In her review of options for procedural pain in newborn infants
Judith Meek is herself premature in her assertion that "the statement that
we are no longer in equipoise over the use of sucrose may be
premature..."[1].
We surveyed current practice and attitudes to procedural pain in
English Neonatal Units in 2011 using paper questionnaires sent to the lead
clinician in each unit. Replies were received from 102 of...
In her review of options for procedural pain in newborn infants
Judith Meek is herself premature in her assertion that "the statement that
we are no longer in equipoise over the use of sucrose may be
premature..."[1].
We surveyed current practice and attitudes to procedural pain in
English Neonatal Units in 2011 using paper questionnaires sent to the lead
clinician in each unit. Replies were received from 102 of 179 units
contacted, of which 29 units had more than 400 admissions/yr, 54 units
had 200-400 admissions/yr and 14 units had less than 200 admissions/yr. 5
units did not report their admission rates.
70 units used sucrose on more than 50% of times for painful
procedures, 10 used sucrose on less than 50% of occasions and 15 did not
use sucrose at all. 72 units agreed that sucrose was safe and effective
at reducing procedural pain. Of the 70 units using sucrose, 60 had a
written guideline for pain relief; such a policy was present in 16 of the
25 units seldom or never using sucrose. Lack of time or demand and
forgetfulness were stated to be the commonest reasons for non-use of
sucrose.
The fact that sucrose is used routinely in at least 73% of units, and
that those units not reporting routine use quoted lack of time or other
operator-dependent factors as being the main reasons for non-use, suggests
that most practitioners are convinced by the considerable scientific
evidence and their own personal experience of the utility of this simple
and safe measure.
We endorse Meek's view of the importance of promoting good nursing
and developmental care; in our study 42 respondents stated that other non-
pharmacological method of pain relief including breast feeding, non-
nutritive sucking, swaddling, cuddling, holding and containment were
useful for reducing procedural pain.
Reference
1 Meek J, Options for procedural pain in newborn infants Arch Dis
Child Educ Pract Ed 2012;97:23-8
Respected Sir.
We have read the entire article. We agree with the history and the
condition of the Alice as mentioned by the respected authors. But, we
strongly believe the molecular diagnosis testing must be performed to
confirm Benign hereditary chorea which is map to chromosome 14q (Vries et
al., 1999). Beside mapping a mutation in TITF-1 gene has been reported to
be associated with hereditary benign chorea (Breedveld...
Respected Sir.
We have read the entire article. We agree with the history and the
condition of the Alice as mentioned by the respected authors. But, we
strongly believe the molecular diagnosis testing must be performed to
confirm Benign hereditary chorea which is map to chromosome 14q (Vries et
al., 1999). Beside mapping a mutation in TITF-1 gene has been reported to
be associated with hereditary benign chorea (Breedveld et al., 2002-2).
This mutation in TITF-1 can be analyzed directly but yet considering the
heterogeneity of the benign hereditary chorea, the region 14q13.1-q21.1 at
chromosome could be screened as reported previously (Breedveld et al.,
2002-3).
We agree the differential clinical diagnosis has been performed but
yet it couldn't stand alone in the hereditary disorders in an era of
productivity where a disease could be diagnosed in 1-2 days based on the
molecular findings to have the best of prognosis.
Reference:
1. de Vries BB, Arts WF, Breedveld GJ, Hoogeboom JJ, Niermeijer MF,
Heutink P.
Benign hereditary chorea of early onset maps to chromosome 14q. Am J Hum
Genet.
2000 Jan;66(1):136-42.
2. Breedveld GJ, van Dongen JW, Danesino C, Guala A, Percy AK, Dure
LS, Harper P,Lazarou LP, van der Linde H, Joosse M, Gr?ters A, MacDonald
ME, de Vries BB, Arts
WF, Oostra BA, Krude H, Heutink P. Mutations in TITF-1 are associated with
benign hereditary chorea. Hum Mol Genet. 2002 Apr 15;11(8):971-9.
3.Breedveld GJ, Percy AK, MacDonald ME, de Vries BB, Yapijakis C,
Dure LS, Ippel EF, Sandkuijl LA, Heutink P, Arts WF. Clinical and genetic
heterogeneity in
benign hereditary chorea. Neurology. 2002 Aug 27;59(4):579-84.
For the sake of completeness, one should add right-to left shunts to
the list of underlying causes under the heading of "certain populations of
children [who] are at increased risk of IPD(invasive pneumococcal
disease)"(1). Although the most striking example was that of a 77 year old
man(2), the prinicple is also applicable to children with atrial septal
defect(ASD) that this congenital anomaly could predispose to recurren...
For the sake of completeness, one should add right-to left shunts to
the list of underlying causes under the heading of "certain populations of
children [who] are at increased risk of IPD(invasive pneumococcal
disease)"(1). Although the most striking example was that of a 77 year old
man(2), the prinicple is also applicable to children with atrial septal
defect(ASD) that this congenital anomaly could predispose to recurrent
pneumococcal meningitis. In this particular instance three episodes of
pneumococcal meningitis occured over a four year period before the
diagnosis of ASD was considered(2). Recurrent bacterial meningitis may
also be a complication of right- to left shunting attributable to
hereditary haemorrhagic telangiectasia(3), but the bacterial pathogen was
not identified in the review article which cited this complication in
two adults aged 49 qnd 50, repectively(3). Accordingly, even though right-
to left shunts are not considered to be a common predisposing cause for
recurrent pneumococcal meningitis in children, a diligent search should be
made for this risk factor when well recognised underlying causes cannot be
identified, especially in patients who have recurrent episodes of
bacterial meningitis
References
(1) Randle E., Ninis N., Inwald D
Invasive pneumococcal disease
Education and Practice 2011;96:183-190
(2)Spencer SE., D'Cruz IA., Tenholder MF
Recurrent meningitis and severe hypoxemia ina 77 year old man
Chest 1997;112:1120-3
(3)Press OW., Ramsey PG
Cenral nervous system infections associated with hereditary hemorrhagic
telangiectasia
American Journal of Medicine 1984;77:86-92
We read with great interest the concise and accurate summary of P J
McKiernan regarding best-practice milestones for long-term care following
paediatric liver transplantation (1).
Although we fully agree with all medical considerations raised by the
author, we reckon that the complexity of the psychosocial challenges met
by the patients and their families as they adjust to the process of organ...
We read with great interest the concise and accurate summary of P J
McKiernan regarding best-practice milestones for long-term care following
paediatric liver transplantation (1).
Although we fully agree with all medical considerations raised by the
author, we reckon that the complexity of the psychosocial challenges met
by the patients and their families as they adjust to the process of organ
donation and the chronicity of the condition is underscored. Perceived
quality of life, adherence to medical treatment and successful transition
to self-managed care in adolescent transplant recipients may be seen as
three interrelated indicators of the long-term psychosocial outcome of
transplantation. The unique challenges met by adolescent transplant
recipients include the need to establish a continuous and separate sense
of self while coming to terms with the idea of being a survivor who owes
life to the gift of either a deceased or a living donor.
Our experience suggests that the long-term follow-up of paediatric
liver transplant recipients necessarily requires a special emphasis on
self-management education and preventive psychosocial counseling regarding
the impact of transplantation on family dynamics -even more so if the
donation was living-related. Living-related organ donation is generally
associated with better short and long-term clinical outcomes in recipients
(2). It raises however important ethical issues and there is some emerging
evidence that there might be a risk of long-term adverse psychosocial
consequences on the well-being and autonomous self-management capacity of
adolescent transplant recipients (3,4). As we continue to expand the
limits of our medical possibilities to successfully treat childhood end-
stage liver disease, we need to acknowledge our uncertainty regarding
psychosocial and developmental issues following living-related donation,
and actively engage the resources of our multidisciplinary healthcare
teams to deal with unforeseeable challenges in the long-term follow-up of
our paediatric patients (5).
1. McKiernan PJ. Long-term care following paediatric liver
transplantation. Arch Dis Child Educ Pract Ed 2011; 96: 82-86
2. Bourdeaux C, Darwish A, Jamart J, Tri TT, Janssen M, Lerut J, Otte
JB, Sokal E, De Ville de Goyet, J, Reding R. Living-related versus
deceased donor pediatric liver transplantation: a multivariate analysis of
technical and immunological complications in 235 recipients. Am J
Transplant 2007; 7: 440-447
3. Fennell RS, Tucker C, Pedersen T Demographic and medical
predictors of medication compliance among ethnically different pediatric
patients. Pediatr Transplant 2001: 5: 343-348
4. Aujoulat I, Schwering KL, Reding R. Living-related donation: a
challenge to adolescent transplant recipients who transit from parental
care to self-managed care? Child: Care, Health and Development (in press)
5. Aujoulat I, Deccache A, Charles A-S, Janssen M, Struyf C,
P?licand J, Ciccarelli O, Dobbels F, Reding R. Non-adherence in adolescent
transplant recipients: The role of uncertainty in health care providers.
Pediatr Transplant 2011; 15: 148-156
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.
In her review of options for procedural pain in newborn infants Judith Meek is herself premature in her assertion that "the statement that we are no longer in equipoise over the use of sucrose may be premature..."[1].
We surveyed current practice and attitudes to procedural pain in English Neonatal Units in 2011 using paper questionnaires sent to the lead clinician in each unit. Replies were received from 102 of...
Respected Sir. We have read the entire article. We agree with the history and the condition of the Alice as mentioned by the respected authors. But, we strongly believe the molecular diagnosis testing must be performed to confirm Benign hereditary chorea which is map to chromosome 14q (Vries et al., 1999). Beside mapping a mutation in TITF-1 gene has been reported to be associated with hereditary benign chorea (Breedveld...
For the sake of completeness, one should add right-to left shunts to the list of underlying causes under the heading of "certain populations of children [who] are at increased risk of IPD(invasive pneumococcal disease)"(1). Although the most striking example was that of a 77 year old man(2), the prinicple is also applicable to children with atrial septal defect(ASD) that this congenital anomaly could predispose to recurren...
Dear Sir,
We read with great interest the concise and accurate summary of P J McKiernan regarding best-practice milestones for long-term care following paediatric liver transplantation (1).
Although we fully agree with all medical considerations raised by the author, we reckon that the complexity of the psychosocial challenges met by the patients and their families as they adjust to the process of organ...
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...
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