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...
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.
Thank you for your letter and the many alternative recommended books,
it is a fascinating topic. My opinions were mainly personal and parenting
styles are a personal choice and differ greatly. I would however wish to
reply firstly to your comments on the 'controlled crying' technique. This
is not 'prolonged, unrelieved stress', it is a well researched technique
of managing sleep behaviours where the...
Thank you for your letter and the many alternative recommended books,
it is a fascinating topic. My opinions were mainly personal and parenting
styles are a personal choice and differ greatly. I would however wish to
reply firstly to your comments on the 'controlled crying' technique. This
is not 'prolonged, unrelieved stress', it is a well researched technique
of managing sleep behaviours where the baby learns to ' self settle', an
essential tool in becoming independent from one's parent. Poor sleep leads
to many problems for parents and children and this technique works but
must be used in a 'controlled' way. Many parents choose not to use it. The
'rope trick' is quirky but again it is a safe behavioural approach to
moving a child from a cot into a bed with support from the parent from
outside the room. A stair gate works in a similar way to stop children
falling down stairs but can be easily scaled at this later age. I think
most parents hope to produce loved, confident and independent children and
there are many ways to do this. I would contest however that as an adult
parent at times this must involve exerting your will over the child's,
especially when their or another's safety is at risk. I think the most
important thing when we as parents make our choices and give advice on
parenting is that the child's best interests are at heart and that the
techniques are safe and if possible evidence based.
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, a...
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.
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
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...
Dear Ellen,
Thank you for your letter and the many alternative recommended books, it is a fascinating topic. My opinions were mainly personal and parenting styles are a personal choice and differ greatly. I would however wish to reply firstly to your comments on the 'controlled crying' technique. This is not 'prolonged, unrelieved stress', it is a well researched technique of managing sleep behaviours where the...
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, a...
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...
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