eLetters

28 e-Letters

published between 2017 and 2020

  • 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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  • CONGENITAL DISORDERS OF GLYCOSILATION IN THE DIFFERENTIAL DIAGNOSIS OF DISORDERS OF COPPER METABOLISM

    We read with interest the article by Jane Armer and Christian De Goede appearing in a recent issue of the Journal (1). We congratulate the Authors for their superb job in summarizing such a difficult field represented by the differential diagnosis of disorders of copper metabolism. However, we noticed that in their accurate recognition of the causes of reduced serum values of ceruloplasmin, the Authors missed to mention the Congenital Disorders of Glycosylation (CDGs), which are rare as single disorders but not as a group. CDGs in fact represent nowadays more than 100 distinct genetic multisystem disorders characterized by defective glycosylation of glycoconjugates.(2) We previously signaled that patients with some types of CDGs may have low ceruloplasmin values and abnormal copper metabolism. (3, 4) Presently we know that in at least 3 types of CDGs with prevalent hepatic presentation ± CNS minor signs (TMEM199-CDG, CCDC115-CDG; ATP6AP1-CDG) and 2 with prevalent neurological presentation ± minor signs of hepatic involvement (PMM2-CDG, COG2-CDG) there is a documented disturbance of copper metabolism (Table 1). The mechanisms underlying these abnormalities are unclear, and may probably depend on the biochemical nature of ceruloplasmin itself (a glycoprotein with 6 N-linked glycans) and/or involve at least partial loss of copper transporting proteins. (5) In conclusion, in addition to the group of rare conditions signaled by the Authors, we suggest that the diagnostic algor...

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  • Reply to: Psychological Interventions have a place in Management of Paediatric Headache

    Reply to: Psychological Interventions have a place in Management of Paediatric Headache
    Michael J Morton, Honorary Clinical Senior Lecturer in Child & Adolescent Psychiatry, University of Glasgow

    We are very grateful to Dr Morton for highlighting the importance of CBT and other psychological / talking therapies for children and young people with headaches, and for drawing our attention to the recent systematic review by Ng et al. Where resources exist and permit referral, this can be offered as an adjunct to acute / rescue treatment advice and as an alternative or adjunct to preventative drug therapies and acupuncture for migraine, and may be transformative for worrying tension-type headaches. Even for the trigeminal autonomic cephalalgias (including paroxysmal hemicranias) and idiopathic stabbing headache, CBT and psychological support for the child and young person and their family and carers can be really helpful. Where access to psychological interventions is difficult or inadequate, we should still request it and support the development of these crucial services. Thank you for this important contribution.

    William Whitehouse and Shakti Agrawal

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