We thank Dr Garcia-Algar and colleagues for their comments and agree that an objective measure of prenatal alcohol exposure (PAE) would be very useful in helping to focus attention on children at risk of fetal alcohol spectrum disorder (FASD) but as described in the manuscript, we are cautious about the measurement of FAEEs and EtG in meconium as the sole measure of PAE in an unselected population.
As acknowledged in our paper, maternal self-report of alcohol consumption in pregnancy is unlikely to be completely accurate, but with 46.4% of our mothers reporting some alcohol consumption, and levels of alcohol consumption broadly comparable with several other national studies. We believe that the rates of alcohol consumption in this study reported in confidence very soon after delivery are close to accurate. We also believe that if a mother does self-report alcohol use during pregnancy this is very likely to be true as, in the UK and perhaps other jurisdictions, there is no advantage of falsely reporting that alcohol has been consumed during pregnancy. As highlighted by others, including McGuire and Bearer(1-3) validation of alcohol biomarkers can only be carried out against self-report as there is no biochemical gold standard.
Within our study infants of those mothers who reported some alcohol intake after 20 weeks’ gestation (no benefit from false report) were less likely to have meconium concentration of EtG ≥30ng/g. A limitation of biomarkers in general in...
We thank Dr Garcia-Algar and colleagues for their comments and agree that an objective measure of prenatal alcohol exposure (PAE) would be very useful in helping to focus attention on children at risk of fetal alcohol spectrum disorder (FASD) but as described in the manuscript, we are cautious about the measurement of FAEEs and EtG in meconium as the sole measure of PAE in an unselected population.
As acknowledged in our paper, maternal self-report of alcohol consumption in pregnancy is unlikely to be completely accurate, but with 46.4% of our mothers reporting some alcohol consumption, and levels of alcohol consumption broadly comparable with several other national studies. We believe that the rates of alcohol consumption in this study reported in confidence very soon after delivery are close to accurate. We also believe that if a mother does self-report alcohol use during pregnancy this is very likely to be true as, in the UK and perhaps other jurisdictions, there is no advantage of falsely reporting that alcohol has been consumed during pregnancy. As highlighted by others, including McGuire and Bearer(1-3) validation of alcohol biomarkers can only be carried out against self-report as there is no biochemical gold standard.
Within our study infants of those mothers who reported some alcohol intake after 20 weeks’ gestation (no benefit from false report) were less likely to have meconium concentration of EtG ≥30ng/g. A limitation of biomarkers in general in the need to use a cut-off value, whereas PAE within a population is likely to be linear. As noted in our manuscript, one of our study weaknesses was our failure to identify and recruit any mothers with recognised heavy alcohol consumption in pregnancy.
Reflecting the complex interaction between mother and fetus, PAE is unlikely to be accurately reflected in a single measurement, and as meconium is only laid down after 16-20 weeks’ gestation, assay of biomarkers in this medium will miss earlier PAE. Furthermore, there is suggestion of genetic variation in predisposition of the fetus to damage from PAE(4).
With increasing judicial involvement and the social implications of the diagnosis of fetal alcohol syndrome/FASD, we stand by our interpretation of our large data set acquired from an unselected maternity population, that it is inappropriate to use fetal alcohol biomarkers in meconium in isolation to determine PAE.
Dear Editor,
in the important prospective surveillance of cases of Sydenham's chorea conducted in England and Ireland, only 7 out of 43 patients with confirmed diagnosis (16 %) were treated with corticosteroids, with significant variability in overall management among different centers (1).
While eradicative antibiotic treatment and subsequent prophylaxis are generally accepted by the medical community, there is still no consensus on the preferred symptomatic treatment for rheumatic chorea.
In various controlled and observational studies, corticosteroid drugs have proven to be more effective than conventional therapy (neuroleptics and antiseizure drugs) in achieving clinical improvement and remission of symptoms among patients with Sydenham chorea (2-4). A short course of corticosteroids could be associated with marked improvement of the involuntary movements, without relevant side effects (4). Conversely, treatment with symptomatic drugs has not been shown to be effective in shortening the duration of chorea symptoms and can be burdened by important side effects (parkinsonism, dystonia or both) (5).
In agreement with several recent position papers, we believe that the time has come to provide clear guidelines for the symptomatic treatment of Sydenham's chorea, by planning further international prospective controlled clinical studies.
References
1. Wooding EL, Morton MJS, Lim M, et alChildhood/adolescent Sydenham’s chorea i...
Dear Editor,
in the important prospective surveillance of cases of Sydenham's chorea conducted in England and Ireland, only 7 out of 43 patients with confirmed diagnosis (16 %) were treated with corticosteroids, with significant variability in overall management among different centers (1).
While eradicative antibiotic treatment and subsequent prophylaxis are generally accepted by the medical community, there is still no consensus on the preferred symptomatic treatment for rheumatic chorea.
In various controlled and observational studies, corticosteroid drugs have proven to be more effective than conventional therapy (neuroleptics and antiseizure drugs) in achieving clinical improvement and remission of symptoms among patients with Sydenham chorea (2-4). A short course of corticosteroids could be associated with marked improvement of the involuntary movements, without relevant side effects (4). Conversely, treatment with symptomatic drugs has not been shown to be effective in shortening the duration of chorea symptoms and can be burdened by important side effects (parkinsonism, dystonia or both) (5).
In agreement with several recent position papers, we believe that the time has come to provide clear guidelines for the symptomatic treatment of Sydenham's chorea, by planning further international prospective controlled clinical studies.
References
1. Wooding EL, Morton MJS, Lim M, et alChildhood/adolescent Sydenham’s chorea in the UK and Ireland: a BPSU/CAPSS surveillance studyArchives of Disease in Childhood 2023;108:736-741.
2. Paz JA, Silva CA, Marques-Dias MJ. Randomized double-blind study with prednisone in Sydenham's chorea. Pediatr Neurol. 2006;34(4):264-9. doi: 10.1016/j.pediatrneurol.2005.08.028.
3. Favaretto E, Gortani G, Simonini G, Pastore S, Di Mascio A, Cimaz R, Taddio A. Preliminary data on prednisone effectiveness in children with Sydenham chorea. Eur J Pediatr. 2020 ;179(6):993-997. doi: 10.1007/s00431-020-03574-y
4. Cappellari AM, Rogani G, Filocamo G, Petaccia A. Corticosteroid Treatment in Sydenham Chorea: A 27-Year Tertiary Referral Center Experience. Children (Basel). 2023;10(2):262. doi: 10.3390/children10020262.
5. Cardoso F. Autoimmune choreas. J Neurol Neurosurg Psychiatry. 2017;88(5):412-417. doi: 10.1136/jnnp-2016-314475.
We read the article by Fauroux et al.(1) with great interest and appreciation, as it highlights the positive impact of NIV or CPAP on children with complex medical conditions in pediatric palliative care (PPC).
However, we do have some points to share.
First, patients with neuromuscular diseases were excluded because they fall into Category 2, defined as “conditions where premature death is inevitable, where there may be long periods of intensive treatment aimed at prolonging life and allowing participation in normal activities”.
In the same classification, Category 3 includes examples of “Progressive conditions without curative treatment options” such as muscular dystrophies(2).
Neuromuscular disorders constitute a broad and diverse category, with a wide range of complexity and, consequently, global care needs. Nowadays, a condition such as spinal muscular atrophy (SMA) diagnosed in the symptomatic stage may fall under the definition of Category 2, while palliative care is not required for patients with SMA treated pharmacologically when they are asymptomatic or have mild symptoms. Therefore, we believe that excluding a priori all patients with neuromuscular diseases leads to an inaccurate representation of the population followed by pediatric palliative care, which is not based on pathology but on patients' needs.
Second, in the article patients were included if their care comprised at least two of the following...
We read the article by Fauroux et al.(1) with great interest and appreciation, as it highlights the positive impact of NIV or CPAP on children with complex medical conditions in pediatric palliative care (PPC).
However, we do have some points to share.
First, patients with neuromuscular diseases were excluded because they fall into Category 2, defined as “conditions where premature death is inevitable, where there may be long periods of intensive treatment aimed at prolonging life and allowing participation in normal activities”.
In the same classification, Category 3 includes examples of “Progressive conditions without curative treatment options” such as muscular dystrophies(2).
Neuromuscular disorders constitute a broad and diverse category, with a wide range of complexity and, consequently, global care needs. Nowadays, a condition such as spinal muscular atrophy (SMA) diagnosed in the symptomatic stage may fall under the definition of Category 2, while palliative care is not required for patients with SMA treated pharmacologically when they are asymptomatic or have mild symptoms. Therefore, we believe that excluding a priori all patients with neuromuscular diseases leads to an inaccurate representation of the population followed by pediatric palliative care, which is not based on pathology but on patients' needs.
Second, in the article patients were included if their care comprised at least two of the following multidisciplinary decisions:
► ‘Limitation of care’
► ‘Do-not-intubate’ decision
► ‘Comfort care only’
► Management by a PPC
► Management by a paediatric pain team
► Presence of an advanced directive.
Advance Care Planning (ACP) in PPC is a structured approach that allows for establishing goals and preferences for future medical treatments and decisions regarding the location of end-of-life care and death. ACP discussions should ideally be ongoing throughout the illness and may include but are not limited to: expressing the child’s care preferences, defining and reassessing the goals of care as the child’s condition evolves, planning for emergency situations, and addressing end-of-life care.(2)
Referring to the "Multidisciplinary Decisions" discussed in the article, we believe that the term “Advanced directive” already includes decisions like "Limitation of Care," "Do-Not-Intubate Orders," and "Comfort Care Only." Moreover, there is a clear distinction between care provided by a PPC team and a pediatric pain team. Specialized PPC services are best suited to support families of children with complex needs.
Above all, we highly appreciated how this study demonstrated that NIV/CPAP significantly reduced dyspnea in most patients in CPP and improved both sleep duration and quality for children and their caregivers. Additionally, this study paves the way to intriguing future research on the topic.
1. Fauroux B, Taytard J, Ioan I, Lubrano M, Le Clainche L, Bokov P, et al. Non-invasive respiratory support in children and young adults with complex medical conditions in pediatric palliative care. Arch Dis Child. 2024.
2. Benini F, Papadatou D, Bernada M, Craig F, De Zen L, Downing J, et al. International Standards for Pediatric Palliative Care: From IMPaCCT to GO-PPaCS. J Pain Symptom Manage. 2022;63(5):e529-e43.
We applaud Wheeler's call to inform young people of their Gillick competence and help them understand its significance to them [https://adc.bmj.com/content/109/8/608]. Young people often have very little understanding of what they can and can't do with regards to their own healthcare.
We explored this issue with young people and they developed an approach called Own It [Own it, supporting young people to take ownership of their healthcare | Connecting Care for Children (imperial.nhs.uk)], which includes a resource to help young people take ownership of their healthcare, and a parallel resource aimed at helping parents/carers 'let go'. Co-production identified a third audience - professionals - and a simple tool followed, designed to help professionals be more competent in giving young people ownership of their healthcare.
The task now is to help professionals become inspired and motivated to change - Wheeler's thoughtful article helps us do that.
I read this with much interest, both as a (long) retired physician and family court magistrate - and an adoptee.
Please allow a bee to buzz in my bonnet: the adjective relinquished is used when referring to infants who process through adoption proceedings. It seems an unfortunate term: care may be relinquished (or, happier, transferred) from the birth mother to adoptive carer(s), but her child is never relinquished.
Likewise, can we do better than the term looked after (children)? I hope all children are looked after.
As authors of a recent article demonstrating an increase in Accident and Emergency presentations for acute vaccine reactions following the introduction of the group B meningococcal vaccine (4CMenB) into the UK infant immunisation schedule in 2015 (1), we welcome correspondence from Mukherjee et al emphasising the ongoing risk of invasive meningococcal disease (IMD) in this country.
These data give a local perspective to the national Public Health England surveillance data demonstrating a 50% reduction in group B meningococcal disease following introduction of the 4CMenB vaccine (2). Despite immunisation with 4CMenB being 82.9% effective against group B invasive meningococcal disease in infants, there were still 56 cases in England in the year to March 2017 in under 1 year olds, and a further 119 cases in 1 to 4 year olds (an age group that currently includes both immunised and unimmunised cohorts) (2) (3). In the context of the epidemiology of meningococcal disease in the UK, the benefits of immunisation with 4CMenB to infants clearly outweigh any risks of a transient febrile reaction. The current 4CMenB immunisation campaign is not expected to induce herd immunity, therefore invasive meningococcal bacteria will continue to circulate in the community and unimmunised infants remain at increased risk of invasive meningococcal disease compared to their immunised peers. Parents and clinicians need t...
As authors of a recent article demonstrating an increase in Accident and Emergency presentations for acute vaccine reactions following the introduction of the group B meningococcal vaccine (4CMenB) into the UK infant immunisation schedule in 2015 (1), we welcome correspondence from Mukherjee et al emphasising the ongoing risk of invasive meningococcal disease (IMD) in this country.
These data give a local perspective to the national Public Health England surveillance data demonstrating a 50% reduction in group B meningococcal disease following introduction of the 4CMenB vaccine (2). Despite immunisation with 4CMenB being 82.9% effective against group B invasive meningococcal disease in infants, there were still 56 cases in England in the year to March 2017 in under 1 year olds, and a further 119 cases in 1 to 4 year olds (an age group that currently includes both immunised and unimmunised cohorts) (2) (3). In the context of the epidemiology of meningococcal disease in the UK, the benefits of immunisation with 4CMenB to infants clearly outweigh any risks of a transient febrile reaction. The current 4CMenB immunisation campaign is not expected to induce herd immunity, therefore invasive meningococcal bacteria will continue to circulate in the community and unimmunised infants remain at increased risk of invasive meningococcal disease compared to their immunised peers. Parents and clinicians need to remain aware of the ongoing risks of this disease and benefits of immunisation against this potentially fatal bacterium.
References
1. Nainani V, Galal U, Buttery J, Snape MD. An increase in accident and emergency presentations for adverse events following immunisation after introduction of the group B meningococcal vaccine: an observational study. Arch Dis Child. 2017.
2. Parikh SR, Andrews NJ, Beebeejaun K, Campbell H, Ribeiro S, Ward C, et al. Effectiveness and impact of a reduced infant schedule of 4CMenB vaccine against group B meningococcal disease in England: a national observational cohort study. Lancet. 2016;388(10061):2775-82.
3. Public Health England. Meningococcal disease: laboratory confirmed cases in England. [Online]. Cited 7th September 2017. Available at: https://www.gov.uk/government/publications/meningococcal-disease-laborat...
Varghese and colleagues draw attention to and argue for better capture of the link between air pollution and fatal or near-fatal asthma at a patient level [1]
Evidence on the detrimental effects of air pollution on health have led to the World Health Organisation proposing stringent targets in guidelines for improving air quality [2,3], which in the UK we fall far short of [4].
There is a clear mismatch: if air pollution is a major risk for 5 million excess deaths per year globally and 30-40 thousand excess deaths in the UK [5], why is that risk rarely discussed in clinical consultations or documented in clinical records? We frequently ask about smoking and pets in the household when taking a clinical history, but not about outdoor air pollution exposure in terms of where children live or how they walk to school in relation to local busy roads.
In 2020 the result of an inquest linked the death of a 9 year old girl, to air pollution based on careful examination of timing of admissions and spikes in air pollution over the preceding years. The coroner rightly criticised many professional groups. This included those responsible for medical education for failing to focus on air pollution and clinicians for failing to warn this girl’s family about the health risks of air pollution [6].
So despite the considerable scientific evidence, air pollution is seldom recorded clinically. It has a code that is rarely used (Exposure to air pollution ICD10 Co...
Varghese and colleagues draw attention to and argue for better capture of the link between air pollution and fatal or near-fatal asthma at a patient level [1]
Evidence on the detrimental effects of air pollution on health have led to the World Health Organisation proposing stringent targets in guidelines for improving air quality [2,3], which in the UK we fall far short of [4].
There is a clear mismatch: if air pollution is a major risk for 5 million excess deaths per year globally and 30-40 thousand excess deaths in the UK [5], why is that risk rarely discussed in clinical consultations or documented in clinical records? We frequently ask about smoking and pets in the household when taking a clinical history, but not about outdoor air pollution exposure in terms of where children live or how they walk to school in relation to local busy roads.
In 2020 the result of an inquest linked the death of a 9 year old girl, to air pollution based on careful examination of timing of admissions and spikes in air pollution over the preceding years. The coroner rightly criticised many professional groups. This included those responsible for medical education for failing to focus on air pollution and clinicians for failing to warn this girl’s family about the health risks of air pollution [6].
So despite the considerable scientific evidence, air pollution is seldom recorded clinically. It has a code that is rarely used (Exposure to air pollution ICD10 Code Z58.1) and is not being listed as a contributing factor on the medical certificates of death [7]. As Smith et al point out there is government advice on when to include “smoking, alcohol and occupational exposures on death certificates but not when to include air pollution” [7].
Does it matter, and do we clinicians have a role in this?
Clearly the answer has to be yes – if we are not even trying to access information on air pollution at a time of hospital admission how can we begin to discuss it? Clinicians are busy and traditionally have received little in their education about the health effects of air pollution.
One way of alerting and educating clinical staff to a patient’s potential exposure is by automating information relating air quality to home postcode in electronic clinical records. This has been done at Great Ormond Street Hospital NHS Foundation Trust, Guys’ and St Thomas’ NHS Foundation Trust and King’s College Hospital NHS Foundation Trust when a patient lives in an area with levels above the WHO 2021 recommendations [8]. Not only does this alert the clinician to the relevant air quality data for that patient but “hover bubbles” provide an educational component and can be used for communication with primary care and the patient/family. Data collected and appropriately coded may be used for future much needed monitoring and research.
We would argue that air pollution is such an important health issue with effects across the lifespan, that we have a professional responsibility to speak widely about it. Without systems to help educate clinicians, inform patient management, and describe individual adverse clinical outcomes more accurately including in communications, we risk air pollution being continued to be overlooked as an important cause of ill health and death. We also lose the authority to demand infrastructure and policy changes required to clean the air we all breathe.
Yours sincerely,
Dr Heather J Lambert, Paediatrician and Research Associate, University of Newcastle upon Tyne
Dr Mark J Hayden, Consultant Paediatric Intensivist, Great Ormond Street Hospital NHS Foundation Trust
Dr Chinthika Piyasena, Consultant Neonatologist, Guys’ and St Thomas’ NHS Foundation Trust
Dr Stephen W Lord , Consultant Cardiologist and Medical Examiner
Newcastle upon Tyne Hospitals NHS Foundation Trust and Chair Medical Education Leaders UK
References
1. Varghese D, Clemens T, McMurray A, et al. Near-fatal and fatal asthma and air pollution: are we missing an opportunity to ask key questions?
Arch Dis Child Epub ahead of print: Oct 2023. doi:10.1136/archdischild-2023-325548
2. Taylor L. WHO cuts air pollution limits to save millions of lives. BMJ 2021;374:n2349.
3. WHO global air quality guidelines: particulate matter (PM2.5 and PM10), ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. 21 Sep 2021. ISBN 9789240034228.
7. Smith LJ, Tomson M, Brown K. Air pollution should be listed on death certificates. BMJ 2023;383:2162.
8. Hayden M, Andersson J, Wilson N, Fecht D. Taking air pollution to the next level – displaying in the patients chart and empowering action. Archives of Disease in Childhood 2023;108:A291-A292.
There was an enquiry as
I immediately saw the relevance of the service provided. Only one phrase seemed to me to be discordant. "...whether a cardiac pacemaker could
be turned off during withdrawal of care, profoundly disturbing from the perspective of the clinicians.' this language , withdrawal of care is inaccurate and unfortunate. We may withdraw interventions, but not care. If the child dies as a consequence of the withdrawal I hope we care for the child during the process of dying, and look after the body with respect after the death. I hope we look after parents and siblings during the process of discussing treatment options and withdrawing. I speculate that a strong reassurance that we will continue to provide care for the child and family may be helpful in discussing withdrawing intervention.
Most of the results in table 3 express the difference as high flow minus low flow except for two in the section "VWS (hours) at 6 and 12 hours "that use low flow minus high flow.
In the abstract the primary outcome is expressed as low flow minus high flow while in Table 3 it is expressed as high flow minus low flow.
This is an underpowered study and rather than say "we find no measurably clinically relevant benefit in the use of HF compared with LF in hypoxic children......" would it be more accurate to say "we conclude there is insufficient evidence to show a difference in HF versus LF....", ie. this is called a Type 2 error.
We thank Dr Garcia-Algar and colleagues for their comments and agree that an objective measure of prenatal alcohol exposure (PAE) would be very useful in helping to focus attention on children at risk of fetal alcohol spectrum disorder (FASD) but as described in the manuscript, we are cautious about the measurement of FAEEs and EtG in meconium as the sole measure of PAE in an unselected population.
As acknowledged in our paper, maternal self-report of alcohol consumption in pregnancy is unlikely to be completely accurate, but with 46.4% of our mothers reporting some alcohol consumption, and levels of alcohol consumption broadly comparable with several other national studies. We believe that the rates of alcohol consumption in this study reported in confidence very soon after delivery are close to accurate. We also believe that if a mother does self-report alcohol use during pregnancy this is very likely to be true as, in the UK and perhaps other jurisdictions, there is no advantage of falsely reporting that alcohol has been consumed during pregnancy. As highlighted by others, including McGuire and Bearer(1-3) validation of alcohol biomarkers can only be carried out against self-report as there is no biochemical gold standard.
Within our study infants of those mothers who reported some alcohol intake after 20 weeks’ gestation (no benefit from false report) were less likely to have meconium concentration of EtG ≥30ng/g. A limitation of biomarkers in general in...
Show MoreDear Editor,
in the important prospective surveillance of cases of Sydenham's chorea conducted in England and Ireland, only 7 out of 43 patients with confirmed diagnosis (16 %) were treated with corticosteroids, with significant variability in overall management among different centers (1).
While eradicative antibiotic treatment and subsequent prophylaxis are generally accepted by the medical community, there is still no consensus on the preferred symptomatic treatment for rheumatic chorea.
In various controlled and observational studies, corticosteroid drugs have proven to be more effective than conventional therapy (neuroleptics and antiseizure drugs) in achieving clinical improvement and remission of symptoms among patients with Sydenham chorea (2-4). A short course of corticosteroids could be associated with marked improvement of the involuntary movements, without relevant side effects (4). Conversely, treatment with symptomatic drugs has not been shown to be effective in shortening the duration of chorea symptoms and can be burdened by important side effects (parkinsonism, dystonia or both) (5).
In agreement with several recent position papers, we believe that the time has come to provide clear guidelines for the symptomatic treatment of Sydenham's chorea, by planning further international prospective controlled clinical studies.
References
1. Wooding EL, Morton MJS, Lim M, et alChildhood/adolescent Sydenham’s chorea i...
Show MoreTo the Editor
We read the article by Fauroux et al.(1) with great interest and appreciation, as it highlights the positive impact of NIV or CPAP on children with complex medical conditions in pediatric palliative care (PPC).
However, we do have some points to share.
First, patients with neuromuscular diseases were excluded because they fall into Category 2, defined as “conditions where premature death is inevitable, where there may be long periods of intensive treatment aimed at prolonging life and allowing participation in normal activities”.
In the same classification, Category 3 includes examples of “Progressive conditions without curative treatment options” such as muscular dystrophies(2).
Neuromuscular disorders constitute a broad and diverse category, with a wide range of complexity and, consequently, global care needs. Nowadays, a condition such as spinal muscular atrophy (SMA) diagnosed in the symptomatic stage may fall under the definition of Category 2, while palliative care is not required for patients with SMA treated pharmacologically when they are asymptomatic or have mild symptoms. Therefore, we believe that excluding a priori all patients with neuromuscular diseases leads to an inaccurate representation of the population followed by pediatric palliative care, which is not based on pathology but on patients' needs.
Second, in the article patients were included if their care comprised at least two of the following...
Show MoreWe applaud Wheeler's call to inform young people of their Gillick competence and help them understand its significance to them [https://adc.bmj.com/content/109/8/608]. Young people often have very little understanding of what they can and can't do with regards to their own healthcare.
We explored this issue with young people and they developed an approach called Own It [Own it, supporting young people to take ownership of their healthcare | Connecting Care for Children (imperial.nhs.uk)], which includes a resource to help young people take ownership of their healthcare, and a parallel resource aimed at helping parents/carers 'let go'. Co-production identified a third audience - professionals - and a simple tool followed, designed to help professionals be more competent in giving young people ownership of their healthcare.
The task now is to help professionals become inspired and motivated to change - Wheeler's thoughtful article helps us do that.
Dear Editor,
I read this with much interest, both as a (long) retired physician and family court magistrate - and an adoptee.
Please allow a bee to buzz in my bonnet: the adjective relinquished is used when referring to infants who process through adoption proceedings. It seems an unfortunate term: care may be relinquished (or, happier, transferred) from the birth mother to adoptive carer(s), but her child is never relinquished.
Likewise, can we do better than the term looked after (children)? I hope all children are looked after.
Language matters - to all of us.
Yours faithfully,
Timothy Chambers
Nainani V, Gulal U, Buttery J, Snape MD
Word count: 234
As authors of a recent article demonstrating an increase in Accident and Emergency presentations for acute vaccine reactions following the introduction of the group B meningococcal vaccine (4CMenB) into the UK infant immunisation schedule in 2015 (1), we welcome correspondence from Mukherjee et al emphasising the ongoing risk of invasive meningococcal disease (IMD) in this country.
These data give a local perspective to the national Public Health England surveillance data demonstrating a 50% reduction in group B meningococcal disease following introduction of the 4CMenB vaccine (2). Despite immunisation with 4CMenB being 82.9% effective against group B invasive meningococcal disease in infants, there were still 56 cases in England in the year to March 2017 in under 1 year olds, and a further 119 cases in 1 to 4 year olds (an age group that currently includes both immunised and unimmunised cohorts) (2) (3). In the context of the epidemiology of meningococcal disease in the UK, the benefits of immunisation with 4CMenB to infants clearly outweigh any risks of a transient febrile reaction. The current 4CMenB immunisation campaign is not expected to induce herd immunity, therefore invasive meningococcal bacteria will continue to circulate in the community and unimmunised infants remain at increased risk of invasive meningococcal disease compared to their immunised peers. Parents and clinicians need t...
Show MoreVarghese and colleagues draw attention to and argue for better capture of the link between air pollution and fatal or near-fatal asthma at a patient level [1]
Evidence on the detrimental effects of air pollution on health have led to the World Health Organisation proposing stringent targets in guidelines for improving air quality [2,3], which in the UK we fall far short of [4].
There is a clear mismatch: if air pollution is a major risk for 5 million excess deaths per year globally and 30-40 thousand excess deaths in the UK [5], why is that risk rarely discussed in clinical consultations or documented in clinical records? We frequently ask about smoking and pets in the household when taking a clinical history, but not about outdoor air pollution exposure in terms of where children live or how they walk to school in relation to local busy roads.
In 2020 the result of an inquest linked the death of a 9 year old girl, to air pollution based on careful examination of timing of admissions and spikes in air pollution over the preceding years. The coroner rightly criticised many professional groups. This included those responsible for medical education for failing to focus on air pollution and clinicians for failing to warn this girl’s family about the health risks of air pollution [6].
So despite the considerable scientific evidence, air pollution is seldom recorded clinically. It has a code that is rarely used (Exposure to air pollution ICD10 Co...
Show MoreThere was an enquiry as
I immediately saw the relevance of the service provided. Only one phrase seemed to me to be discordant. "...whether a cardiac pacemaker could
be turned off during withdrawal of care, profoundly disturbing from the perspective of the clinicians.' this language , withdrawal of care is inaccurate and unfortunate. We may withdraw interventions, but not care. If the child dies as a consequence of the withdrawal I hope we care for the child during the process of dying, and look after the body with respect after the death. I hope we look after parents and siblings during the process of discussing treatment options and withdrawing. I speculate that a strong reassurance that we will continue to provide care for the child and family may be helpful in discussing withdrawing intervention.
Most of the results in table 3 express the difference as high flow minus low flow except for two in the section "VWS (hours) at 6 and 12 hours "that use low flow minus high flow.
In the abstract the primary outcome is expressed as low flow minus high flow while in Table 3 it is expressed as high flow minus low flow.
This is an underpowered study and rather than say "we find no measurably clinically relevant benefit in the use of HF compared with LF in hypoxic children......" would it be more accurate to say "we conclude there is insufficient evidence to show a difference in HF versus LF....", ie. this is called a Type 2 error.
"Nineteen per cent of reported cases had an elevated ASOT (200 IU/mL or above) and the mean titre was 600 IU/mL. "
Is 600 the mean of all ASOT measured, or just the 19% of children with elevated results?
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