eLetters

118 e-Letters

  • 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

    References

    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.

  • 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.

  • Lower risk group of brief resolved unexplained events is minority of infants with apparent life-threatening events

    We read with interest the clinical practice guideline by Tieder, et al. (1), proposing the new concept of Brief Resolved Unexplained Events (BRUE) replacing the old concept of apparent life-threatening events (ALTE) and the comments by Tate, et al (2). We agree that the majority of the causes of ALTE are proven not really life-threatening after the evaluation. However, we think that application of the concept of lower risk infants of BRUE and its practical recommendation might be cautious.
    We have reported the analysis of 112 cases of ALTE at our institution and eighteen of them had recurrent episodes (3). We also analyzed these 112 cases of ALTE how many of them belong to the lower risk infant group of BRUE. We identified eighteen cases to belong to the lower risk group (unpublished data). Among this group, four of them had ALTE recurrence.
    The BRUE guideline recommends that no necessary laboratory work to be avoided in the lower risk infants and it also recommends not to admit these infants to hospital for observation purpose. However, based on our experience, the majority of ALTE infants belong to the higher risk group and 22% (4/18) of lower risk infants presented the recurrent episodes after the first ALTE episode. Therefore, we suggest that the guideline should be examined who are really the lower risk infants and how to manage these lower risk infants, in prospective studies.

    Satoshi Nakagawa, Riyo Ueda, and Osamu Nomura

    1. Tieder JS,...

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  • Use of 0.9% saline as maintence fluid is bad medicine

    I read with interest the review by Green and Lillie[1] of the NICE guideline (N29) on intravenous fluid therapy in children[2]. The new guideline correctly questions the routine use of the Holliday-Segar formula for calculation of maintenance fluids[3], but the recommendation of 0.9% saline as the maintenance fluid must still be questioned.

    The review opens with two contradictory statements in the first two paragraphs:

    “The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal.”

    and, in reference to the NICE guideline:

    “…its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.”

    I agree wholeheartedly with the first statement but it does not fit with the second proposal of a “standardised” approach. The problem hinges around the idea of “replacement” and “maintenance” fluids and this was reviewed in an excellent paper by Malcolm Coulthard in 2007 when he questioned the switch from 0.18% saline to 0.45% saline as the recommended maintenance fluid[4]. The arguments he used are now doubly relevant when you move to 0.9% saline.

    Patients who need fluid “replacement” need an iv fluid matching extracellular fluid composition and 0.9% saline fits the bill. Patients who need iv “maintenance” fluid need some...

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