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Recent eLetters

Displaying 1-10 letters out of 87 published

  1. Prenatal and neonatal paracetamol (acetaminophen) may increase the risk for ADHD and asthma.

    Dr. Catherine Williams argues against and Dr. Damian Roland for using antipyretics in feverish children (Arch Dis Child Educ Pract Ed 2014;99:158-159) but they do not mention that paracetamol may be a risk factor for ADHD and asthma.

    In the last two years, an animal study1, two cohort studies2 3, and an ecologic study4 have presented evidence for an increased risk of disturbed neuropsychiatric development after prenatal or neonatal exposure to paracetamol.

    In a very large randomized, controlled trial, asthmatic children with an acute respiratory infection who used paracetamol needed more outpatient asthma visits compared to those on ibuprofen5. McBride6 pointed out that many observations suggest a causative association between acetaminophen and asthma: (1) the strength of the association; (2) the consistency across geography, culture, and age; (3) the dose-response relationship; (4) the coincidence of increasing asthma prevalence and increasing acetaminophen use; (5) no other abrupt environmental change that could explain this increase in asthma morbidity; (6) the relationship between per-capita sales of acetaminophen and asthma morbidity across countries; and (7) the biologically plausible mechanism of glutathione depletion in airway mucosa.

    It is not true that there is "absence of evidence of harm" of antipyretics. Ibuprofen has been less studied and may or may not be safer than paracetamol after 6 months of age. Given the small benefits of antipyretics, my conclusion is that paracetamol could be used by pregnant women, infants and children for acute pain (benefit probably outweighs harm) but not for fever (benefit close to nil).

    References 1. Viberg H, Eriksson P, Gordh T, et al. Paracetamol (acetaminophen) administration during neonatal brain development affects cognitive function and alters its analgesic and anxiolytic response in adult male mice. Toxicol Sci. 2013 Dec 21. 2. Brandlistuen RE, Ystrom E, Nulman I, et al. Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int J Epidemiol. 2013 Dec;42(6):1702-13. 3. Liew Z, Ritz B, Rebordosa C, et al. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr 2014 Feb 24 [Epub ahead of print]. 4. Bauer AZ, Kriebel D. Prenatal and perinatal analgesic exposure and autism: an ecological link. Environmental Health 2013 12:41. 5. Lesko SM, Louik C, Vezina RM, et al. Asthma morbidity after the short- term use of ibuprofen in children. Pediatrics. 2002 Feb;109(2):E20. 6. McBride JT. The Association of Acetaminophen and Asthma Prevalence and Severity. Pediatrics 2011;128:1181-1185.

    Conflict of Interest:

    I have been editor, coauthor or peer reviewer for Swedish national clinical guidelines for infections in children. These guidelines recommend less use of antipyretics, especially to infants younger than 6 months.

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  2. Re: Viable alternatives to Toddler Taming

    Dear Ellen,

    Thank you for your letter and the many alternative recommended books, it is a fascinating topic. My opinions were mainly personal and parenting styles are a personal choice and differ greatly. I would however wish to reply firstly to your comments on the 'controlled crying' technique. This is not 'prolonged, unrelieved stress', it is a well researched technique of managing sleep behaviours where the baby learns to ' self settle', an essential tool in becoming independent from one's parent. Poor sleep leads to many problems for parents and children and this technique works but must be used in a 'controlled' way. Many parents choose not to use it. The 'rope trick' is quirky but again it is a safe behavioural approach to moving a child from a cot into a bed with support from the parent from outside the room. A stair gate works in a similar way to stop children falling down stairs but can be easily scaled at this later age. I think most parents hope to produce loved, confident and independent children and there are many ways to do this. I would contest however that as an adult parent at times this must involve exerting your will over the child's, especially when their or another's safety is at risk. I think the most important thing when we as parents make our choices and give advice on parenting is that the child's best interests are at heart and that the techniques are safe and if possible evidence based.

    Regards

    Deborah Shanks

    Conflict of Interest:

    None declared

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  3. Viable alternatives to Toddler Taming

    I read with interest Deborah Shanks' article on the book Toddler Taming by Christopher Green (Vermilion, 2006). Senior colleagues recommended that I read this book during my community paediatric placement, and several of my peers also told me they found it useful both personally and professionally.

    I would like to offer an alternative for those who, like me, seek gentler, more compassionate parenting methods, and would prefer to recommend these to patients too. Happily, many excellent books exist which address this need and the evidence in support of its application.

    Controlled crying may be effective in achieving the desired outcome, but if it works by inducing a state of learned helplessness following prolonged, unrelieved distress, then it surely cannot be recommended.

    In her well researched and extensively referenced book Why Love Matters (Routledge, 2004), Sue Gerhardt, a psychoanalytic psychotherapist and founder of the Oxford Parent Infant Project (1), comments in her chapter Corrosive Cortisol that (p.66-73): "the stress response system is affected by how much early stress it has to deal with, and how well the system is helped to recover [...] a well-resourced and well-regulated infant becomes a child and adult who can regulate himself or herself well. [...]Probably the most stressful experience of all for a baby or toddler is to be separated from his or her mother or caregiver, the person who is supposed to keep him or her alive. "

    A more readable alternative with plenty of photographs and diagrams is child psychotherapist Margot Sunderland's What Every Parent Needs to Know: The Remarkable Effects of Love, Nurture and Play on Your Child's Development (Dorling Kindersley, 2006). In this she explains (p.38-42) how periods of prolonged, uncomforted distress can develop an over-sensitive stress-response system, resulting in a constant sense of threat and anxiety in later life, with the associated potential for depression, addictive behaviours and stress-related physical illness.

    Our children are not animals to be tamed. They are human beings with valid feelings and needs. However difficult it may be (I am the parent of three-year-old twins: I know how difficult it can be), it remains the responsibility of parents to consider and respond promptly to those feelings and needs, day and night. Issues of maternal isolation within the nuclear family in our western culture are clearly relevant here, but beyond the scope of this letter.

    In addition the conflict between healthcare professionals and those advocating attachment parenting styles as regards the issue of co-sleeping and the risk of infant death must be noted. The imperative to put babies to sleep on their backs in their own cots, which goes against the instincts of both mothers and babies, results in crying babies and exhausted parents, and when help is sought from doctors there may be a strong felt pressure to supply a functional solution. Bedside co-sleepers, or a cot next to the parents' bed are safe alternatives to full co- sleeping that enable a baby's needs to be met to a far greater extent than if they are put to sleep in the next room. For older children full or partial co-sleeping represents a viable option, and toddlers may prefer to sleep in their parents' bedroom for some time.

    Nonviolent Communication: A Language of Life (Puddledancer Press 2003), and its companion title Raising Children Compassionately: Parenting the Nonviolent Communication Way (Puddledancer Press 2005), by Marshall B. Rosenberg PhD offers a practical framework for approaching a multitude of parenting issues, and is also a useful tool for positive communication in clinical settings. In his introduction to the latter, Rosenberg comments (p.1): "I'd first like to call your attention to the danger of the word "child", if we allow it to apply a different quality of respect than we would give to someone who is not labeled a child."

    Imprisoning children in their bedrooms (the 'rope trick') solely because they wish to leave and their parents or carers do not want them to, is an example of one human being exerting their will over another by means of force (to be distinguished from the protective use of force that is sometimes necessary to prevent an individual from causing harm to themselves or others), and by virtue of their greater size and strength. Such behaviour would likely be illegal were it perpetrated on another adult, and would certainly constitute an infringement of their basic human rights.

    In her book Raising Our Children, Raising Ourselves (Book Publishers Network, 2005), Naomi Aldort PhD offers an alternative to commonly taught coercive parenting practices, stating that (p.xiv-xv): "Most parents already know how to control children gently; what we don't know is how NOT to control them and live in peace and joy with them. We know such gentle controls as natural consequences, an agreed-upon "non-punitive" timeout, engaging cooperation, bribes, and praise. Yet obedience, compliance, and even engaged co-operation mean the child succumbs to the will of the adult, even if she seems content to do so (because she wants your love and she is relieved to earn it). [...] An autonomous child, whose life flows in her direction, acts productively because she wants to. [...] [...] giving up her will is the cause of most of the difficulties with children.

    References:

    1. Oxford Parent Infant Project: http://www.oxpip.org.uk/ Accessed on 25th May 2014.

    Conflict of Interest:

    None declared

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  4. Duration of Prolonged Rupture of Membranes for Early-Onset Neonatal Sepsis

    Dear Sir, We would like to draw your attention to an apparent inconsistency in two related guidelines published by the National Institute of Health and Clinical Excellence (NICE), in response to your recent review article of the NICE guideline on antibiotics for early onset neonatal sepsis (EONS) [1]. Maternal prolonged rupture of membranes (PROM) before delivery is a commonly used risk-factor to suspect EONS. The duration of rupture of membranes, for it to be termed "prolonged", is controversial. Most published studies have chosen "candidate" cut-off times from 12 - 24 hours, with no "ideal" study looking at the relationship between duration of membrane rupture and subsequent neonatal infection. NICE have recently published clinical guidelines (CG149) for the management of newborn infants with EONS [2]. While this guideline clearly defines PROM for preterm infants as that lasting for greater than 18 hours, they have not done so for term infants. Instead, they have referred clinicians to the guideline "Intra-partum care: Care of healthy women and children during childbirth" (CG55) [3]. CG55 suggests that membranes need to be ruptured for greater than 24 hours at term before being called prolonged.

    This apparent difference in definition of PROM between preterm and term infants is unprecedented in the neonatal literature. All comparable national clinical guidelines [4,5] and neonatal textbooks have a single time-threshold to define PROM at all gestations. To minimise errors and for operational ease, a single definition for both term and preterm infants would be preferable. In view of the above, we urge NICE to clarify this inconsistency in the guidelines. We would also like to invite comments from neonatal colleagues regarding their interpretation and implementation of these guidelines. We propose that 18 hours be the accepted cut-off for infants of all gestations, as supported by your recent review of CG 149 [1].

    References 1. Caffrey Osvald E, Prentice P (2014) NICE clinical guideline: antibiotics for the prevention and treatment of early-onset neonatal infection. Arch Dis Child Educ Pract Ed 99: 98-100. 2. NICE (2012) Antibiotics for early-onset neonatal infection CG149. NICE clinical guideline. Manchester: National Institute for Health and Clinical Excellence. pp. 40. 3. NICE (2007) Intrapartum care. NICE clinical guideline. Manchester: National Institute for Health and Clinical Excellence. pp. 69. 4. Verani JR, McGee L, Schrag SJ (2010) Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep 59: 1-36. 5. Money D, Allen VM (2013) The prevention of early-onset neonatal group B streptococcal disease. J Obstet Gynaecol Can 35: 939-951.

    Conflict of Interest:

    None declared

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  5. Pulse oximetry in Children - consider variant haemoglobin.

    We read with interest the recent review by Sinha et al[1] regarding physiological background, technological basis and limitations of pulse oximetry. The factors listed by the authors that may affect the accuracy of pulse oximetry include motion artifact, inadequate perfusion, nail polish, and high-ambient infrared light.

    We would like to add to that list structural variants of haemoglobin. Over 1,000 variant haemoglobins have been described [2], and while the majority are not associated with abnormal SpO2 readings, a reduced SpO2 may in some instances be the main finding associated with variant haemoglobin. Variant haemoglobins with low SpO2 as measured by pulse oximetry may be associated with either reduced SaO2 or normal SaO2, as measured by arterial blood gas analysis, as reviewed by Verhovsek et al [3].

    The finding of an unexplained reduced SpO2 can give rise to extensive cardiopulmonary investigations. Diagnosis of variant hemoglobin should be considered early on in the investigation of patients who are found to have unexpectedly low oxygen saturation but do not have clinical evidence of cardiopulmonary disease. Arterial blood gas analysis (which may in some cases of variant haemoglobin show a normal SaO2) or the simple expedient of carrying out pulse oximetry on parents (as haemoglobin variants are autosomally transmitted) may direct investigations towards a haemoglobin variant and spare the patient unnecessary cardiopulmonary investigations. Furthermore, with the increasing recommendations for use of pulse oximetry as a screening tool for detecting congenital heart disease [4], it is worth remembering haemoglobin variants as potential cause of unexplained low SpO2.

    Conflict of Interest:

    None declared

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  6. Let`s not forget CSF lactate

    The authors have done an impressive task by taking us through the physiological and biochemical basis and the clinical value of serum/blood lactate. However, I was hopeful that they would touch on CSF lactate as an important investigation tool, not only useful for paediatric neurologists but for general paediatricians alike.

    Lumbar puncture (LP) is commonly performed as part of the evaluation process of a child with suspected meningitis. In two meta-analyses, elevated CSF lactate was found to be a good indicator that can differentiate between bacterial meningitis and viral meningitis.(1) Interestingly, its diagnostic accuracy was better than CSF white cell count, glucose and protein.(1) The test is cheap, widely-available and the result is usually available by the time you get your other biochemical results back. A word of caution though: the sensitivity of the test declines significantly in those who had antibiotics pre-treatment.

    Other less common causes of elevated CSF lactate include: encephalitis, other cerebral inflammatory conditions, mitochondrial diseases, Menkes disease, LP within 72 hrs after a seizure (2), biotinidase deficiency and stroke.(2)

    References: 1. Brouwer MC, Thwaites GE, Tunkel AR, et al. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis. Lancet 2012;10;380(9854):1684-92.

    2. Chow SL, Rooney ZJ, Cleary MA, et al. The significance of elevated CSF lactate. Arch Dis Child 2005;90:1188-1189.

    Conflict of Interest:

    None declared

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  7. Re:Epilepsy-related Tongue biting as another cause for recurrent oral ulcers

    Thank you for identifying another cause of mouth ulcers for consideration in this specific group of patients. You highlight the point that in children with poorly controlled seizures, ulcers will resolve by achieving seizure control if they are related to tongue-biting, thereby avoiding unnecessary investigation for an alternative cause.

    Conflict of Interest:

    None declared

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  8. Epilepsy-related Tongue biting as another cause for recurrent oral ulcers

    Sascha Meyer (MD), Isabel Oster (MD), Sylvia Peterlini (MD), Ludwig Gortner (MD, Professor), Georg Kutschke (MD)

    Dear Sir and Madam,

    We read with interest the 15 minute consultation on recurrent oral ulceration in a child by Le Doare et al. (1). In their report, the authors provide a wide range of differential diagnoses that may lead recurrent oral ulcerations (1).

    In our opinion, it is important to take into consideration other causes for oral ulcers in children - most importantly recurrent seizures (2, 3). This is of great importance because in addition to local treatment and use of a bite guard, administration of anti-epileptic drugs is of utmost importance. This medical problem is illustrated in Fig. 1 and Fig. 2.

    With kind regards

    Sascha Meyer, Isabel Oster, Sylvia Peterlini, Ludwig Gortner, Georg Kutschke

    University Children`s Hospital of Saarlnd 66421 Homburg Germany

    References: 1) Le Doare K, Hullah E, Challacombe S, Menson E. Fifteen-minute consultation: a structured approach to the management of recurrent oral ulceration in a child. Arch Dis Child Educ Pract Ed. 2013 Sep 19. doi: 10.1136/archdischild-2013-304471. [Epub ahead of print]. 2) Cerqueira DF, Vieira AS, Maia LC, Sweet E. Severe tongue injury in an adolescent with epilepsy: a case report. Spec Care Dentist. 2007 Jul- Aug;27(4):154-7. 3) Sanders BJ, Weddell JA, Dodge NN. Managing patients who have seizure disorders: dental and medical issues. J Am Dent Assoc. 1995 Dec;126(12):1641-7.

    Figure 1: Multiple oral and tongue ulcers in a 2-year-old-girl

    Figure 2: Sleep EEG recording demonstrating generalized seizure activity accompanied by a short episode of myoclonus, increased oral muscular tone, and bleeding from the oral cavity

    Conflict of Interest:

    None declared

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  9. Re: Question 2 -NeurofibromatosisType1

    Dear Editor, We read with interest the article by Peter A Lio et. al. (1). With regards to question no.2, the authors have rightly pointed out that Neurofibromatosis Type 1 (NF1) is the most likely diagnosis.

    Once the diagnosis of NF1 is confirmed, an affected individual should have a thorough initial assessment with particular attention to features of NF1, a physical examination with particular attention to the skin, skeleton, cardiovascular system & neurological systems, ophthalmologic evaluation including slit lamp examination and developmental assessment in children.

    Ongoing surveillance should include annual physical examination comprising regular blood pressure monitoring, annual head circumference monitoring (rapid increase might indicate tumour or hydrocephalus, annual ophthalmologic examination (including fundoscopy and visual fields) until age 7, regular developmental and growth assessment.Further investigations as indicated.

    However, we are aware that presently in this child's case only one criteria for diagnosis is met. As the diagnosis of NF1 has major implications for the child and the family, we would be interested in finding out whether one should confirm the diagnosis at this stage with genetic test and start the surveillance process as per the guidelines (2) or should one wait for the second major criteria to appear?

    Reference: 1. Peter A Lio, Kachiu C Lee. Brown birthmarks. Arch Dis Child Educ Pract Ed 2013;98:171-172 2. Ferner RE, Huson SM, Thomas N, et al. Guidelines for the diagnosis and management of individuals with neurofibromatosis 1. J Med Genet 2007;44:81 -88

    Conflict of Interest:

    None declared

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  10. How to adjust for case-mix when comparing outcomes across healthcare providers

    We welcome Santhakumaran's article (1) describing some of the problems and misunderstandings that can arise when adjusting for case-mix differences between hospitals. In our recent paper (2) we quantified the bias that is likely to arise when comparing standardised mortality ratios (SMRs) between one neonatal unit and another. In our paper it was shown that, using actual observed differences in case-mix, even if two neonatal units were performing identically for each patient group the ratio of their SMRs could range from 0.79 to 1.68.

    However, this is not to say that the SMR has no role when reporting of clinical outcomes. First, when case-mix differences are small the likely bias that occurs when comparing two SMRs is also likely to be small. Second, the value of the SMR can indicate where intervention (e.g. training, guidelines) may be the most beneficial. For example, with Santhakumaran's two hypothetical neonatal units (Table 1 (1)) it seems entirely reasonable for the hypothetical manager to conclude that prioritizing intervention in unit A (the unit with the highest SMR) would result in improved outcomes for more patients than would the same intervention in unit B, since there are more deaths in unit A than in unit B.

    1 Santhakumaran S. How to adjust for case-mix when comparing outcomes across healthcare providers Arch Dis Child Educ Pract Ed Published Online First: 30 September 2013 doi:10.1136/archdischild-2013-303940

    2 Evans TA, Seaton SE, Manktelow BN. Quantifying the potential bias when directly comparing standardised mortality ratios for in-unit neonatal mortality. PLoS ONE 8(4):e61237

    Conflict of Interest:

    None declared

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