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Support for a "united airways approach" to best practice(1) comes
from a study which evaluated factors influencing asthma remission in a
cohort enrolled at the age of 7, and followed-up for 39 years(from 1968 to
2007), remission being defined either as "no asthma attacks for 2 years
and no current asthma medication use" or "no self-reported asthma in adult
life but with parent-reported childhood asthma"(2). In that communi...
Support for a "united airways approach" to best practice(1) comes
from a study which evaluated factors influencing asthma remission in a
cohort enrolled at the age of 7, and followed-up for 39 years(from 1968 to
2007), remission being defined either as "no asthma attacks for 2 years
and no current asthma medication use" or "no self-reported asthma in adult
life but with parent-reported childhood asthma"(2). In that community-
based study, which enrolled 8583 seven year olds at its inception,
childhood allergic rhinitis was negatively associated with remission(Odds
Ratio 0.38; 95% Confidence Interval 0.25 to 0.58), hence the "bottom line"
that "early, aggressive treatment of allergic rhinitis[and eczema]...might
facilitate asthma remission"(2). Accordingly, facilitation of asthma
remission might be enhanced by coprescription of montelukast with
corticosteroid nasal sprays as an adjunct to immunotherapy, given the fact
that, on the basis of experimental evidence(3)(4), montelukast has the
potential to mitigate the risk of airways remodeling associated with long-
term exposure to allergens. This potential is one worth exploiting, given
the fact that sublingual immunotherapy(a modality with better safety
profile than subctaneous immunotherapy), requires a sufficiently high dose
to be administerd for at least 3 years to acheive full efficacy(5). When
montelukast is coprescribed with the topical corticosteroid fluticasone
for allergic rhinitis, a high degree of improvement(p < 0.001, compared
with baseline) is achieved in total daytime symptom score, and this
compares favourably with the modest degree(p < 0.05, compared with
baseline) of improvemnt obtained with the sole use of fluticasone nasal
spray(6). Accordingly coprescription of montelukast combines the advantage
of generating symptomatic improvement in allergic rhinitis with the
potential to mitigate the risk of airways remodeling in the long term, the
theoretical basis for the latter postulate being the study wich showd that
8 weeks treatment with montelukast could attenuate the increase in
myelofibroblasts which would otherwise have occured following low-dose
allergen challenge in adults of mean age 25.5 with mild asthma(3). These
observations were in accord with the finding, in the mouse model of
asthma, that montelukast-related blockade of the cysteinyl leukotriene
receptor could reverse established allergen-induced airways smooth muscle
cell layer thickening and subepithelial fibrosis(4).
References
(1) Fiocchi A., Fox AT
Preventing progression of allergic rhinitis: the role of specific
immunotherapy
Arch Dis Child Educ Pract Ed 2011;96:91-100
(2) Burgess JA., Matheson MC., Gurrin LC et al
Factors influencing asthma remission: a longitudinal study from childhood
to middle age
Thorax 2011;66:508-511
(3)Kelly MM., Chakir J., Vethanayagam D et al
Montelukast treatment attenuates the increase in myofibroblasts following
low-dose allergen challenge
CHEST 2006;130:741-753
(4)Henderson WR., Chiang GKS., Yien Y-t., Chi EY
Reversal of allergen-induced airways remodeling by CystLT1 Receptor
blockade
Am J Resp Crit Care Med 2006;173:7180728
(5) Incorvaia C., Masier S., Scurati S et al
The current role of sublingual immunotherapy in the treatment of allergic
rhinitis in adults and children
Journal of Asthma and Allergy 2011;4:13-17
(6) Modgill V., Badyal DK., Verghese A
Efficacy and safety of montelukast add-on therapy in allergic rhinitis
Methods Find Exp Clin Pharmacol 2010;32:669-674
I would like to respond to Prof. AS Garden's excellent article on
Vulvovaginitis and other common gynaecological conditions (1).
The author states that treatment of Lichen Sclerosus is with potent
topical steroids such as Clobetasol propionate 0.05% , applied twice daily
for periods of up to 2 weeks. This may be a minor issue but topical
steroids are classified into 4 grades of potency (mild, moderate, potent
and very po...
I would like to respond to Prof. AS Garden's excellent article on
Vulvovaginitis and other common gynaecological conditions (1).
The author states that treatment of Lichen Sclerosus is with potent
topical steroids such as Clobetasol propionate 0.05% , applied twice daily
for periods of up to 2 weeks. This may be a minor issue but topical
steroids are classified into 4 grades of potency (mild, moderate, potent
and very potent/ ultra potent) and Clobetasol propionate (Dermovate) is
classed as very potent or ultra potent topical steroid as per the British
National Formulary nomenclature.
The current recommendation by British Association of Dermatologists on
management of Lichen Sclerosus (2) is to use an ultrapotent topical
steroid such as Clobetasol propionate 0.05% ointment (Dermovate) as first
line treatment in either sex or age group.
The author further comments that a short period of 2 weeks results in
resolution of symptoms fairly quickly in up to 96% patients. This gives
the false impression that LS responds very well to treatment and only a
short period of 2 weeks of steroids is necessary. In practice however the
condition though more amenable to treatment in young girls, shows a
variable response and requires longer duration of treatment with topical
steroids up to 12 weeks.
The current recommendation (2) is that topical steroids should be applied
once daily for a period of 4 weeks, then on alternate nights for 4 weeks
decreasing to twice weekly application for a further 4 weeks. About 60% of
patients experience complete remission of symptoms, others will continue
to have flares and remissions.
One study using a less potent steroid -Mometasone furoate (Elocon) showed
that this was also effective (3). In my personal practice a case in a pre-
pubertal child managed recently with local paediatric dermatology
colleagues , Elocon 0.1% ointment was used as first line treatment due to
the ever present anxiety of atrophy of skin with topical steroids. Signs
and symptoms resolved quite rapidly over a period of 4 weeks though
treatment was gradually tapered over a further 8 weeks.This choice of
treatment gives the option of using the ultrapotent steroid (Dermovate) as
a backup if the potent steroids (Elocon) fail. In severe cases the advice
is to use Dermovate as first line treatment.
Topical emollients in conjunction are also very beneficial.
Perianal involvement is a frequent finding in young girls, who may present
with constipation because of painful fissures. Hence treatment of
constipation simultaneously is also extremely important, and for this
readers can refer to another excellent guidance by NICE published in 2010
(4)
References:
1.Garden AS. Vulvovaginitis and other common childhood gynaecological
conditions. Archives of Disease in Childhood , Education and Practice
2011;96 (2):73-78.
2.Neill SM,Lewis FM,Tatnall FM and Cox NH. British Association of
Dematologists' guidelines for the management of lichen sclerosus 2010.
British Journal of Dermatology 2010;163:672-682.
3.Cattaneo A,de Magnis A, Botti E et al. Topical mometasone furoate for
vulvar lichen sclerosus. J Reprod Med 2003;48:444-8.
4.NICE guidance CG 99 .Constipation in children and young people. May 2010
Safer options (other than fluoride) for prevention of tooth decay
Despite reports of decreased dental carries after water and
toothpaste fluoridation, Studies indicate, however, that the prevalence
and, to a lesser extent, the intensity of dental fluorosis have increased
in schoolchildren in both fluoridated and fluoride-deficient areas.
Several studies show that young children inadvertently ingest sizable
pro...
Safer options (other than fluoride) for prevention of tooth decay
Despite reports of decreased dental carries after water and
toothpaste fluoridation, Studies indicate, however, that the prevalence
and, to a lesser extent, the intensity of dental fluorosis have increased
in schoolchildren in both fluoridated and fluoride-deficient areas.
Several studies show that young children inadvertently ingest sizable
proportions of toothpaste during toothbrushing. The findings of at least
four studies suggest that the use of fluoride toothpastes by young
children is a risk factor for cancer, bone malformation, heart diseases.
The direct dose-response relation between effectiveness and fluoride
concentration of toothpastes is far from clear-cut and, at best, is weak.
Thus, many countries have reduced the dose of fluoride in toothpaste for
children1.
A clinical trial have investigated the cariostatic effectiveness of a
low (550 ppm) fluoride toothpaste in comparison with a standard (1050 ppm)
control paste in pre-school children who were 2-years-old at the start of
the 3-year trial. A total of 1,523 children were examined in schools and
had photographs taken of their upper permanent incisor teeth. The latter
were scored using the Thylstrup and Fejerskov (TF) index for fluorosis and
the modified Developmental Defects of Enamel (DDE) index. Differences
between the groups were small in real terms but using the TF index the
child and tooth prevalence of opacities were significantly lower in the
children who had used the test paste with lower fluoride content2.
Recent Cochrane review included 25 studies: 2 RCTs, 1 cohort study, 6
case-control studies and 16 cross-sectional surveys. Only one RCT was
judged to be at low risk of bias. The other RCT and all observational
studies were judged to be at moderate to high risk of bias. Studies were
included in four intervention/exposure comparisons. A statistically
significant reduction in fluorosis was found if brushing of a child's
teeth with fluoride toothpaste commenced after the age of 12 months odds
ratio 0.70 (random-effects: 95% confidence interval 0.57 to 0.88) (data
from observational studies). Inconsistent statistically significant
associations were found between starting using fluoride toothpaste/tooth
brushing before or after the age of 24 months and fluorosis (data from
observational studies). From the RCTs, use of higher level of fluoride was
associated with an increased risk of fluorosis. Hence authors' concluded
that there should be a balanced consideration between the benefits of
topical fluorides in caries prevention and the risk of the development of
fluorosis. Authors have recommended that future trials assessing the
effectiveness of different types of topical fluorides (including
toothpastes, gels, varnishes and mouthrinses) or different concentrations
or both should ensure that they include an adequate follow-up period in
order to collect data on potential fluorosis 3.
It is apparent that neither water fluoridation 1, 2, 3 nor toothpaste
fluoride seem to prevent tooth decay without side effects of dental and
skeletal fluorosis, the prevention of tooth decay has fallen into debate
& controversies. In the light of the article and commentary 6, it has
therefore become imperative to look for alternative options. Few of the
options are Gycyrrhizol, licorice extract, Guaijaverin - a plant flavonoid
which have wide safety margins and should be used to reduce plaque, caries
and cavity 4,5.
References:
1. Horowitz HS. The need for toothpastes with lower than conventional
fluoride concentrations for preschool-aged children. J Public Health Dent.
1992 Summer;52(4):216-21.
2. Holt RD, Morris CE, Winter GB, Downer MC. Enamel opacities and
dental caries in children who used a low fluoride toothpaste between 2 and
5 years of age. Int Dent J. 1994 Aug;44(4):331-41.
3. Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV, Marinho VC.
Topical fluoride as a cause of dental fluorosis in children. Cochrane
Database Syst Rev. 2010 Jan 20;(1):CD007693.
4. G.R. Prabu, A. Gnanamani et al. Guaijaverin - a plant flavonoid as
potential antiplaque agent against Streptococcus mutans. Journal of
Applied Microbiology.Volume 101, Issue 2, pages 487-495, August 2006
5. Chu-hong Hu1, Jian He1, Randal Eckert2 Development and evaluation
of a safe and effective sugar-free herbal lollipop that kills cavity-
causing bacteria Int J Oral Sci (2011) 3: 13-20.
6. Dyer Tom. Review: increasing fluoride concentrations in
toothpastes improved prevention of dental caries. Arch. Dis. Child. Ed.
Pract. 2011
Non infectious CRP elevation and correlation with gestational age
Dear editor,
We read with interest the discussion on the reliability of CRP as a sepsis
marker in the newborn in the context of non infectious conditions
following the interesting article on the use of CRP by McWilliam and
Riordan (1). We have recently conducted an analysis on this topic
including 690 newborns having CRP values done within the firs...
Non infectious CRP elevation and correlation with gestational age
Dear editor,
We read with interest the discussion on the reliability of CRP as a sepsis
marker in the newborn in the context of non infectious conditions
following the interesting article on the use of CRP by McWilliam and
Riordan (1). We have recently conducted an analysis on this topic
including 690 newborns having CRP values done within the first three days
of life. (2) Meconium aspiration syndrome was significantly associated
with elevated CRP values up to 86 mg/L in term newborns (p=.009) and
application of (in our case naturally porcine) surfactant with elevated
CRP values up to 32 mg/L in term and preterm newborns (p<.001). A CRP
response to surfactant was already reported in previous studies (3-4) but
the mechanisms of pathophysiology are not clear.
Concerning the correlation of CRP response to infection with gestational
age, we provide further evidence for a more marked CRP response in term
compared to preterm newborns with mean values of 23 mg/L vs. 10 mg/L (95th
percentile 99 mg/L vs. 40 mg/L). Similarly, Turner et al. described higher
CRP values in term compared to preterm newborns after any proinflammatory
stimulus. (5) Interestingly, the literature provides little information on
this correlation with gestational age even though CRP is surely one of the
best studied infection markers for neonatal sepsis.
Yours sincerely,
Nora Hofer
References
1. McWilliam S, Riordan A. How to use: C-reactive protein. Arch Dis
Child Educ Pract Ed. 2010;95(2):55-8.
2. Hofer N, Mueller W, Resch B. Non-infectious conditions and gestational
age influence C-reactive protein values in newborns during the first 3
days of life. Clin Chem Lab Med. 2011;49(2):297-302.
3. Walti H, Eahat M, Desfreres L, Relier J. Natural Exogenous Surfactant
Therapy Stimulates the Acute Phase Reaction in Premature Neonates. Pediatr
Research. 1996;39(4):355
4. Kukkonen AK, Virtanen M, Jaervenpaeae AL, Pokela ML, Ikonen S, Fellman
V. Randomized trial comparing natural and synthetic surfactant: increased
infection rate after natural surfactant? Acta Paediatr 2000;89(5):556-61.
5. Turner MA, Power S, Emmerson AJB. Gestational age and the C reactive
protein response. Arch Dis Child Fetal Neonatal Ed 2004;89(3):F272-3.
the "Best Practice" article by Randle et al. (1) on invasive
pneumococcal disease gives a complete and up-to-date review on this topic.
Notwithstanding the Authors did not mention the fact that at least
complicated pneumonia (necrotizing pneumonia, pleural effusion, pleural
empyema, lung abscess) are not related to penicillin-resistance of
Streptococcus pneumoniae (2-4). Since an increasing number o...
the "Best Practice" article by Randle et al. (1) on invasive
pneumococcal disease gives a complete and up-to-date review on this topic.
Notwithstanding the Authors did not mention the fact that at least
complicated pneumonia (necrotizing pneumonia, pleural effusion, pleural
empyema, lung abscess) are not related to penicillin-resistance of
Streptococcus pneumoniae (2-4). Since an increasing number of cases
complicated pneumonia among invasive pneumococcal disease has been
described (2), it should be clearly stated that this effect is not related
to penicillin-resistance, but rather to the so called "serotype
replacement" after the introduction of 7-valent vaccine (1,5), which
cannot be excluded with the 13-valent vaccine too (1). In our opinion,
this data is not irrelevant and secondary in everyday clinical practice,
and should be pointed out in order to provide the best medical practice
and to avoid useless drug choice or changes, since treatment failure is
usually due to instrinsic pathogenicity of Streptococcus pneumoniae and
children with either intermediate or highly resistant penicillin-resistant
Streptococcus pneumoniae were not more likely to experience treatment
failure (3).
Gianluca Tornese, Federico Marchetti
Department of Peadiatrics
Institute of Child Health IRCCS "Burlo Garofolo" University of Trieste
Trieste, Italy
References
1. Randle E, Ninis N, Inwald D. Invasive pneumococcal disease. Arch
Dis Child Educ Pract Ed. 2011;0:adc.2010.191718v1-edpract191718
2. Tan TQ, Mason EO Jr, Wald ER, et al. Clinical characteristics of
children with complicated pneumonia caused by Streptococcus pneumoniae.
Pediatrics. 2002;110(1 Pt 1):1-6.
3. Cardoso MR, Nascimento-Carvalho CM, Ferrero F, et al. Penicillin-
resistant pneumococcus and risk of treatment failure in pneumonia. Arch
Dis Child. 2008;93(3):221-5.
4. Clifford V, Tebruegge M, Vandeleur M, Curtis N. Question 3: can
pneumonia caused by penicillin-resistant Streptococcus pneumoniae be
treated with penicillin? Arch Dis Child. 2010;95(1):73-7.
5. Singleton RJ, Hennessy TW, Bulkow LR, et al. Invasive pneumococcal
disease caused by nonvaccine serotypes among alaska native children with
high levels of 7-valent pneumococcal conjugate vaccine coverage. JAMA.
2007;297(16):1784-92.
We read with interest the paper by BR Davies and WD Carroll about the
role of inhaled corticosteroids (ICS) in management of wheeze in children
<5 years. As the authors underline, asthma in children is defined by
the clinical progression from episodic to multi-triggered, unremitting
wheeze. The first and more common condition is atopic persistent asthma,
characterized by atopic features such as aeroallergen sensitizati...
We read with interest the paper by BR Davies and WD Carroll about the
role of inhaled corticosteroids (ICS) in management of wheeze in children
<5 years. As the authors underline, asthma in children is defined by
the clinical progression from episodic to multi-triggered, unremitting
wheeze. The first and more common condition is atopic persistent asthma,
characterized by atopic features such as aeroallergen sensitization and
dermatitis. Atopic asthma is responsive to ICS and allergen avoidance.
There is another group of asthmatic children, though, where no atopic
sensitization or familiarity for atopy can be detected. In these children,
wheezing episodes are often more severe and wheeze rapidly progresses from
episodic to persistent, earlier in pre-school age (non-atopic persistent
asthma, NAPA) (1). Long-term therapy with ICS is effective, whereas
prophylactic allergen avoidance is useless. In both groups of patients
with atopic and non-atopic persistent asthma, eosinophils in the nasal
mucus are easily detected with a microscopic examination after
hematossilin-eosin stain. A positive result in a non atopic patient allows
us to diagnose NAPA. On the other hand, a negative result definitely rules
out an allergic disease. We therefore suggest that this simple test is
performed in every child with persistent asthma, in order to predict the
response to ICS therapy.
1. G Longo, E Panontin, G Ventura. Non atopic persistent asthma in
children. Thorax 2009;64:459.
Dr Horridge provides a practical overview of the approach to
assessment and investigation of the child with disordered development and
emphasises the importance of a thorough history. We were surprised that Dr
Horridge did not discuss the importance of obtaining the history of in
utero exposure to teratogens, particularly alcohol.
Fetal alcohol exposure is the most common preventable cause of
intellectual disabi...
Dr Horridge provides a practical overview of the approach to
assessment and investigation of the child with disordered development and
emphasises the importance of a thorough history. We were surprised that Dr
Horridge did not discuss the importance of obtaining the history of in
utero exposure to teratogens, particularly alcohol.
Fetal alcohol exposure is the most common preventable cause of
intellectual disability in the USA.(1,2) The Fetal Alcohol Spectrum
Disorders (FASD) are the range of diagnoses which may result from fetal
alcohol exposure, including Fetal Alcohol Syndrome (FAS) and Alcohol
Related Neurodevelopmental Disorder (ARND). Children with classical FAS
have prenatal and/or postnatal growth impairment, characteristic facial
dysmorphology (including short palpebral fissures, a smooth philtrum and a
thin upper vermilion border), and structural and/or functional problems
involving the central nervous system. Children with ARND have a history
of prenatal alcohol exposure and a complex pattern of significant
neurological dysfunction which is not explained by genetic or
environmental factors. Children with FAS usually have an IQ in the
borderline range, although IQ scores occur in the range for profound
intellectual disability to above average. Although over 75% of children
with ARND have an IQ in the normal range these children present with a
range of developmental disorders involving speech and language, executive
function and social skills.(3,4)
As the physical features of fetal alcohol exposure may be subtle or
absent in children with ARND, the paediatrician needs to take a history of
fetal alcohol exposure including amount, frequency and timing in any child
with developmental delay. In Australia, less than a quarter of
paediatricians routinely ask about alcohol consumption in pregnancy and
only 19% know the diagnostic criteria for FAS.(5) There are potential
benefits to making an early diagnosis of a FASD4. Paediatricians who do
not consider alcohol exposure as a cause of developmental delay may miss
opportunities both for early education and health interventions to improve
the child outcomes and prevention of subsequent alcohol-exposed
pregnancies.
References
1. Abel EL, Sokol RJ. Fetal alcohol syndrome is now leading cause of
mental retardation. Lancet 1986;2(8517):1222.
2. May PA, Gossage JP. Estimating the prevalence of fetal alcohol
syndrome. A summary. Alcohol Res Health 2001;25(3):159-67.
3. Elliott EJ, Peadon E. Fetal Alcohol Spectrum Disorders. Best
Practice: BMJ Publishing Group Limited, 2010.
(http://bestpractice.bmj.com/best-practice/welcome.html)
4. Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O'Malley K,
Young JK. Risk factors for adverse life outcomes in fetal alcohol syndrome
and fetal alcohol effects. J Dev Behav Pediatr 2004;25(4):228-38.
5. Elliott EJ, Payne J, Haan E, Bower C. Diagnosis of foetal alcohol
syndrome and alcohol use in pregnancy: a survey of paediatricians'
knowledge, attitudes and practice. J Paediatr Child Health 2006;42(11):698
-703.
In the article of Delane Shingadia and Shamez Ladhani about the
treatment of malaria in table 3 it is mentioned that primaquine is used in
higher doses for preventing relapses in P.malariae infections. This must
be a typing error since the same authors stated in an earlier article
about the malaria treatment (1) that this dosage is used for preventing
relapses in P.vivax infections. Plasmodium malari...
In the article of Delane Shingadia and Shamez Ladhani about the
treatment of malaria in table 3 it is mentioned that primaquine is used in
higher doses for preventing relapses in P.malariae infections. This must
be a typing error since the same authors stated in an earlier article
about the malaria treatment (1) that this dosage is used for preventing
relapses in P.vivax infections. Plasmodium malariae infection does not
lead to the development of hypnozoites and therefore no additional relapse
prevention is needed.
Sincerely
Bernhard R. Beck
(1) UK malaria treatment guidelines; Journal of Infection, Volume
54, Issue 2, February 2007, Pages 111-121
Du Toit, Meyer and Shah have offered an excellent approach to cow's
milk protein allergy (CMPA) and related disorders.(1)
There is evidence to suggest that an increasing number of infants are
seeking medical attention with symptom-complex suggestive of gastro-
oesophageal disease (GORD).(2) Infants with cow's milk protein allergy
(CMPA), especially those with non-IgE mediated cow's milk-induced
reactions, prese...
Du Toit, Meyer and Shah have offered an excellent approach to cow's
milk protein allergy (CMPA) and related disorders.(1)
There is evidence to suggest that an increasing number of infants are
seeking medical attention with symptom-complex suggestive of gastro-
oesophageal disease (GORD).(2) Infants with cow's milk protein allergy
(CMPA), especially those with non-IgE mediated cow's milk-induced
reactions, present with a variety of symptoms which may be clinically
indistinguishable from those with primary GORD.(2,3)
CMPA and GORD occur frequently in young infants and various studies
have demonstrated that CMPA may be present in up to 50% case of GORD and
in a high proportion of the patients GORD symptoms may be induced by the
underlying CMPA.(4)
Recognising the fact that there is a strong association between GORD
and CMPA, all infants presenting with symptoms of GORD require careful
evaluation to detect whether the GORD is primary or secondary to CMPA. A
detailed history, observation of feeding and physical examination of the
infant are always mandatory to detect signs of secondary GORD.(5)
Oesophageal pH monitoring shows some typical characteristics and
immunological tests may be helpful if an association is suspected (6);
however the only clue to the diagnosis especially in non-IgE mediated
CMPA, is often by elimination diet and milk challenge. The time interval
between the milk intake and the suspected reaction to milk is of crucial
importance; most infants with immediate symptoms may have IgE-mediated
CMPA and should be referred for allergy evaluation with further delay and
milk challenges should only be undertaken in a supervised environment.
Infants presenting with symptom-complex suggestive of GORD with the
clinical history of atopy or cutaneous allergic reactions (as urticaria,
angio-oedema, facial or buccal mucosal oedema), respiratory symptoms
(cyanosis, croup, respiratory distress or wheeze) or symptoms suggestive
of cardiopulmonary collapse (pallor, shock) or apparent life threatening
event should alert the clinician that GORD is secondary to CMPA to
initiate cow's milk-free diet and hypoallergic feeds.
Although soya-based infant formulas have been recommended as a first-
choice alternative for infants with cow's milk allergy, it must be
remembered that nearly half the children with CMPA also have an allergy to
soya (7) and hence the symptoms may remain unchanged or show only partial
improvement if the feeds are switched over from cow's milk to soya-based
formula.
References:
1) du Toit G, Meyer R, Shah N, Identifying and managing cow's milk
protein allergy. Arch Dis Child Educ Pract Ed 2010;95:134-144
doi:10.1136/adc.2007.118018
2) Mir Nisar. Epidemic of gastro-oesophageal reflux in young infants.
Rapid response to: From Drugs and Therapeutics Bulletin. Managing gastro-
oesophageal reflux in infants. Brit Med J 2010; 341:495-498
Doi:10,1136/bmj.c4420
3) Vandenplas Y, Brueton M, Dupont C et al. Guidelines for the
diagnosis and management of cow's milk protein allergy in infants Arch Dis
Child 2007;92:902-908 doi:10.1136/adc.2006.110999
4) Salvatore S, Vendenplas Y. Gastroesophageal Reflex and Cow Milk
Allergy; Is There a Link? Pediatr 2002; 110; 972-984 Doi:
10.1542/peds.110.5.972
5) Mir, Nisar. Presentation and Diagnosis of Gastro-oesophageal
Reflux in babies MIMS Advances. Infant Nutrition 2005;4:1-4
6) Cavataio F, Lacona G, Montalto G et al. Clinical and pH-metric
characteristics of gastro-oesophageal reflex secondary to cows' milk
protein allergy. Arch Dis Child 196; 75: 51-56 Doi; 10.1136/adc.75.1.51
7) Klemola T, Vanto T, Juntunen-Backman K et al. Allergy to soy
formula and to extensively hydrolyzed whey formula in infants with cow's
milk allergy: a prospective, randomized study with a follow-up to the age
of 2 years. J Pediatr. 2002 ;140(2):219-24.
Nisar A Mir
Consultant Paediatrician
Warrington & Halton Hospitals NHS Foundation Trust
In an Editorial from last year (Evid Based Nurs 2009;12:99-101),
DiCenso et al, added one more layer to the preappraised evidence pyramid.
Basically, we have now 2 synopses: synopses of studies and synopses of
syntheses.
Synopses of single studies appear above studies and below syntheses.
They provide a brief summary of an important single study. This type of
synopsis can be found in evidence-based abstraction...
In an Editorial from last year (Evid Based Nurs 2009;12:99-101),
DiCenso et al, added one more layer to the preappraised evidence pyramid.
Basically, we have now 2 synopses: synopses of studies and synopses of
syntheses.
Synopses of single studies appear above studies and below syntheses.
They provide a brief summary of an important single study. This type of
synopsis can be found in evidence-based abstraction journals.
Synopses of syntheses appear above the syntheses layer. They
summarize the findings of a systematic review. One example of this layer
is the Database of Abstracts of Reviews of Effects (DARE).
The structure of this new pyramid makes sense since a good systematic
review is better than a single study. In the end, it is just a guide to
try to make searching for evidence more efficient.
Support for a "united airways approach" to best practice(1) comes from a study which evaluated factors influencing asthma remission in a cohort enrolled at the age of 7, and followed-up for 39 years(from 1968 to 2007), remission being defined either as "no asthma attacks for 2 years and no current asthma medication use" or "no self-reported asthma in adult life but with parent-reported childhood asthma"(2). In that communi...
I would like to respond to Prof. AS Garden's excellent article on Vulvovaginitis and other common gynaecological conditions (1). The author states that treatment of Lichen Sclerosus is with potent topical steroids such as Clobetasol propionate 0.05% , applied twice daily for periods of up to 2 weeks. This may be a minor issue but topical steroids are classified into 4 grades of potency (mild, moderate, potent and very po...
Safer options (other than fluoride) for prevention of tooth decay
Despite reports of decreased dental carries after water and toothpaste fluoridation, Studies indicate, however, that the prevalence and, to a lesser extent, the intensity of dental fluorosis have increased in schoolchildren in both fluoridated and fluoride-deficient areas. Several studies show that young children inadvertently ingest sizable pro...
Non infectious CRP elevation and correlation with gestational age
Dear editor, We read with interest the discussion on the reliability of CRP as a sepsis marker in the newborn in the context of non infectious conditions following the interesting article on the use of CRP by McWilliam and Riordan (1). We have recently conducted an analysis on this topic including 690 newborns having CRP values done within the firs...
Dear Editor,
the "Best Practice" article by Randle et al. (1) on invasive pneumococcal disease gives a complete and up-to-date review on this topic. Notwithstanding the Authors did not mention the fact that at least complicated pneumonia (necrotizing pneumonia, pleural effusion, pleural empyema, lung abscess) are not related to penicillin-resistance of Streptococcus pneumoniae (2-4). Since an increasing number o...
We read with interest the paper by BR Davies and WD Carroll about the role of inhaled corticosteroids (ICS) in management of wheeze in children <5 years. As the authors underline, asthma in children is defined by the clinical progression from episodic to multi-triggered, unremitting wheeze. The first and more common condition is atopic persistent asthma, characterized by atopic features such as aeroallergen sensitizati...
Dr Horridge provides a practical overview of the approach to assessment and investigation of the child with disordered development and emphasises the importance of a thorough history. We were surprised that Dr Horridge did not discuss the importance of obtaining the history of in utero exposure to teratogens, particularly alcohol.
Fetal alcohol exposure is the most common preventable cause of intellectual disabi...
Dear Editor
In the article of Delane Shingadia and Shamez Ladhani about the treatment of malaria in table 3 it is mentioned that primaquine is used in higher doses for preventing relapses in P.malariae infections. This must be a typing error since the same authors stated in an earlier article about the malaria treatment (1) that this dosage is used for preventing relapses in P.vivax infections. Plasmodium malari...
Du Toit, Meyer and Shah have offered an excellent approach to cow's milk protein allergy (CMPA) and related disorders.(1)
There is evidence to suggest that an increasing number of infants are seeking medical attention with symptom-complex suggestive of gastro- oesophageal disease (GORD).(2) Infants with cow's milk protein allergy (CMPA), especially those with non-IgE mediated cow's milk-induced reactions, prese...
In an Editorial from last year (Evid Based Nurs 2009;12:99-101), DiCenso et al, added one more layer to the preappraised evidence pyramid. Basically, we have now 2 synopses: synopses of studies and synopses of syntheses.
Synopses of single studies appear above studies and below syntheses. They provide a brief summary of an important single study. This type of synopsis can be found in evidence-based abstraction...
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