediatric
Services - 2015"
www.rcpch.ac.uk/sites/default/files/page/Facing%20the%20Future%20Standards%20web.pdf
Two alternative explanations are given by Professor Taylor for the
global problem with ADHD diagnosis, but he overlooks one interesting
possibility- perhaps the reported prevalences are about right. That is,
perhaps the rates really do vary considerably between populations and are
rising in the USA and in other countries.
Professor Taylor recognises some obvious facts. Firstly, there is a
large unmet need. Seco...
Two alternative explanations are given by Professor Taylor for the
global problem with ADHD diagnosis, but he overlooks one interesting
possibility- perhaps the reported prevalences are about right. That is,
perhaps the rates really do vary considerably between populations and are
rising in the USA and in other countries.
Professor Taylor recognises some obvious facts. Firstly, there is a
large unmet need. Secondly the reported rates are very high in some places
and are changing quite rapidly. Thirdly, places where medical treatment is
well established have higher prevalence.
It can be pointed out that a large unmet need might be due to a
rising prevalence and that wealthy places with higher prevalence are
likely to have more established treatments. In short, we are offered no
good reason to disbelieve the data.
The unspoken reason why the prevalence data is questioned is that it
doesn't fit with our aetiological model. ADHD is supposedly genetic.
Professor Taylor, however, points out that the diagnosis for an individual
is not made based on aetiology and can't be disproved by aetiology. It is
made on well established behavioural diagnostic criteria.
Are we not left with the serious possibility that our aetiological
model is wrong. Genetics are involved with every condition. Might not twin
studies identify epigenetic as well as genomic processes? Epigenetics is
a science which is moving the ground beneath our feet. If we should not
dither in rigid constructions when the roof is falling 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...
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.
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.
Your recent Perspective, ‘How do we ensure safe prescribing for
children’ (1) highlighted an important and potentially avoidable cause of
morbidity and mortality in childhood. We would like to add that
significant errors in paediatric prescribing happen at the dispensing
stage too, with between 2 and 58% of drug errors being related to
dispensing errors (2).
We briefly describe a case which highlights this...
Your recent Perspective, ‘How do we ensure safe prescribing for
children’ (1) highlighted an important and potentially avoidable cause of
morbidity and mortality in childhood. We would like to add that
significant errors in paediatric prescribing happen at the dispensing
stage too, with between 2 and 58% of drug errors being related to
dispensing errors (2).
We briefly describe a case which highlights this problem and suggest ways
to design out much of the error associated with the dispensing of
paediatric prescriptions.
A baby was assessed at 4 weeks of age to have cow’s milk protein
intolerance and gastro-oesophageal reflux in out patients. At 16 weeks of
age, he was prescribed an age and weight appropriate course of ranitidine
together with a 3 ml syringe for the mother to give it. The drug was
mistakenly dispensed as 3 mls of ranitidine rather than the 0.4 ml it
should have been. Fortunately, the child had been prescribed ranitidine
previously and the mother noticed quickly that she had been dispensed an
incorrect amount.
In our hospital, a typical British DGH, a single prescription form is
available for use for prescriptions for all ages, in all departments.
We suggest that the number of dispensing errors where children and young
people are involved could be significantly reduced by incorporating some
or all of the following suggestions to hospital prescription forms.
All prescriptions should contain basic data including Title,
Surname, Initials, Address, Date of Birth, Consultant, Unit Number, Date,
prescribing doctor’s signature and contact details, and pharmacist
dispensed by.
Additionally, we suggest that prescriptions for children should –
1. Be manufactured in different coloured paper to adult prescriptions.
2. Be clearly stamped across the sheet ‘This is a paediatric prescription’
3. Incorporate the child’s weight in a separate and clearly designated
box
4. Specify dose per unit mass(e.g. mg /kg)
5. Supply should be specified by number of days in a separate column
6. Provide a separate section for prescribing non drug articles such as
syringes, inhaler devices, dressing materials etc.
These changes would serve to highlight to the pharmacy staff that the
prescription was for a child and that appropriate attention was required
to dispense the medication safely and correctly. We suggest that
redesigning prescription forms for children in this way would be
relatively simple and cheap to do, and have the potential to significantly
reduce paediatric morbidity and mortality associated with paediatric
dispensing errors.
References
1) Sammons H, Conroy S. How do we ensure safe prescribing for children?
Arch Dis Child 2008; Vol. 93, No2:98-99.
2) Miller M, Robinson, K, et al. Medication errors in paediatric care: a
systematic review of epidemiology and an evaluation of evidence supporting
reduction strategy recommendations. Quality and Safety in Health Care
2007;16:116-126.
Urmilla Pillai¹, Anna Mathew¹, Saffron Mawby², Stuart Nicholls¹
¹Department of Paediatrics, Worthing Hospital, Worthing, UK.
²Pharmacy Department, Worthing Hospital, Worthing, UK
We thank Dr Kraemer for his constructive response and commend his
initiative to facilitate weekly staff meetings within neonatal intensive
care units. We concur that communication is an essential component of
addressing not only moral distress but improving workplace culture.
As Dr Kraemer notes, finding the best forum for such discussions
continues to be challenging. In our various institutions we continue to...
We thank Dr Kraemer for his constructive response and commend his
initiative to facilitate weekly staff meetings within neonatal intensive
care units. We concur that communication is an essential component of
addressing not only moral distress but improving workplace culture.
As Dr Kraemer notes, finding the best forum for such discussions
continues to be challenging. In our various institutions we continue to
struggle to address a range of questions about when and how to communicate
in ways that will be genuinely helpful. Some questions are about the
nature of the discussion, such as: Do such meetings only really cater for
those who are most vocal, or who have the ability to articulate their
concerns? (And if so, what approaches will help those who struggle to be
heard?) How do we bring the honesty and transparency of 'tea room'
discussions to these more formal clinical meetings?
Some questions are practical: How can such meetings meet the needs of
both day and night time healthcare professionals? When the facilitator is
the clinical lead, who will support and care for him/her as he/she seeks
to support and highlight all other voices in the matter?
Other questions are about attitudes and values: How do we turn the
attitude that such discussions "don't change anything", into positive
responses that both advance medicine and serve the patients and their
families? At times our efforts to build trust, communicate openly and to
walk a line of integrity still seem to fall short of what is needed or
expected to maintain morale and a safe workplace environment.
It is our hope that our current longitudinal study into moral
distress will highlight the key time points where further interventions
and debriefing meetings will be most effective in addressing healthcare
professionals' valid concerns while providing a unified team that is
equipped to care for the best interests of the patient and the family, no
matter how challenging that may be.
Wright and Wales highlight the issues of childhood obesity but there
is a lack of clear guidance on who should deal with it. The suggestion to
" opportunistically discuss a childs weight" is easier said than done.
Whose responsibility is it ? There is little immediate consequence if it
is not done.
Obesity is rarely the presenting complaint to a doctor. So tackling
obesity, in addition to the primary complaint is two co...
Wright and Wales highlight the issues of childhood obesity but there
is a lack of clear guidance on who should deal with it. The suggestion to
" opportunistically discuss a childs weight" is easier said than done.
Whose responsibility is it ? There is little immediate consequence if it
is not done.
Obesity is rarely the presenting complaint to a doctor. So tackling
obesity, in addition to the primary complaint is two consultations. With
time pressures in healthcare this is challenging.
The obesity diagnosis, for a child , and sometimes the parents is
breaking bad news, it is traumatic and difficult, and often avoided for
that reason. The family doctor hopes the Paediatrician will do it and
vice versa.
The Paediatrician rarely sees the long term consequences of obesity -
hypertension, Type 2 diabetes, cardiovascular disease and arthritis and
does not own these problems. By the time we see these patients it is often
too late.
The obese child is often from an obese family which requires the doctor to
address the parents obesity as well, something that Paediatricians cannot
do.
They recommend walking ( may require a supervisor, some children
dislike it and not easy in winter) cycling ( see walking) and use of
sports centres ( requires transport and organization)
"Encouraging" a child to play less video games is like asking an addict
to use less drugs. Prescribe the following: unplug the television, turn
off the wifi and put the kids out the door to the garden or street. If
these fail refer to the enforcer for radical phonectomy!. This can
result in hours of activity.
The authors don't emphasize the difficulties of getting obese children
active. In calorie burning sports the obese child is often the goalie (
with little calorie burning) or the substitute , or cannot compete e.g.
running - where weight is a major disadvantage. The child often
leaves the team after a time having had no matches and a feeling of
inferiority.
The indignity of always being last in the race will put any child off
running. Coaches who focus on the elite and have a win at all cost
mentality give little time , or worse , to the weaker children.
Could I suggest that any sporting organization, club or school that
receives government or municipal funding, is obliged to play every child
on the team in every match for at least half an hour. They should allow
every child to play on at least one team regardless of ability. Failure to
comply should result in reduction of funds.
There are too many lost kids. They are lost between the specialties
and they are lost between the schools and clubs. Time to find them again.
Brian McNicholl FRCEM FRCS FRCPI FFSEM MCh
Consultant Emergency Medicine and amateur sports coach
University College Hospital
Galway
Ireland
This article helps us think about how we would like to provide
services to infants, children and young people (ICYP) in response to
changing needs, financial constraints and a push for multi-agency
integrated working.
We propose that paediatric services should have integrated mental health
expertise in primary care, community and hospital based services. This
would allow for prevention and early intervention, development...
This article helps us think about how we would like to provide
services to infants, children and young people (ICYP) in response to
changing needs, financial constraints and a push for multi-agency
integrated working.
We propose that paediatric services should have integrated mental health
expertise in primary care, community and hospital based services. This
would allow for prevention and early intervention, development of staff
confidence and expertise when confronted with mental health difficulties
as part of the paediatric presentations, as well as timely assessments,
formulation and treatment of mental health disorders.
Such integrated working would facilitate the early detection of mental
health difficulties which may be the primary difficulty and improve the
quality of paediatric treatment and attendant outcomes. This relates not
only to ICYP with chronic illness and complex disability, but also to
those who present at general paediatric clinics. Much time is spent by
paediatric colleagues without the relevant training and expertise in
addressing psychological difficulties which are regularly part of the
clinical presentation and separate services prevent development of skills
in managing these where appropriate, as well as causing delay to ICYP who
need to be referred elsewhere.
An integrated health response facilitates working across social services,
education and other agencies which is seen as the most helpful response to
supporting children's well-being as well as in the domain of child
protection and disability.
Anyone considering the commissioning, continuation or development of
paediatric services should be thinking of ICYP holistically and
remembering that "there is no health without mental health".
It is encouraging to see a clinical service making an effort to examine the patterns of growth found in their condition. However the conclusions drawn from their data seem greatly overstated. They describe a pattern of 'progressive growth failure' in nearly a quarter of children with ataxia telangiectasia (AT), yet there is an average decline across all children of less than half a centile space over 3 years. These children are...
It is encouraging to see a clinical service making an effort to examine the patterns of growth found in their condition. However the conclusions drawn from their data seem greatly overstated. They describe a pattern of 'progressive growth failure' in nearly a quarter of children with ataxia telangiectasia (AT), yet there is an average decline across all children of less than half a centile space over 3 years. These children are as a group very short, with a majority being below the 2nd centile, but far fewer are thin, making a nutritional origin for this short stature unlikely. Even those children who are thin are not necessarily malnourished. Our experience in a specialist feeding clinic is that children with neurodisability and chronic disorders often have low lean mass due to low muscle mass, which may actually coexist with normal or even high fat levels (1).
It is clear from the figure that three of the 12 children who received PEG feeding showed marked weight and some height gain, but others showed no weight acceleration or even a decline, with an overall median annualised gain of less than a third of a centile space. PEG feeding is an invasive, expensive, life changing treatment and to be justified there must be the substantial objective evidence of benefit. It thus seems unreasonable to infer from these findings that more children with AT should be PEG fed at an earlier stage. This should be reserved for individual children where there are clearcut problems with swallowing, or objective evidence of low fat reserves measured using skinfolds or other methods.
1.Wright CM, Smith K, Morrison j. Withdrawing feeds from children on long term enteral feeding: factors associated with success and failure. Arch-Dis-Child 2011 96(5):433-9.
Conflict of Interest:
I work in a clinic that specialises in helping children withdraw form or avoid tube feeding
Chapman et al (1) present a valuable evaluation of the performance characteristics of 18 commonly used paediatric early warning systems. They observed that the performance of the 12 “scoring” systems (where cumulative component values for vital signs are used to identify thresholds for escalation of care) was superior to 6 “trigger” systems (where breaching set thresholds for one or more vital signs lead to escalation without the need for adding numerical scores), based on sensitivity, specificity and area under the operating curve (AUROC). Although they do not specifically claim that this finding should be extrapolated to suggest that all scoring systems outperform trigger systems, this is the implication both in the results and discussion section. Indeed, the associated editorial by Lillitos & Maconochie confirms this implied conclusion, when they state that “In conclusion…overall, PEWS perform better than Trigger systems.” (2)
We contend that this is an erroneous and misleading conclusion and far outstrips the scope and methodology of the study. Firstly, the findings are related to the performance of 16 specific tools and no comment can be made about whether it is the Trigger or the Score aspects which are responsible for this difference. Using the analogy of a therapeutic trial, there can be no basis to conclude that this is a “class effect” rather than specific to each tool. Secondly, the authors themselves recognise that it is the thresholds for escalation...
Show MoreThe team from Evelina are to be commended for questioning the current direction of travel of acute hospital practice, seeking to find "policy- based evidence" supporting the drive for increasingly consultant-delivered healthcare and their detailed report should help inform wider discussions, not just in paediatrics but across the entire spectrum of acute hospital medicine.
Apart from two specific instances (very sh...
Two alternative explanations are given by Professor Taylor for the global problem with ADHD diagnosis, but he overlooks one interesting possibility- perhaps the reported prevalences are about right. That is, perhaps the rates really do vary considerably between populations and are rising in the USA and in other countries.
Professor Taylor recognises some obvious facts. Firstly, there is a large unmet need. Seco...
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...
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...
Sir
Your recent Perspective, ‘How do we ensure safe prescribing for children’ (1) highlighted an important and potentially avoidable cause of morbidity and mortality in childhood. We would like to add that significant errors in paediatric prescribing happen at the dispensing stage too, with between 2 and 58% of drug errors being related to dispensing errors (2). We briefly describe a case which highlights this...
We thank Dr Kraemer for his constructive response and commend his initiative to facilitate weekly staff meetings within neonatal intensive care units. We concur that communication is an essential component of addressing not only moral distress but improving workplace culture.
As Dr Kraemer notes, finding the best forum for such discussions continues to be challenging. In our various institutions we continue to...
Wright and Wales highlight the issues of childhood obesity but there is a lack of clear guidance on who should deal with it. The suggestion to " opportunistically discuss a childs weight" is easier said than done. Whose responsibility is it ? There is little immediate consequence if it is not done. Obesity is rarely the presenting complaint to a doctor. So tackling obesity, in addition to the primary complaint is two co...
This article helps us think about how we would like to provide services to infants, children and young people (ICYP) in response to changing needs, financial constraints and a push for multi-agency integrated working. We propose that paediatric services should have integrated mental health expertise in primary care, community and hospital based services. This would allow for prevention and early intervention, development...
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