Dear Sir,
We would like to draw your attention to an apparent inconsistency in two
related guidelines published by the National Institute of Health and
Clinical Excellence (NICE), in response to your recent review article of
the NICE guideline on antibiotics for early onset neonatal sepsis (EONS)
[1].
Maternal prolonged rupture of membranes (PROM) before delivery is a
commonly used risk-factor to suspect EONS. The durat...
Dear Sir,
We would like to draw your attention to an apparent inconsistency in two
related guidelines published by the National Institute of Health and
Clinical Excellence (NICE), in response to your recent review article of
the NICE guideline on antibiotics for early onset neonatal sepsis (EONS)
[1].
Maternal prolonged rupture of membranes (PROM) before delivery is a
commonly used risk-factor to suspect EONS. The duration of rupture of
membranes, for it to be termed "prolonged", is controversial. Most
published studies have chosen "candidate" cut-off times from 12 - 24
hours, with no "ideal" study looking at the relationship between duration
of membrane rupture and subsequent neonatal infection.
NICE have recently published clinical guidelines (CG149) for the
management of newborn infants with EONS [2]. While this guideline clearly
defines PROM for preterm infants as that lasting for greater than 18
hours, they have not done so for term infants. Instead, they have referred
clinicians to the guideline "Intra-partum care: Care of healthy women and
children during childbirth" (CG55) [3]. CG55 suggests that membranes need
to be ruptured for greater than 24 hours at term before being called
prolonged.
This apparent difference in definition of PROM between preterm and
term infants is unprecedented in the neonatal literature. All comparable
national clinical guidelines [4,5] and neonatal textbooks have a single
time-threshold to define PROM at all gestations. To minimise errors and
for operational ease, a single definition for both term and preterm
infants would be preferable.
In view of the above, we urge NICE to clarify this inconsistency in the
guidelines. We would also like to invite comments from neonatal colleagues
regarding their interpretation and implementation of these guidelines. We
propose that 18 hours be the accepted cut-off for infants of all
gestations, as supported by your recent review of CG 149 [1].
References
1. Caffrey Osvald E, Prentice P (2014) NICE clinical guideline:
antibiotics for the prevention and treatment of early-onset neonatal
infection. Arch Dis Child Educ Pract Ed 99: 98-100.
2. NICE (2012) Antibiotics for early-onset neonatal infection CG149. NICE
clinical guideline. Manchester: National Institute for Health and Clinical
Excellence. pp. 40.
3. NICE (2007) Intrapartum care. NICE clinical guideline. Manchester:
National Institute for Health and Clinical Excellence. pp. 69.
4. Verani JR, McGee L, Schrag SJ (2010) Prevention of perinatal group B
streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep
59: 1-36.
5. Money D, Allen VM (2013) The prevention of early-onset neonatal group B
streptococcal disease. J Obstet Gynaecol Can 35: 939-951.
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 haemo...
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.
The authors have done an impressive task by taking us through the
physiological and biochemical basis and the clinical value of serum/blood
lactate. However, I was hopeful that they would touch on CSF lactate as an
important investigation tool, not only useful for paediatric neurologists
but for general paediatricians alike.
Lumbar puncture (LP) is commonly performed as part of the evaluation
process of a chi...
The authors have done an impressive task by taking us through the
physiological and biochemical basis and the clinical value of serum/blood
lactate. However, I was hopeful that they would touch on CSF lactate as an
important investigation tool, not only useful for paediatric neurologists
but for general paediatricians alike.
Lumbar puncture (LP) is commonly performed as part of the evaluation
process of a child with suspected meningitis. In two meta-analyses,
elevated CSF lactate was found to be a good indicator that can
differentiate between bacterial meningitis and viral meningitis.(1)
Interestingly, its diagnostic accuracy was better than CSF white cell
count, glucose and protein.(1) The test is cheap, widely-available and the
result is usually available by the time you get your other biochemical
results back. A word of caution though: the sensitivity of the test
declines significantly in those who had antibiotics pre-treatment.
Other less common causes of elevated CSF lactate include:
encephalitis, other cerebral inflammatory conditions, mitochondrial
diseases, Menkes disease, LP within 72 hrs after a seizure (2),
biotinidase deficiency and stroke.(2)
References:
1. Brouwer MC, Thwaites GE, Tunkel AR, et al. Dilemmas in the diagnosis of
acute community-acquired bacterial meningitis. Lancet
2012;10;380(9854):1684-92.
2. Chow SL, Rooney ZJ, Cleary MA, et al. The significance of elevated
CSF lactate. Arch Dis Child 2005;90:1188-1189.
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.
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.
Sascha Meyer (MD), Isabel Oster (MD), Sylvia Peterlini (MD), Ludwig
Gortner (MD, Professor), Georg Kutschke (MD)
Dear Sir and Madam,
We read with interest the 15 minute consultation on recurrent oral
ulceration in a child by Le Doare et al. (1). In their report, the authors
provide a wide range of differential diagnoses that may lead recurrent
oral ulcerations (1).
Sascha Meyer (MD), Isabel Oster (MD), Sylvia Peterlini (MD), Ludwig
Gortner (MD, Professor), Georg Kutschke (MD)
Dear Sir and Madam,
We read with interest the 15 minute consultation on recurrent oral
ulceration in a child by Le Doare et al. (1). In their report, the authors
provide a wide range of differential diagnoses that may lead recurrent
oral ulcerations (1).
In our opinion, it is important to take into consideration other
causes for oral ulcers in children - most importantly recurrent seizures
(2, 3). This is of great importance because in addition to local treatment
and use of a bite guard, administration of anti-epileptic drugs is of
utmost importance. This medical problem is illustrated in Fig. 1 and Fig.
2.
With kind regards
Sascha Meyer, Isabel Oster, Sylvia Peterlini, Ludwig Gortner, Georg
Kutschke
University Children`s Hospital of Saarlnd
66421 Homburg
Germany
References:
1) Le Doare K, Hullah E, Challacombe S, Menson E. Fifteen-minute
consultation: a structured approach to the management of recurrent oral
ulceration in a child. Arch Dis Child Educ Pract Ed. 2013 Sep 19. doi:
10.1136/archdischild-2013-304471. [Epub ahead of print].
2) Cerqueira DF, Vieira AS, Maia LC, Sweet E. Severe tongue injury in an
adolescent with epilepsy: a case report. Spec Care Dentist. 2007 Jul-
Aug;27(4):154-7.
3) Sanders BJ, Weddell JA, Dodge NN. Managing patients who have seizure
disorders: dental and medical issues. J Am Dent Assoc. 1995
Dec;126(12):1641-7.
Figure 1: Multiple oral and tongue ulcers in a 2-year-old-girl
Figure 2: Sleep EEG recording demonstrating generalized seizure
activity accompanied by a short episode of myoclonus, increased oral
muscular tone, and bleeding from the oral cavity
Dear Editor,
We read with interest the article by Peter A Lio et. al. (1). With regards
to question no.2, the authors have rightly pointed out that
Neurofibromatosis Type 1 (NF1) is the most likely diagnosis.
Once the diagnosis of NF1 is confirmed, an affected individual should
have a thorough initial assessment with particular attention to features
of NF1, a physical examination with particular attention to the s...
Dear Editor,
We read with interest the article by Peter A Lio et. al. (1). With regards
to question no.2, the authors have rightly pointed out that
Neurofibromatosis Type 1 (NF1) is the most likely diagnosis.
Once the diagnosis of NF1 is confirmed, an affected individual should
have a thorough initial assessment with particular attention to features
of NF1, a physical examination with particular attention to the skin,
skeleton, cardiovascular system & neurological systems, ophthalmologic
evaluation including slit lamp examination and developmental assessment in
children.
Ongoing surveillance should include annual physical examination
comprising regular blood pressure monitoring, annual head circumference
monitoring (rapid increase might indicate tumour or hydrocephalus, annual
ophthalmologic examination (including fundoscopy and visual fields) until
age 7, regular developmental and growth assessment.Further investigations
as indicated.
However, we are aware that presently in this child's case only one
criteria for diagnosis is met. As the diagnosis of NF1 has major
implications for the child and the family, we would be interested in
finding out whether one should confirm the diagnosis at this stage with
genetic test and start the surveillance process as per the guidelines (2)
or should one wait for the second major criteria to appear?
Reference:
1. Peter A Lio, Kachiu C Lee. Brown birthmarks. Arch Dis Child Educ Pract
Ed 2013;98:171-172
2. Ferner RE, Huson SM, Thomas N, et al. Guidelines for the diagnosis and
management of individuals with neurofibromatosis 1. J Med Genet 2007;44:81
-88
We welcome Santhakumaran's article (1) describing some of the
problems and misunderstandings that can arise when adjusting for case-mix
differences between hospitals. In our recent paper (2) we quantified the
bias that is likely to arise when comparing standardised mortality ratios
(SMRs) between one neonatal unit and another. In our paper it was shown
that, using actual observed differences in case-mix, even if two neo...
We welcome Santhakumaran's article (1) describing some of the
problems and misunderstandings that can arise when adjusting for case-mix
differences between hospitals. In our recent paper (2) we quantified the
bias that is likely to arise when comparing standardised mortality ratios
(SMRs) between one neonatal unit and another. In our paper it was shown
that, using actual observed differences in case-mix, even if two neonatal
units were performing identically for each patient group the ratio of
their SMRs could range from 0.79 to 1.68.
However, this is not to say that the SMR has no role when reporting
of clinical outcomes. First, when case-mix differences are small the
likely bias that occurs when comparing two SMRs is also likely to be
small. Second, the value of the SMR can indicate where intervention (e.g.
training, guidelines) may be the most beneficial. For example, with
Santhakumaran's two hypothetical neonatal units (Table 1 (1)) it seems
entirely reasonable for the hypothetical manager to conclude that
prioritizing intervention in unit A (the unit with the highest SMR) would
result in improved outcomes for more patients than would the same
intervention in unit B, since there are more deaths in unit A than in unit
B.
1 Santhakumaran S. How to adjust for case-mix when comparing outcomes
across healthcare providers Arch Dis Child Educ Pract Ed Published Online
First: 30 September 2013 doi:10.1136/archdischild-2013-303940
2 Evans TA, Seaton SE, Manktelow BN. Quantifying the potential bias
when directly comparing standardised mortality ratios for in-unit neonatal
mortality. PLoS ONE 8(4):e61237
I read with interest the "Fifteen minute consultation: headache in
children under 5 years of age" recently published online.
It would also be worth remembering and will be reassuring to all of us to
know that although some characteristics of early-onset headache can be
different from that of late-onset headaches for e.g. shorter duration, the
overall impact of the headache on the school performance and learning and
clini...
I read with interest the "Fifteen minute consultation: headache in
children under 5 years of age" recently published online.
It would also be worth remembering and will be reassuring to all of us to
know that although some characteristics of early-onset headache can be
different from that of late-onset headaches for e.g. shorter duration, the
overall impact of the headache on the school performance and learning and
clinical severity do not significantly differ from the later.
In other words, early-onset of headaches does not necessarily imply
poorer long term headache disability or harmful aetiology. (1)
Reference:
1. Ravid S, Gordon S, Schiff Aet. al. Headache in Children: Young Age at
Onset Does Not Imply a Harmful Etiology or Predict a Harsh Headache
Disability. Journal of Child Neurology2013: 28(7) 857-862
I read with interest "The Fifteen-minute consultation on the infant
with a large head" published recently by Arnab Seal.
Clinicians should also be aware of 'Benign Enlargement of Subarachnoid
Space (BESS)'. It is described under various names in literature including
benign extra-axial collections of infancy, external hydrocephalus,
subdural effusions, etc (1).
It presents in infancy with rapid enlarged of head circumferen...
I read with interest "The Fifteen-minute consultation on the infant
with a large head" published recently by Arnab Seal.
Clinicians should also be aware of 'Benign Enlargement of Subarachnoid
Space (BESS)'. It is described under various names in literature including
benign extra-axial collections of infancy, external hydrocephalus,
subdural effusions, etc (1).
It presents in infancy with rapid enlarged of head circumference on the
background of normal development.
It should be differentiated from isolated or familial macrocephaly as the
head circumference is normal at birth followed by rapid growth in infancy
crossing more than 2 centiles. Hence although it would fall in category E
(figure 2) neuroimaging (Computed tomography (CT)/Magnetic resonance
imaging (MRI) head) would be required to rule out any intracranial
pathology and establish the diagnosis. In the majority of cases there is a
positive family history of macrocephaly, thus can be misdiagnosed as
familial macrocephaly if neuroimaging is not undertaken.
The anterior fontanelle is enlarged along with enlargement of fronto-
parietal subarachnoid space. There is no associated brain atrophy or signs
of raised intracranial pressure.
As the name indicates it is completely benign condition and no surgical
intervention is required. This condition is self-limiting with spontaneous
resolution usually by 2 years of age. Although the macrocephaly may
persist it plateaus by 2 years of age and associated with resolution of
subarachnoid space as the child grow older (1).
It is important to monitor the head growth and developmental progress. If
there is any deviation from normal in neuro-development or there is
persistence of rapid head growth beyond 2 years of age further evaluation
is required to exclude other intracranial pathologies (2).
In summary, clinicians should consider BESS in any infant presenting with
rapid head growth and normal development. This is a benign self-limiting
condition and no surgical intervention is required.
The Fifteen-minute consultation on the infant with a large head just
published on line (1) has one major weakness: no mention of which chart
the child's head is compared to. Comparison with representative Belgian,
Norwegian (2) and British data (3) has shown that European infants' heads
appear large compared to the WHO standards. We have undertaken further
analyses of the data from the Southampton Women's Survey used fo...
The Fifteen-minute consultation on the infant with a large head just
published on line (1) has one major weakness: no mention of which chart
the child's head is compared to. Comparison with representative Belgian,
Norwegian (2) and British data (3) has shown that European infants' heads
appear large compared to the WHO standards. We have undertaken further
analyses of the data from the Southampton Women's Survey used for our
previous paper (3) and these suggest that, out of 1731 healthy infants
aged 6 months, 3.3% have a head circumference (HC) above the WHO 99.6th
centile and half of these (1.8% of all infants) will also have crossed 2
or more centile spaces upwards since birth. Reassuringly, between 6 and 12
months there was much less centile crossing and only 5 infants (0.3% of
all infants) move further upwards by more than the equivalent of one
centile space (0.67SD). It is probably these latter children who should
be investigated further.
If compared to the previous UK 1990 growth chart only around 0.5% of
children will have a head circumference above the 99.6th, but it should be
born in mind that compared to the UK 1990 UK more infants' heads appear
small. After the age of 6 months between 5-8% of children have heads
below the UK1990 2nd centile (3) and our further analyses of the latter
data3 suggest that by 6 months of age 17% of healthy infants will have
crossed 2 or more centile spaces downwards compared to the UK 1990
reference.
So the growth chart you choose makes a huge difference: make sure you
know which one is being referred to!
Reference List
(1) Seal A. Fifteen-minute consultation on the infant with a large
head. Arch Dis Child Educ Pract Ed 2013.
(2) Juliusson PB, Roelants M, Hoppenbrouwers K, Hauspie R, Bjerknes R.
Growth of Belgian and Norwegian children compared to the WHO growth
standards: prevalence below -2 and above +2 SD and the effect of
breastfeeding. Arch Dis Child 2011; 96(10):916-921.
(3) Wright CM, Inskip HM, Godfrey K, Williams AF, Ong KK. Monitoring head
size and growth using the new UK-WHO growth standard. Arch Dis Child 2011;
96(4):386-388.
Conflict of Interest:
I am academic lead for the RCPCH growth chart group that published the new UK-wHO growth charts
Dear Sir, We would like to draw your attention to an apparent inconsistency in two related guidelines published by the National Institute of Health and Clinical Excellence (NICE), in response to your recent review article of the NICE guideline on antibiotics for early onset neonatal sepsis (EONS) [1]. Maternal prolonged rupture of membranes (PROM) before delivery is a commonly used risk-factor to suspect EONS. The durat...
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 haemo...
The authors have done an impressive task by taking us through the physiological and biochemical basis and the clinical value of serum/blood lactate. However, I was hopeful that they would touch on CSF lactate as an important investigation tool, not only useful for paediatric neurologists but for general paediatricians alike.
Lumbar puncture (LP) is commonly performed as part of the evaluation process of a chi...
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
...Sascha Meyer (MD), Isabel Oster (MD), Sylvia Peterlini (MD), Ludwig Gortner (MD, Professor), Georg Kutschke (MD)
Dear Sir and Madam,
We read with interest the 15 minute consultation on recurrent oral ulceration in a child by Le Doare et al. (1). In their report, the authors provide a wide range of differential diagnoses that may lead recurrent oral ulcerations (1).
In our opinion, it is import...
Dear Editor, We read with interest the article by Peter A Lio et. al. (1). With regards to question no.2, the authors have rightly pointed out that Neurofibromatosis Type 1 (NF1) is the most likely diagnosis.
Once the diagnosis of NF1 is confirmed, an affected individual should have a thorough initial assessment with particular attention to features of NF1, a physical examination with particular attention to the s...
We welcome Santhakumaran's article (1) describing some of the problems and misunderstandings that can arise when adjusting for case-mix differences between hospitals. In our recent paper (2) we quantified the bias that is likely to arise when comparing standardised mortality ratios (SMRs) between one neonatal unit and another. In our paper it was shown that, using actual observed differences in case-mix, even if two neo...
I read with interest the "Fifteen minute consultation: headache in children under 5 years of age" recently published online. It would also be worth remembering and will be reassuring to all of us to know that although some characteristics of early-onset headache can be different from that of late-onset headaches for e.g. shorter duration, the overall impact of the headache on the school performance and learning and clini...
I read with interest "The Fifteen-minute consultation on the infant with a large head" published recently by Arnab Seal. Clinicians should also be aware of 'Benign Enlargement of Subarachnoid Space (BESS)'. It is described under various names in literature including benign extra-axial collections of infancy, external hydrocephalus, subdural effusions, etc (1). It presents in infancy with rapid enlarged of head circumferen...
The Fifteen-minute consultation on the infant with a large head just published on line (1) has one major weakness: no mention of which chart the child's head is compared to. Comparison with representative Belgian, Norwegian (2) and British data (3) has shown that European infants' heads appear large compared to the WHO standards. We have undertaken further analyses of the data from the Southampton Women's Survey used fo...
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