121 e-Letters

  • Excellent article, but a slight error in Figure One

    I congratulate Uzuna, Bailie and Murray on an excellent summary of common oncological abdominal masses and an approach for the general paediatrician. Ensuring that children with abdominal masses are correctly identified, investigated and referred by their local paediatrician is crucial, particularly as there is evidence of later diagnosis in the UK compared to other European countries (Pritchard-Jones et al., 2016)

    They note that urinary catecholamines can be a useful rule-in test for suspected neuroblastoma (90% sensitivity). The Childrens Cancer and Leukaemia Group in the UK recommends that all children with a suspected renal tumour should also have urinary catecholamines assessed to reduce the risk of incorrectly treating a neuroblastoma as it may be difficult to determine if a mass is renal or adrenal by imaging alone. Biopsy of renal tumours in young children without features atypical of Wilms tumour is no longer recommended as it rarely changes clinical management, but this approach will only be successful if the child is fully assess for "atypical features", such as raised urinary catecholamines. In my experience there can be a significant wait for urinary catecholamine results and so having a sample sent by the local team is valuable.

    I would also like to highlight a small error in the legend that they have included for the Figure I provided (Figure 1). The National Cancer Registration and Analysis Service does not routinely include all...

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  • A more careful interpretation of meta-regression is required

    I read with interest Dr Rao's commentary on Nath et al.,'s meta-analysis of trials of atraumatic and traditional lumbar puncture needles. This is a high quality paper which complies with PRISMA guidelines for the reporting of systematic reviews and meta-analyses and provides strong evidence for the use of atraumatic needles to reduce the incidence of postdural post puncture headache (PDPH).

    However, Dr Rao is incorrect to state that the subgroup analysis of patients <18 years showed a significant difference in PDPH in this population. In fact the opposite is true as the p-value is >0.05 and the confidence interval for the RR spans 1. Instead Nath et al., show that having pre-specified age as a potential interactor/confounder there is no significant difference in the risk of PDPH for <18yr vs >18yr.

    This is a subtle, but important distinction. First because it is possible the meta-regression was not adequately powered to detect a difference if one is present (a false negative). Second because age is a continous variable and so dichotomising in this way reduces statistical power to detect differences at different ages (e.g. there is a benefit in older children but not in younger children).

    A more accurate interpretation of the study is that it shows that overall atraumatic lumbar puncture needles have lower risk of PDPH and that there is no evidence that this is not the case for patients under 18.

  • Pharmacological treatment of children presenting with psychosis.

    This is a very helpful article describing the approach to children presenting with psychosis in the ED. I welcome the emphasis placed on environmental measures taken to manage agitation, which is especially important for children with Learning Disability and/or neurodevelopmental disorders. Children and young people should always be offered the option of oral medication in the first instance. We have found Promethazine or Lorazepam to be useful if medication is required in the under 12 year olds. For those aged over 12 years they may also be helpful and if necessary could be augmented by Olanzapine, Quetiapine or Risperidone, rather than using Haloperidol in this age group due to its side-effect profile.

  • The Let-Down reflex and milk supply

    The most recent Infant Feeding Survey (2010)1 showed that the most frequently given reasons for stopping breastfeeding in the second week were: insufficient milk (28%) and the baby being ‘too demanding’ or ‘always hungry’ (17%).
    Mothers and those advising them therefore should pay great attention to the milk supply.
    The breast is not a bottle, milk is transferred to the baby by the action of the all-important let-down reflex as the pulses of oxytocin reach the breast alveoli. This reflex governs not only milk delivery (transfer) to the baby but also has a significant role to play in milk production, there are many oxytocin receptors in the milk producing breast alveoli.
    I had looked at the factors affecting the let-down reflex and feeding patterns in the article I wrote for Acta Paediatrica2.
    I agree with Doctors Levene and O’Brien’s comment in Figure 1 that ‘longer feeds may mean baby is not feeding effectively’. We had found (in a different study3) that long feeds seemed to be associated with poor weight gain.

    1Infant Feeding Survey 2010. McAndrew.F. Thompson J. Fellows L et al. The information Centre for Health and Social Care 20.11.12
    2Are we getting the best from breastfeeding. Walshaw C.A. Acta Paediatr 2010 Sept j 99(9) 1292-7 doi 10.1111/j 1651-2227.2010.01812
    3 Does breastfeeding method influence infant weight gain? Walshaw CA. Owens JM. Scally AJ et al Arch Dis Chld 2008 Apr;93(4):292-6

  • Hemihypertrophy

    I was fascinated by the recent article by Catherine Mark et al.
    The clinical approach suggested seems reasonable, however, this will miss a lot more clinical conditions that are/may be associated with hemihypertrophy.1 The list produced in figure 2 is too restrictive.
    The presence of cutaneous malformations and macrocephaly should be sought clinically. These may point towards PIK3CA-Related Segmental Overgrowth.2 3 The UK Genetic Testing Network do offer a gene panel for diagnosis. On occasions because of mosaicism, tissue biopsy may be necessary to clinch the diagnosis.
    New targeted treatment options include the use of mTOR inhibitors like Sirolimus or Everolimus.4


    1. http://www.overgrowthstudy.medschl.cam.ac.uk/for-health-care-professionals/

    2. https://decipher.sanger.ac.uk/gene-disorder/NBK153722#overview

    3. https://www.ncbi.nlm.nih.gov/books/NBK153722/

    4. https://clinicaltrials.gov/ct2/show/NCT02428296

  • Knowledge-Attitude-Practice gap in Breastfeeding Practices

    Dear Editor,
    We read with interest the article by Levene et al on the importance of breastfeeding and ways to improve it. [1] This article meticulously narrates the common barriers and possible solutions for them. It reminds me a famous quote by Keith Hansen “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics”. [2] The Lancet breastfeeding series [3] meticulously calculated the individual as well as global physical, social and economic benefits of the breastfeeding. Despite knowledge about the benefits of the breastfeeding, there is a wide gap in attitude and practice of it. It is one of the paradoxes positive health practice which is more common among the low-income countries than the richer ones. For example, in countries like Rwanda and Sri Lanka, the exclusive breastfeeding rates are as high as 85% and 76% respectively. [3] So, there is something beyond the knowledge alone, i.e. attitude towards breastfeeding which is not stressed much. To bridge this KAP gap for this novel cost-effective investment, we need to work on improving the attitude of mothers as well as healthcare professionals towards breastfeeding. A practical solution will be to do quality improvement studies using PDSA cycles at small scales and identify the barriers at that particular setup. It might be possible that the barriers across the countries are significantly different, in that case, “one model fits all” strateg...

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  • Rational Use of Procalcitonin in Neonatal Sepsis

    Dear Editor,
    We read with interest the article by Robinson et al on use of Procalcitonin (PCT) in the pediatric population.[1] This article meticulously narrates the importance as well as shortcomings of the PCT in pediatric population. Being a neonatologist, I read the neonatal part very carefully and found few points which are either contrary or extension to the above article.
    1. Authors stated that the number of patient used to generate nomogram for neonatal PCT were too low, to validate it and quotes an old study with 83 healthy subjects (1998) by Chiesa et al. However, the same group published another study in 2011 (not cited by authors) with 421 healthy participants, which provides largest normative data on PCT.[2] The nomograms are robust for term neonates but for preterms < 33 weeks the data is very small and needs further studies.
    2. Author stated that PCT is better marker for early-onset sepsis (EOS) than late sepsis, which is not true. This statement is based on extrapolation of an old meta-analysis by Yu et al[3] which included 22 studies. In this meta-analysis also they found that PCT has moderate diagnostic accuracy in early as well as late-onset sepsis. So, the basis of author’s statement that PCT is better marker for early-onset sepsis is not very clear. On the contrary, Vouloumanou et al[4] published a systematic review and meta-analysis of 29 studies and concluded that the diagnostic accuracy is higher for late-onset neonatal se...

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  • Different guidance for a different time?

    Thanks Dr. Roussis, if I have read your comment correctly you express worry that guidelines, systems and protocols of the present were built on the combined wisdom of the past. That a new generation of doctors will use guidance as their clinical 'crux' and gestalt will become an increasingly less used (and perhaps required) commodity. This risks the loss of future knowledge that is encapsulated in the neuronal synapses of the experienced clinicians and can't be found within the electronic pages of a NICE pathway for example.

    If I am correct in your interpretation I agree this is a challenge. I would argue it is a challenge born of necessity in some respects though - the volume of information is much larger, the density of disease far different (a pre-test probability of meningococcal meningitis was much easier to calculate prior to the vaccine era ) and societal expectation more informed. This does not mean we should continue blindly forward. The application of combined wisdom has always been necessary (as you say perhaps "ubi pus, ibi evacua" was the first guideline) but I think we have lost our need to teach how to interpret this information taking into account the individual patient in front of us.

    Thank you for comments - debate in this area is certainly necessary and as stated in the article I personally believe social media has had a role, and will continue to do so, in driving this forward.

  • Can we reproduce clinical wisdom fast track

    Medicine has been practiced for thousands of years. Physicians (and surgeons perhaps) were armed with plenty of gut feeling and gestalt in order to practice effectively within their contemporary technical boundaries that should not be underestimated. The Latin aphorism "ubi pus, ibi evacua" is as valid today as always. As a mini flowchart it proved its value and effectiveness over time: incision and drainage of an abscess. However things were not always as simple. There have been a lot of arbitrary diagnostic and treatment modalities until not too long ago. Modern medicine with a trend towards evidence-based practice is a product of the second half of the 20th Century. Technology allowed the development of (patho) physiology and established knowledge of standard parameters of human body functions. This was a fairly straightforward process in the stability of the developed adult human body. It is however a significantly less solid process with the developing body of a child. The development and application of flowcharts cannot be as definitive as in adults even in a modern paediatric environment. Therefore it is true that one must rely on a larger average of developed clinical wisdom and sixth sense when making clinical decisions on sick children. It is also very true that clinical wisdom relates directly with one’s ability to reflect upon and learn from mistakes.
    The generation of doctors that will be retiring within the next ten years paved the way for a s...

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  • Response to letter re: ‘A source of tension’

    I would like to thank the authors for making this important point and highlighting the error in Illuminations (ADC E&P, 102(5), pp. 265-266.); ‘A source of tension’. A check for appropriate placement of support lines and tubes is just as important as identifying pathology when reviewing imaging. In small infants variations in head position may significantly alter the endotracheal tube (ETT) tip position and the difference between one vertebral body level and the next may be as little as 5-10mm.  Therefore careful examination of the chest radiograph followed by any necessary alteration of the ETT will reduce the likelihood of complications secondary to misplacement. 

    It is also important to carefully check your manuscript when submitting material for publication. My intention was to point out the suboptimal positions of both the ETT and nasogastric (NG) tubes, in addition to the large tension pneumothorax.  The ETT tip is too low in the distal trachea, and the NG tube tip is in the lower oesophagus and should be advanced into the stomach. Unfortunately, somewhere in the process of author checking and internal review this was omitted in error. Thanks once again for pointing this out.