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.

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

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

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